Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Belleview Valley Nursing Home during CMS and state inspections, most recent first.
Failure to Address PTSD Triggers and Supportive Interventions: The facility did not identify, assess, or include trauma history, triggers, or non-pharmacological interventions in the care plans for three residents with PTSD. One resident had documented trauma, abuse history, nightmares, irritability, and anxiety; another reported recurring bad dreams and triggering resident behaviors; and a third had PTSD with psychotropic medications and observed mood changes and distractibility. Staff interviews confirmed PTSD care plans should include triggers and interventions, but the plans did not reflect those needs.
Unsanitary food storage and kitchen sanitation: Surveyors found debris, grime, food buildup, dirty vents, broken light covers, and poor ice machine and freezer conditions throughout the kitchen and dry storage areas. Rodent droppings were observed on shelving, staff reported seeing mice in the kitchen and dry storage, and the DM and Maintenance Director acknowledged ongoing pest and cleaning concerns, with no cleaning log in use.
Unsafe and Unclean Resident and Common Areas: A resident room bathroom door had a large hole that had been present for months, and several common areas were observed in disrepair, including damaged dining room counters, a hole in a conference room baseboard, and multiple dirty shower/restroom areas. The men's shower rooms had leaking and slow-draining sinks, debris and soiled items on the floor, sticky buildup, discolored water around a toilet stall, and a musty odor. The facility had no maintenance policy and no maintenance request documentation for the affected areas.
The facility failed to follow physician orders for two residents. One resident with UTI symptoms was started on Macrobid, but the ordered UA with C&S was not obtained and the provider was not documented as notified of results. Another resident with schizoaffective disorder and MRSA had repeated missed wound treatment administrations, including Benzac AC Wash and vinegar-and-water gauze soaks, with the resident reporting that staff did not consistently complete the ordered care.
Failure to Maintain Required QAA/QAPI Meetings: The facility failed to document quarterly QAA/QAPI committee meetings with the required members. The QAPI policy listed required members such as the Administrator, DON, Medical Director, and other department leaders, but the facility had no meeting minutes or sign-in sheets to show the minimum quarterly meetings occurred. The Administrator stated the last meeting was sometime in October and that prior records were unavailable.
The facility failed to follow infection control practices during incontinent care, oxygen care, catheter care, wound care, and medication passes. Staff did not consistently perform hand hygiene, change gloves between dirty and clean tasks, or use EBP gowns and gloves for residents with wounds or catheters. The report also states the facility did not correctly complete TB screening for three residents and did not have an IPCP binder available for review.
The facility failed to complete a significant change MDS within 14 days of a resident’s admission to hospice services for one of two sampled residents. A resident was admitted to hospice, but the significant change MDS was not completed within the required timeframe. The DON and Administrator stated that a significant change MDS should be completed within 14 days of a resident’s change in condition or hospice admission.
Improper catheter care was observed for a resident with an indwelling urinary catheter and BPH. The drainage bag was repeatedly seen uncovered while the resident was in a wheelchair in the room, with visitors, and outside smoking, and during catheter care the CNA placed the tubing through the top of the brief above the bladder instead of below it. The CNA did not don a gown despite EBP signage, and the LPN, DON, and Administrator stated the bag should be covered outside the room or with visitors and the tubing should be below the bladder.
A resident with CKD stage 5 and HTN who went to dialysis three times per week did not receive a lunch bag or snack when lunch was missed while away from the facility. Staff interviews showed dietary prepared bag lunches for residents going to dialysis or appointments and placed them for nursing to give out, and the DON and Administrator said residents should receive food before leaving; however, an LPN said he/she had not seen or provided one for the resident.
A resident with multiple medical and psychiatric diagnoses, who required supervision while smoking and was on supplemental oxygen, was repeatedly observed smoking in their room in violation of facility policy. The resident sustained second-degree burns after igniting a cigarette while wearing a nasal cannula, causing a fire in the bed. Facility staff were aware of the ongoing unsupervised smoking and access to contraband but did not investigate the source or update the care plan with new interventions.
A facility failed to provide an appropriate discharge notice and plan for a resident with schizoaffective disorder, Type II Diabetes, and COPD, who was sent to the hospital for altered mental status. The facility did not document attempts to meet the resident's needs or specify services the receiving facility would provide. Despite the hospital's assessment that the resident could return, the corporate nurse decided not to allow the resident back, leading to a deficiency.
A deficiency was identified involving the failure to protect residents from abuse, including physical, mental, sexual abuse, physical punishment, and neglect, during an uncorrected survey visit.
A resident was physically abused by another resident who punched them in the back of the head after a verbal altercation. This caused the victim's head to hit a medication cart, resulting in bruising and swelling on their cheekbone. The facility census was 83.
A resident was not checked on for over seven hours during the night shift, resulting in a fall around midnight. The resident remained on the floor until staff entered the room at 6:55 A.M. The facility also failed to identify, assess, and plan interventions for falls.
A facility failed to protect a resident from abuse and placed others at risk by housing aggressive residents on a secured unit. An aggressive resident, with a history of physical altercations, was placed on the unit and engaged in an altercation with another resident, causing injury. The facility lacked criteria for placement on the secured unit, and decisions were made by an Administrator without psychiatric training. Staff and the facility's Psychiatrist expressed concerns about the safety and effectiveness of this practice.
The facility failed to protect residents from involuntary seclusion by placing them in a secured unit without proper assessment or documentation. Three residents with psychiatric diagnoses were placed on the secured unit following altercations, without involving them or their guardians in the decision. Interviews revealed that this practice was used for staff convenience or discipline, with no established criteria for placement or removal, raising concerns about the safety of vulnerable residents.
A resident with a history of aggression and mental health disorders was not allowed to return to the facility after hospital discharge due to violent behaviors. The facility failed to provide an appropriate discharge notice, plan, or reassessment, and did not notify the resident's legal guardian in a timely manner. The resident remained in the hospital as no alternative placement was found.
A resident with a history of behavioral problems was physically restrained by a maintenance supervisor, resulting in bruising. The facility failed to protect the resident from further abuse and did not report the incident promptly. Multiple staff members witnessed the event, but the facility's initial investigation was inadequate.
A facility failed to investigate an abuse allegation and protect a resident after the Maintenance Supervisor grabbed the resident's arm, resulting in bruising. The resident, with a complex medical history, reported the incident, but the facility did not follow its abuse policy, and the MS continued to work around the resident until days later. The initial investigation was inadequate, and multiple staff members failed to report the incident immediately.
A facility failed to provide a crisis plan for a resident with significant behavioral health needs, leading to multiple self-harm incidents and elopement attempts. The facility's assessment was outdated and inaccurate, and staff were not trained to manage the resident's behaviors. Interviews with staff and the Medical Director confirmed the facility's inability to provide the necessary care.
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, and did not designate a RN to serve as the Director of Nursing (DON) on a full-time basis. This deficiency was confirmed through a review of nursing schedules, time sheets, and direct observations, and was acknowledged by the Assistant Director of Nursing (ADON) and Administrator.
The facility failed to provide annual performance reviews and regular in-service education for two CNAs, CNA G and CNA M, as required by policy. Interviews with other CNAs and the ADON revealed further inconsistencies and missing documentation in the performance review process. The Administrator confirmed that performance reviews for nurse aides had not yet been initiated.
The facility failed to ensure staff reconciled narcotics at each shift change for four medication carts, missing numerous reconciliation opportunities. Interviews revealed inconsistencies in following the reconciliation process, with staff often not adhering to the facility's policy.
The facility failed to maintain sanitary conditions in the kitchen, dry food storage room, and dining room, with issues such as grime buildup, damaged equipment, and flies. Staff did not follow proper food handling practices, increasing the risk of cross-contamination and food-borne illness. Facility policies for cleaning and food storage were not adequately implemented.
The facility failed to review and update the facility assessment annually, resulting in inaccuracies regarding the number of residents with intellectual/developmental disabilities and behavioral healthcare needs. Essential competencies such as catheter care, falls, communication, and behavioral health were also omitted.
The facility failed to ensure the medical director worked with the clinical team to assure residents' well-being. The medical director did not participate in the Facility Assessment, resident care policies, or QAA Committee meetings. The Facility Assessment was not updated, and the medical director's signature was absent from QAPI meeting sheets for several months. The administrator confirmed the medical director's non-attendance, and the medical director cited scheduling conflicts and lack of policy review participation since at least 2020.
The facility did not notify the State agency when their DON was terminated, as required by policy. The DON's last day was 03/29/24, and no replacement was hired by 04/16/24. The Administrator confirmed the lack of notification during an interview.
The facility failed to implement a QAPI program with necessary policies and protocols to identify and correct quality deficiencies. Despite having a policy in place, there was no documentation of improvements or outcomes, and the Administrator confirmed that only data tracking was performed without further action. This deficiency had the potential to affect all 96 residents.
The facility failed to ensure the QAPI committee developed and implemented policies for data collection and monitoring, did not create action plans for quality deficiencies, and did not conduct an annual PIP. The Administrator confirmed no PIP had been conducted since February, and the facility's RN waiver became void when the last DON left.
The facility failed to maintain quarterly QAA committee meetings with the required members, including the Medical Director, DON, and IP. Review of signature sheets showed significant gaps in attendance, and there was no documentation of issues found or plans to resolve issues. The Administrator confirmed the Medical Director does not attend the meetings, and attendance is tracked solely by signature sheets.
The facility failed to maintain an effective training program for all staff, lacking policies, records of completed training, and performance evaluations for required programs. The ADON admitted to missing in-services and destroyed paperwork from previous DONs. The Administrator confirmed the need for proper documentation and policies.
The facility failed to ensure all staff participated in an abuse, neglect, and exploitation prevention program and a dementia management training program, with a process in place to track attendance. The ADON could not find the in-services from previous DONs, and the Administrator confirmed that the facility should have documentation of the required training.
The facility failed to conduct mandatory training for all staff on the QAPI program, which is essential for improving the quality of care and clinical outcomes for residents. The ADON and Administrator were unable to provide any training records, and staff interviews confirmed the lack of training. This deficiency had the potential to affect all residents and staff in the facility.
The facility failed to develop, implement, and maintain an effective NA in-service training program, with no policy or records provided. The facility assessment was outdated and inaccurate, and several CNAs had not received performance evaluations. The ADON admitted to not knowing about training documentation, and the Administrator confirmed that performance reviews had not been initiated.
The facility failed to develop, implement, and maintain an effective behavioral health training program for staff, affecting two employees hired within the last year. The facility assessment was not reviewed annually, and the number of residents with mental health conditions was inaccurately reported. There was no documentation of behavioral health training for two CNAs, and the ADON admitted to not knowing the specific training for behavioral residents.
The facility failed to protect residents' privacy during showers, as multiple residents reported others entering the shower room without knocking and using the toilet. CNAs confirmed these incidents, and the facility lacked a policy to ensure privacy during bathing.
The facility failed to provide a safe, clean, and comfortable environment, with observations of musty odors, grime, debris, and damaged furniture in resident rooms and common areas. Interviews revealed inconsistent cleaning practices and inadequate maintenance reporting and management, contributing to ongoing issues with cleanliness and repair.
The facility failed to develop and implement individualized comprehensive care plans for several residents, including those with severe cognitive impairments, mental health diagnoses, and tobacco use. Observations showed discrepancies between the care provided and the care plans, such as the use of bed rails and smoking safety measures not being addressed.
The facility failed to follow physician's orders for six residents, leading to missed medication administrations and a missed medical appointment. Residents did not receive scheduled injections, and one resident continued to receive incorrect medication dosages for 40 days. Additionally, a resident missed a cardiologist appointment due to a failure in securing a confirmation number from Medicaid transport.
The facility failed to ensure that four residents receiving hospice services had a complete hospice coordinated plan of care. Medical records lacked facility staff signatures, and one resident had no hospice care documentation at all. Interviews with the ADON and Administrator confirmed the absence of a coordinated plan of care signed by both hospice and facility staff.
The facility failed to ensure the environment remained free of accident hazards by not appropriately assessing four residents who were identified as smokers to ensure they were able to smoke safely. Residents were observed smoking without necessary safety measures, such as smoking aprons, and staff were unaware of the requirements. Care plans did not address smoking safety or supervision, leading to unsafe smoking practices.
The facility failed to identify, assess, and provide supportive interventions for seven residents diagnosed with PTSD. Despite their complex mental health conditions, there were no PTSD assessments or care plans addressing their past trauma or triggers. Staff acknowledged the lack of proper documentation and individualized care plans, highlighting a significant oversight in the facility's care for residents with PTSD.
The facility failed to maintain proper infection control practices during colostomy and suprapubic catheter care for a resident, and during blood sugar checks and insulin administration for three residents. Staff did not perform hand hygiene between tasks or properly dispose of used medical equipment.
The facility failed to maintain an effective pest control program, leading to a fly infestation in critical areas such as the kitchen, dining room, and resident rooms. Staff interviews confirmed the issue, and the lack of targeted measures for flies in pest control invoices highlighted a significant gap in the facility's pest management program.
A facility failed to provide an appropriate assistive device for a resident with hemiplegia, resulting in discomfort and pain. The resident's wheelchair, provided by hospice, had a thick concave pad that raised the resident's left shoulder to an uncomfortable height. Staff acknowledged the issue but were uncertain about providing a different wheelchair.
The facility failed to consistently document the code status for two residents. One resident's medical record showed conflicting information between a full code status and a DNR form, while another resident's care plan indicated a DNR status despite the resident's preference for a full code. Staff interviews revealed that the facility used colored dots to indicate code status, but inconsistencies were noted due to the absence of a Director of Nursing and oversight lapses.
The facility failed to issue a SNF ABN and did not have the NOMNC signed by a resident's representative. The resident continued to stay in the facility with skilled Medicare days remaining, and staff changes led to the forms not being completed and signed appropriately.
The facility failed to notify the state survey agency regarding an allegation of staff-to-resident abuse when a staff member grabbed a resident by the arm and wrist, resulting in a bruise. The ADON did not conduct a thorough investigation or report the incident, and the Administrator did not ensure proper reporting, leading to a deficiency in handling abuse allegations.
The facility failed to notify residents, their representatives, and the Missouri State Long-Term Care Ombudsman in writing before transferring three residents to the hospital. Staff interviews revealed inconsistencies and confusion regarding the responsibility for completing and following up on transfer/discharge notifications.
The facility failed to provide written notification of their bed-hold policy to residents and/or their representatives at the time of transfer for three residents. Interviews with staff revealed inconsistencies and lack of clarity in the process of issuing these notifications.
Failure to Address PTSD Triggers and Supportive Interventions
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for three residents with PTSD. The facility policy titled, Policy and Procedure PTSD, required identification, assessment, care planning, service delivery, documentation, and follow-up for residents with a history of trauma and/or PTSD to promote safety, dignity, psychosocial well-being, and quality of life. However, the care plans for the three sampled residents did not include trauma history, triggers, or non-pharmacological interventions related to PTSD or related behaviors. One resident had diagnoses including PTSD, major depressive disorder, schizoaffective disorder depressive type, and suicidal ideations. The resident’s trauma informed care assessment showed the resident experienced a traumatic event, had nightmares, avoided reminders, felt numb or detached, and felt guilty. Psychiatric notes documented a history of physical and sexual abuse, substance abuse, and increased irritability and yelling at staff. During observation and interview, the resident appeared fidgety and anxious, avoided eye contact, became quiet when discussing the past, and stated that loud people were triggering and that nightmares occurred sometimes. The care plan did not include goals for psychosocial or mental health needs, trauma history, triggers, or non-pharmacological interventions. A second resident with PTSD and schizoaffective disorder bipolar type had an order for prazosin for nightmares, but the care plan did not address trauma history, triggers, behaviors, goals for psychosocial or mental health needs, or non-pharmacological interventions. During observation and interview, the resident was tearful, fidgety, and anxious while discussing nightmares, church leaders, mental health providers, and police, and stated that bad dreams were recurring, some resident behaviors were triggering, and that someone to talk to about triggers would help. A third resident with PTSD, anxiety, bipolar disorder, and cognitive impairment had psychotropic medications ordered for mood and PTSD, but the care plan did not address trauma history or triggers. During observation, the resident was very distracted, fidgety, and had rapid mood changes during conversation. Staff interviews confirmed that PTSD care plans should include triggers and non-pharmacological interventions, but the three residents’ plans did not reflect those needs.
Unsanitary food storage and kitchen sanitation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions. Survey observations in the kitchen showed the commercial dishwasher exterior with flaky white grime and debris on the floor beneath it, debris and grime on the floors below the reach-in freezer, reach-in refrigerator, range, and food preparation counter, food debris inside the microwave, dust and a brown substance on ceiling diffusers, black grime and dust above the dishwashing area window-mounted air conditioning unit, white grime and a brown substance on the ice machine and its ventilation louvers, black grime on the ice machine drain line, and debris and insulation on the floor beneath it. The commercial can opener had a worn cutting blade with an oily film and black grime, the floor and plumbing pipes below the dishwashing area counters and three-compartment sinks had debris, oily film, and brown grime, and four connected ceiling lights over food preparation areas had broken fluorescent light fixture covers and bug debris. No cleaning log was available, and the facility did not provide a dietary cleaning rotation or food storage policy. In the dry food storage area, surveyors observed scattered food debris on the floor, along the walls below the food shelves, and behind the chest-type freezer, along with wooden shelving surfaces containing food debris and rodent droppings. In the rear kitchen exit area, the floor below the reach-in freezer had scattered debris, a chest-type freezer had 1 inch of frost buildup along the interior walls, and an upright freezer had 1 inch of frost buildup along the shelves and a discolored, non-intact door gasket. The Dietary Manager stated rodent droppings were a concern on the shelving and live mice were often seen in the kitchen and dining area, and staff interviews confirmed mice had been seen in the kitchen and dry storage and rodent droppings had been cleaned up in the past. The Maintenance Director stated rodent glue traps had recently been restocked, that he had been told there were mice in dry storage, that the ceiling vents were probably dirty, and that the ice machine drain was normally not cleaned.
Unsafe and Unclean Resident and Common Areas
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment. The report documented a 6 inch by 3 inch hole in the bathroom door of a resident room, which the resident said had been present since moving into the room about three months earlier and had already been discussed with the Maintenance Director because it was frustrating. The facility also did not provide a maintenance policy, and the Maintenance Request Log had no documentation of maintenance requests for the concerned areas. Multiple common areas were observed in poor condition. In the A hall dining room, the wooden food service counter behind the steam table had an approximate 2 foot by 6 inch non-intact section along the floor without a baseboard, the metal food and drink service counter near the ice machine had an approximate 6 foot by 6 inch scraped front section near the floor, and the front office conference room had a 1 inch diameter hole in the wooden baseboard near the door. In the A Hall men's shower/restroom furthest from the nurse's station, the left sink leaked into a bucket, the right sink backed up when the left faucet was turned on, soiled towels and other items were on the floor, the toilet stall had discolored water around it, hair and debris were on the floor, the shower room floor had a sticky film, and there was an unidentifiable musty odor. In the other A Hall men's shower room, the right sink contained hair, drained very slowly, and the floor had a sticky film and scattered debris. In the C Hall shower room and restroom, there was a buildup of a black substance around the bottom of the shower walls near the floor.
Failure to Follow Physician Orders for Ordered Labs and Treatments
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice when physician orders were not followed for two residents. For one resident with urinary symptoms including burning, urgency, and frequency, the physician ordered a urinalysis with culture and sensitivity and ordered Macrobid 100 mg by mouth twice daily for 14 days, with instructions to notify the provider when UA results were obtained. The record showed the antibiotic was started, but there was no documentation that the ordered UA with C&S was obtained and no documentation that the provider was notified of results. The DON stated the nursing staff drew labs, but did not perform the UA with C&S as ordered before starting the antibiotic, and no UA with C&S was completed afterward. For another resident with schizoaffective disorder and MRSA infection, the physician ordered wound treatments including vinegar-and-water gauze soaks and Benzac AC Wash External Liquid for open scalp areas. Review of the TAR showed multiple missed opportunities for both treatments across September, October, November, and early December, including repeated missed administrations of the Benzac AC Wash and missed vinegar-soak treatments. The resident stated the wound on the top of the scalp should have been healed, but some nurses performed the treatment and others did not, and staff told the resident he/she needed to ask for the treatment to be done. The DON stated treatments were expected to be completed as ordered and within the ordered time frame, and the Administrator stated physician orders should be followed.
Failure to Maintain Required QAA/QAPI Meetings
Penalty
Summary
The facility failed to maintain quarterly Quality Assessment and Assurance/Quality Assurance and Improvement Program (QAA/QAPI) committee meetings with the required members. The facility census was 81. Review of the facility policy titled Quality Assurance and Improvement Program, dated 05/31/24, showed that the QAPI program was intended to establish data-driven, facility-wide processes to improve quality of care, quality of life, and clinical outcomes, and that facility management members were accountable for QAPI efforts. The policy listed required committee members including the Administrator, DON, Medical Director, Activities Director, Social Services Director, Dietary Manager, Housekeeping and Laundry Supervisor, Maintenance Director, additional facility staff, and contracted staff such as the Pharmacy Consultant, Dietician, and Rehabilitation Director. The policy did not address the Infection Preventionist as a committee member. Review of the facility's QAA/QAPI records showed no documentation that the facility maintained the minimum required quarterly QAA/QAPI meetings with the required members. During interview on 12/08/25 at 3:08 P.M., the Administrator stated the last QAA/QAPI meeting was sometime in October 2025, but she did not have the minutes or sign-in sheet for that meeting. She also stated the meetings should be held at least quarterly and that she did not have records of previous QAA/QAPI meetings prior to becoming the Administrator.
Infection Control and TB Screening Failures
Penalty
Summary
The facility failed to implement its infection prevention and control program during multiple resident care activities, including wound care, incontinent care, oxygen care, catheter care, and medication administration. The report states the facility also failed to correctly screen three residents for TB as required by state regulation 19 CSR 20-20.100, and that no infection control binder was provided for review. The DON stated the facility did not have an IPCP and instead used an infection control program in the electronic medical record to track infections and antibiotic use. During incontinent care for one resident, two CNAs and an LPN entered the room without performing hand hygiene, used gloves inconsistently, and moved between dirty and clean tasks without changing gloves or washing hands. One CNA touched the inside of a urine-saturated brief, another exited the room without hand hygiene, and one CNA used the same soiled gloves while cleaning the resident and assisting the resident back to bed. The report also describes oxygen care for another resident in which staff found the nasal cannula on the floor, handled it without hand hygiene, and placed it back in the resident’s nares; on another occasion, an LPN picked up the cannula from the floor and draped it across the bedside table. The resident had continuous oxygen ordered at 2-4 lpm via nasal cannula. The report further describes catheter care and wound care where staff did not follow EBP or infection control practices. For one resident with a suprapubic catheter, staff did not sanitize hands or wear gowns during catheter-related care and transfers, and touched the resident and equipment without EBP precautions. For another resident with an indwelling catheter, staff wore gown and gloves but did not sanitize hands at key points and touched the catheter drainage spout to the urinal. During wound care for a resident with wounds, an LPN did not wear a gown, brought a treatment cart into the room, touched the sink faucet and treatment supplies with the same gloves, failed to change gloves or perform hand hygiene between tasks, and placed supplies on the resident’s mini-fridge and later back into the cart without cleaning them. During medication administration, a CMT did not perform hand hygiene between residents and touched tablets with bare hands while preparing medications for two residents.
Failure to Complete Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change MDS within 14 days of a resident’s admission to hospice services for one resident out of two sampled residents. Resident #5 was admitted to the facility on an unspecified date and was admitted to hospice services on 08/22/25. Review of the resident’s significant change MDS showed that the resident received hospice services, but the facility did not complete a significant change MDS within 14 days of the hospice admission. The facility did not provide a policy regarding completion of significant change MDS assessments. During interviews, the DON stated that a significant change MDS should be completed if a significant change lasted longer than two weeks or if the resident was admitted to hospice, and that it should be completed within 14 days of the change in condition. The Administrator also stated that a significant change MDS should be completed within 14 days of a change in the resident’s condition.
Improper Catheter Positioning and Lack of Dignity Bag
Penalty
Summary
The facility failed to ensure proper catheter care for Resident #74, who had an indwelling urinary catheter and a diagnosis of benign prostatic hyperplasia. The resident’s physician order sheet showed an order to change the catheter monthly. During observations on multiple occasions, the resident was seen sitting in a wheelchair with the catheter drainage bag hanging from the wheelchair without a dignity bag, including while in the room with the door open, while outside smoking with other residents and staff, and while being pushed in the hallway to the smoking area. During catheter care observation, CNA A performed hand hygiene and donned gloves but did not don a gown despite enhanced barrier precautions signage on the door. CNA A positioned the clean catheter tubing through the top of the brief above the resident’s bladder and fastened the brief, leaving the tubing not positioned below the level of the bladder. CNA A and LPN C stated the drainage bag should be covered with a dignity bag when the resident had visitors or was outside the room, and the tubing should be positioned below the bladder so gravity could help drain urine. The DON and Administrator also stated the bag should be covered outside the room or with visitors and the tubing should be kept below the bladder.
Missed Meal Support for Dialysis Resident
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met for one resident who received dialysis three times per week for chronic kidney disease stage 5 and essential hypertension. The resident’s care plan stated dialysis was received on Tuesday, Thursday, and Saturday at a dialysis center. During interview, the resident said transportation took him/her to dialysis early in the morning, after breakfast, and he/she did not eat again until returning from dialysis after lunch time, but the facility did not provide a lunch and/or snack to take along when lunch was missed. Interviews with staff showed dietary staff prepared bag lunches with sandwiches, snacks, and a drink for residents going to dialysis or other appointments and placed them in the A Hall refrigerator for nursing staff to give to residents before departure. The DON and Administrator stated residents going to dialysis should receive a lunch bag with a sandwich and/or snacks, and if one was not ready, nurses were to make something from the kitchen or ask dietary staff for food before the resident left. However, an LPN said he/she had never seen or provided a bagged lunch for the resident, and another LPN said he/she had not personally given the resident a bagged lunch/snack before dialysis. Dietary staff also stated bagged lunches/snacks were made each morning for residents with scheduled appointments.
Failure to Supervise Smoking Resident on Oxygen Results in Burns and Fire Hazard
Penalty
Summary
A facility failed to provide adequate supervision and maintain an environment free from accident hazards for a resident who required supervision while smoking. The resident, who had diagnoses including COPD, schizoaffective disorder, borderline personality disorder, intermittent explosive disorder, and anxiety, was assessed as cognitively intact and able to ambulate independently. Despite facility policies prohibiting smoking in resident rooms and the possession of lighters or cigarettes in rooms, the resident was repeatedly observed smoking in their room while receiving supplemental oxygen via nasal cannula. On one occasion, the resident sustained second-degree burns to the nose, fingers, and collarbone after lighting a cigarette while still wearing the nasal cannula, which ignited and caused a fire in the bed. Burned areas were noted on the bed sheets, mattress, and the resident's clothing. The resident reported that the nasal prongs ignited, burning the nose, and that the sheets and mattress caught fire, which the resident attempted to extinguish. The facility's records showed that the care plan was not updated to reflect the resident's ongoing noncompliance with smoking policies or the incident of injury, and no new interventions were documented. Interviews with facility leadership revealed that staff were aware of the resident's continued access to cigarettes and lighters, as well as ongoing unsupervised smoking in the room, but no investigation was conducted to determine the source of the contraband. The DON expressed uncertainty about how to prevent residents from bringing in lighters and was not familiar with facility policies regarding contraband. The resident stated that cigarettes and lighters were obtained during outings with staff and from other residents, and that no one from the facility had inquired about the source. Despite repeated education, the resident continued to smoke in the room, and the facility did not implement additional interventions or update the care plan accordingly.
Inappropriate Discharge and Lack of Reassessment for Resident
Penalty
Summary
The facility failed to provide an appropriate facility-initiated discharge notice and discharge plan for a resident, and did not reassess the resident's status after discharge from an acute care hospital. The resident, who had a history of schizoaffective disorder, Type II Diabetes, and COPD, was sent to the hospital for evaluation of altered mental status. Despite the resident's delusional behavior, there was no documentation of harmful behaviors prior to the hospital discharge, nor was there a physician's documentation of specific needs that could not be met by the facility. The facility's discharge policy requires that a resident should not be discharged unless specific conditions are met, such as the resident's needs cannot be met, or the safety of others is endangered. However, the facility did not document any attempts to meet the resident's needs or specify the services the receiving facility would provide. The discharge notice cited the resident's refusal of treatments and threats as reasons for discharge, but these were not supported by physician documentation. Interviews revealed that the decision to not allow the resident to return was made by the corporate nurse, despite the hospital's assessment that the resident was fine to return. The Director of Nurses and other staff indicated that the resident was not considered a danger to self or others, and the decision to discharge was not based on physical aggression. The facility's failure to follow proper discharge procedures and lack of documentation led to the deficiency.
Failure to Protect Residents from Abuse
Penalty
Summary
The deficiency involves the failure to protect residents from various forms of abuse, including physical, mental, sexual abuse, physical punishment, and neglect. This issue was identified during an uncorrected survey visit, as referenced by Event ID J4LN14. The report does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular residents or staff involved.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident punched them in the back of the head following a verbal altercation. This incident caused the affected resident's head to move forward, resulting in their face hitting a medication cart, which led to bruising and swelling on their cheekbone. The facility census at the time was 83.
Failure to Monitor Resident Leads to Prolonged Fall Incident
Penalty
Summary
The facility failed to ensure that staff adhered to professional standards of practice, resulting in a deficiency. Specifically, staff did not check on a resident for over seven hours during the night shift. This lapse in care led to the resident falling around midnight and remaining on the floor of their bedroom until staff discovered them at 6:55 A.M. Additionally, the facility did not adequately identify, assess, or implement care plan interventions related to falls for this resident. The facility's census at the time was 83.
Failure to Protect Residents from Abuse and Inadequate Placement Practices
Penalty
Summary
The facility failed to protect a resident from physical abuse and placed other vulnerable residents at risk by housing aggressive residents on a secured unit. Resident #1, who had a history of physical aggression, was placed on the secured unit after returning from a hospital evaluation. This unit housed residents with dementia, those receiving hospice care, or those requiring total care. Resident #1 engaged in an altercation with Resident #2, resulting in Resident #2 being pushed into a toilet and sustaining facial bruising. The facility's policy did not provide criteria for placement on the secured unit, and no new interventions were added to Resident #1's care plan since 06/02/22. Resident #2, who had severe cognitive impairment and required supervision, was unable to communicate effectively and wandered into other residents' rooms. The facility's self-report indicated that Resident #1 had trapped Resident #2 in a bathroom and was aggressive towards them. Staff intervened, but the incident highlighted the lack of safety measures for vulnerable residents on the secured unit. The facility's practice of placing aggressive residents on the secured unit without proper assessment or documentation further increased the risk of abuse. Interviews with staff revealed that the decision to place aggressive residents on the secured unit was made by the Administrator, who lacked psychiatric training. The facility did not have the capability to provide one-on-one care, and the secured unit was used as an intervention for aggressive behavior. The facility's Psychiatrist was unaware of this practice and expressed concerns about its effectiveness. The Director of Nursing also raised concerns about the safety of vulnerable residents on the secured unit.
Involuntary Seclusion of Residents Without Proper Assessment
Penalty
Summary
The facility failed to protect residents from involuntary seclusion, as evidenced by the placement of three residents in a secured unit without proper assessment or documentation. The facility lacked a policy or system to identify clinical criteria for placing residents in a secured or locked area, and the decision to place residents on the secured unit was made without involving the residents or their guardians. This practice was used as a response to altercations, with residents being placed on the secured unit for staff convenience or discipline rather than for clinical reasons. Resident #3, who had diagnoses of schizophrenia, bipolar disorder, and depression, was placed on the secured unit following an altercation, without any documented assessment or involvement of the resident or guardian in the decision. Similarly, Resident #4, with diagnoses of schizophrenia, anxiety, and PTSD, and Resident #5, with schizophrenia, anxiety, and a seizure disorder, were also placed on the secured unit without proper documentation or involvement of their guardians. These actions were taken despite the residents having intact cognition and no documented behavioral symptoms that would warrant such placement. Interviews with facility staff, including the Administrator and the DON, revealed that the practice of placing aggressive residents on the secured unit was a standard response to altercations, with no established criteria for placement or removal. The Administrator admitted to making these decisions without a background in psychiatric care, and the DON expressed concerns about the safety of vulnerable residents on the secured unit. A psychiatrist consulted by the facility also criticized the practice, noting that it could exacerbate aggressive behavior in residents with psychiatric diagnoses.
Inadequate Discharge Planning and Notice for Resident
Penalty
Summary
The facility failed to provide an appropriate facility-initiated discharge notice and discharge plan for a resident, who was not allowed to return to the facility after being discharged from an acute care hospital. The resident, who had a history of aggression and suicidal/homicidal ideation, was admitted with diagnoses including schizoaffective disorder, bipolar mood disorder, epilepsy, autistic disorder, and developmental disorder of scholastic skills. The resident's Pre-Admission Screening/Resident Review (PASRR) Level II Evaluation indicated that their needs could be met in a nursing facility, and they required a safe structured environment and support services. The resident exhibited violent behaviors, including tearing boards from a fence, striking a nurse, and making threats with a fire extinguisher, which led to multiple hospitalizations. Despite these incidents, the facility did not provide documentation from a physician regarding the specific needs or services they could not meet, nor did they document efforts to meet those needs or the services the receiving facility would provide. Additionally, there was no discharge plan or reassessment of the resident's status after hospital discharge, and the facility failed to notify the resident's legal guardian in a timely manner. The facility issued an emergency discharge notice to the resident and their legal guardian, citing the resident's behaviors as endangering the safety of others and the facility's inability to meet their needs. However, the notice lacked documentation of a discharge plan and efforts to find alternative placement. The resident remained in the hospital for over a month, as the legal guardian and hospital struggled to find a suitable placement, and the facility did not allow the resident to return.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility staff failed to ensure residents were free from abuse when the maintenance supervisor (MS) grabbed the arm and wrist of a resident during a behavioral episode. The resident, who had a history of mental health support needs including behavioral problems, was blocking the path of a medication cart and yelling. The MS intervened and physically restrained the resident, resulting in bruising to the resident's right upper arm. The facility did not take appropriate steps to protect the resident from additional abuse and allowed the MS to continue working around residents. The incident was reported to the Assistant Director of Nursing (ADON) the following day, who reviewed the security camera footage but did not observe the abuse. The ADON did not interview the resident or other staff members and did not assess the resident. The Administrator was informed of the incident but also believed it was not a reportable event based on the ADON's review. It was only after further review that the Administrator acknowledged the MS had grabbed the resident's arm, leading to the MS's suspension and eventual termination. The resident reported the incident to a Licensed Practical Nurse (LPN) the day after it occurred, and a picture of the bruise was taken. However, no further documentation or investigation was conducted until several days later. Multiple staff members, including a Certified Medication Technician (CMT), a Certified Nursing Assistant (CNA), and the Assistant Dietary Manager (ADM), witnessed the incident and confirmed the MS's actions. Despite this, the facility failed to immediately protect the resident and did not report the incident to the State Agency in a timely manner.
Failure to Investigate Abuse Allegation and Protect Resident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse and did not implement interventions to prevent further abuse for a resident after the Maintenance Supervisor (MS) grabbed the resident's arm and wrist in a restraining manner, resulting in a physical struggle and bruising. The incident occurred when the resident blocked the path of a medication cart and the MS intervened, leading to the physical altercation. Despite the resident reporting the incident and visible bruising being noted, the facility did not follow its abuse policy, and the MS continued to work around the resident until the investigation was properly conducted days later. The resident involved had a complex medical history, including diagnoses of PTSD, autistic disorder, borderline personality disorder, oppositional defiant disorder, disruptive mood disorder, anxiety, and ADHD. The resident's care plan indicated a potential for physical aggression and outlined specific interventions to manage agitation, which were not followed during the incident. The initial investigation by the Assistant Director of Nurses (ADON) was inadequate, as it did not include interviews with the resident or staff, nor a proper assessment of the resident's injuries. Multiple staff members witnessed the incident but did not report it immediately, and the ADON failed to recognize the severity of the situation upon reviewing the video footage. The Administrator was also misinformed about the incident's details, leading to a delay in appropriate action. The facility's failure to promptly and thoroughly investigate the abuse allegation and protect the resident from further harm resulted in a deficiency identified by the surveyors.
Failure to Provide Crisis Plan for Resident with Behavioral Health Needs
Penalty
Summary
The facility failed to provide a crisis plan for a resident with significant behavioral health needs, as directed by the Pre-Admission Screening and Resident Review (PASRR). The resident, who required supervision due to physical aggression, self-harming behaviors, and mental illness, exhibited escalating behaviors over several months. These behaviors included self-harm with various objects, ingestion of harmful substances, and attempts to elope from the facility. Despite these incidents, the facility did not implement any interventions or train staff on how to manage these behaviors effectively. The facility's assessment, dated over a year prior, was not reviewed annually and contained inaccuracies regarding the number of residents with intellectual and/or developmental disabilities. It also failed to address the behavioral healthcare needs of residents, including those with PTSD and trauma history. The facility did not have a policy on crisis intervention, and the competencies required by the facility did not include behavioral health or meeting the needs of individuals with mental illness or intellectual disabilities. Interviews with staff, including CNAs, LPNs, the Assistant Director of Nursing, and the Administrator, revealed that the facility was not equipped to provide the necessary care for the resident. Staff members were not trained to handle the resident's behaviors, and the facility could not ensure the resident's safety. The Medical Director also expressed doubts about the facility's ability to care for residents with such behaviors. The deficiency was determined to be at the immediate and serious jeopardy level, although corrective actions were implemented to address the issue at the time of the survey.
Failure to Provide Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, and did not designate a RN to serve as the Director of Nursing (DON) on a full-time basis. This deficiency was observed through a review of nursing schedules, time sheets, and direct observations, which showed that no RN was scheduled or worked for the required hours on multiple days. Specifically, there was no documentation of an RN working eight consecutive hours on 106 out of 112 days reviewed, and no DON was scheduled or worked from April 1, 2024, to April 16, 2024. The facility's policy and Facility Assessment Tool both required the presence of RNs and a full-time DON, but these requirements were not met. During an interview, the Assistant Director of Nursing (ADON) and Administrator confirmed that the facility did not have a DON since the last one worked on March 29, 2024, and was terminated on April 1, 2024. The facility had advertised for a new DON and recently hired two RNs who were in orientation, but they still needed at least one more RN to cover all required days. This deficiency had the potential to affect all 96 residents residing in the facility.
Failure to Conduct Annual Performance Reviews and In-Service Education for CNAs
Penalty
Summary
The facility failed to provide annual individual performance reviews or evaluations and regular in-service education for two certified nursing assistants (CNAs), identified as CNA G and CNA M. CNA G, hired on 03/02/23, did not receive any in-service education or an annual performance review for the period from 03/02/23 to 03/02/24. Similarly, CNA M, hired on 01/26/23, did not receive any in-service education or an annual performance review for the period from 01/26/23 to 01/26/24. The facility's policy mandates that a performance review must be completed for every nurse aide at least once every 12 months, and regular in-service education should be provided based on these reviews. However, the facility failed to adhere to this policy for the two sampled CNAs out of a facility census of 96 residents. Interviews with other CNAs and the Assistant Director of Nursing (ADON) revealed further inconsistencies in the performance review process. CNA E, who had worked at the facility for about one and a half years, mentioned that they should have received a performance evaluation but were informed that the facility was not conducting them at the moment. CNA C, who had been employed for over a year, stated they had not heard about performance evaluations and had not received one. CNA N reported receiving a performance evaluation in 02/23 but not in 02/24, despite having worked at the facility for over a year. The ADON admitted that in-service records from previous Directors of Nursing (DON) were missing or destroyed, and although in-services were conducted monthly, there was no documentation to support this. The Administrator confirmed that performance reviews for nurse aides had not yet been initiated.
Failure to Reconcile Narcotics at Shift Change
Penalty
Summary
The facility failed to ensure staff reconciled narcotics at each shift change for four out of four medication carts, potentially affecting all residents. The facility's policy required narcotics to be counted at the beginning and end of every shift by the outgoing and incoming nurses, with both signing the narcotics count record. However, the review of narcotic count logs revealed numerous missed opportunities for reconciliation across different halls and units. For instance, on A Hall, staff missed 130 out of 149 opportunities to reconcile narcotics over a period of several weeks. Similar patterns were observed in B Hall and the Secured Units, with staff missing a significant number of reconciliation opportunities, indicating a systemic issue in narcotic management and documentation. Interviews with staff members revealed inconsistencies in following the reconciliation process. One CMT mentioned that no one counted the secured unit cart with them because they often followed themselves on most days. Another CMT admitted to not waiting for nurses to finish their reports, which could last up to two hours, before counting the narcotics. The Administrator and ADON confirmed that narcotic counts should be completed at every shift change and whenever the keys to the medication cart were exchanged. Despite this, the logs and interviews indicated that these procedures were not consistently followed, leading to potential discrepancies in narcotic counts and a failure to adhere to the facility's policy.
Failure to Maintain Sanitary Conditions in Food Storage and Preparation Areas
Penalty
Summary
The facility failed to store and distribute food under sanitary conditions, as observed during multiple inspections. The kitchen had significant cleanliness issues, including food debris and oily film buildup on the floor beneath the range, grime on the commercial dishwasher, and damaged wall baseboards. Additionally, the can opener and ceiling lights had grime buildup, and there were flies present in the kitchen food prep area. The reach-in refrigerator and chest freezer were not properly maintained, with scattered debris and frost buildup, respectively. The dry food storage room also had scattered debris, undated and unlabeled food items, and flies. The dining room had grime buildup on the ice dispenser machine, an uncovered trash can, and flies around the dining tables and serving area. The facility's policies for cleaning and food storage were not followed, leading to these unsanitary conditions. During meal preparation, staff did not adhere to proper hygiene practices. An uncovered bucket with a dish cloth and gray liquid was observed on the serving area counter. Dietary aides were seen handling food without proper restraints for facial hair and using bare hands to touch ready-to-eat foods. Unwrapped desserts were left exposed in the dining area, attracting flies. Interviews with the Assistant Dietary Manager, Dietary Aide, Interim Maintenance Director, and Administrator confirmed that the facility's policies were not being followed, and there were several issues that needed to be addressed, including the presence of flies and the need for deep cleaning and maintenance. The facility's failure to maintain sanitary conditions in the kitchen, dry food storage room, and dining room, along with improper food handling practices by staff, increased the risk of cross-contamination and food-borne illness. The facility's policies for cleaning and food storage were not adequately implemented, leading to unsanitary conditions that had the potential to affect all residents. Staff shortages and lack of adherence to policies contributed to the deficiencies observed during the survey.
Failure to Update Facility Assessment Annually
Penalty
Summary
The facility failed to review and update the facility assessment at least annually, as required. The assessment, dated 02/12/23, was not updated by the due date of 02/12/24. Additionally, there was no documentation that the Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees reviewed the facility assessment. The assessment contained inaccuracies, such as the incorrect number of residents with intellectual and/or developmental disabilities and the omission of residents with behavioral healthcare needs, including those with PTSD. Furthermore, the competencies required by the facility did not include essential areas such as catheter care, falls, communication, behavioral health, or meeting the needs of individuals with mental illness or intellectual/developmental disabilities. During an interview, the Administrator and Assistant Director of Nursing (ADON) acknowledged that they expected the facility assessment to be completed and reviewed annually. They admitted to performing the assessment together in February but failed to update the date. They confirmed the presence of intellectually disabled residents, multiple residents with PTSD, and numerous residents exhibiting behaviors, indicating that the competencies listed should have been included in the assessment. This oversight highlights significant gaps in the facility's preparedness to meet the diverse needs of its residents.
Medical Director's Lack of Involvement in Facility Assessment and QAA Committee
Penalty
Summary
The facility failed to ensure the medical director worked with the clinical team to assure residents attain or maintain their highest practicable physical, mental, and psychosocial well-being. The medical director did not participate in conducting the Facility Assessment, implementing resident care policies, or attending the Quality Assessment and Assurance (QAA) Committee. The Facility Assessment was not updated as required, and there was no documentation that the QAA and Quality Assurance Performance Improvement (QAPI) committees reviewed it. The medical director's signature was absent from the QAPI meeting signature sheets for several months. The administrator confirmed that the medical director did not attend the QAA committee meetings, and the medical director stated that the new administration scheduled the QA meetings on days he could not attend. He also mentioned that he had not participated in the review of the facility's policies and procedures since at least 2020.
Failure to Notify State Agency of DON Termination
Penalty
Summary
The facility failed to provide written notice to the State agency responsible for licensing when their Director of Nursing (DON) was no longer employed. The facility's policy required a full-time DON, and the Facility Assessment Tool confirmed this requirement. The Nursing Schedule from 04/01/24 through 04/16/24 showed no documentation of a DON being scheduled or working during this period. The DON's Termination Notice indicated the last day worked was 03/29/24, with a termination date of 04/01/24. Observations confirmed that no DON was present in the facility from 04/09/24 through 04/16/24. During an interview, the Administrator admitted they had not notified the State agency about the DON's termination because they had not yet hired a replacement.
Failure to Implement QAPI Program
Penalty
Summary
The facility failed to have a Quality Assurance and Performance Improvement (QAPI) program in place with the necessary policies and protocols to identify and correct quality deficiencies. The facility's policy, dated 04/10/19, outlined the purpose and procedures for the QAPI program, including tracking adverse events, implementing action plans, and summarizing reports and findings. However, the facility did not follow this plan, as there was no documentation showing what needed to be improved or the outcomes of addressing issues. The Administrator confirmed that while there was a tracking tool for data, there was no further documentation or action taken beyond data collection. This deficiency had the potential to affect all 96 residents in the facility.
Failure to Implement QAPI Policies and Conduct PIPs
Penalty
Summary
The facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented policies and procedures for collecting and using data, and monitoring concerns across all departments. The QAPI committee did not develop and implement action plans to correct identified quality deficiencies and did not conduct at least one Performance Improvement Project (PIP) annually, focusing on a high-risk area. The facility's policy, dated 04/10/19, outlined the need for PIPs and root cause analysis (RCA) to address issues, but these were not followed. During an interview, the Administrator confirmed that no PIP had been conducted since she started in February, and there was no record of any prior PIP. Additionally, the facility had an approved waiver for not having a Registered Nurse (RN) for the required amount of time, but this waiver became null and void when the last Director of Nursing (DON) left.
Failure to Maintain Required QAA Committee Meetings
Penalty
Summary
The facility failed to maintain quarterly Quality Assessment and Assurance (QAA) committee meetings with the required members. The facility's policy indicated that the QAA committee should include the Administrator, Director of Nursing (DON), Medical Director, and other key staff members, and that meetings should be held monthly. However, review of the signature sheets for meetings from December 2023 through March 2024 showed that the Medical Director did not attend any of the meetings, the DON missed three meetings, the Administrator missed one meeting, and the Infection Preventionist (IP) missed three meetings. The Administrator confirmed that the Medical Director does not attend the meetings and that attendance is tracked solely by signature sheets, which showed significant gaps in required attendance. Additionally, there was no documentation of issues found or plans to resolve issues during these meetings. During an interview, the Medical Director confirmed that he/she had not attended a QAPI meeting since the previous year. The Administrator also acknowledged that not all required members attend every meeting and that the only record of attendance is the signature sheets. This lack of consistent attendance and documentation had the potential to affect all staff and residents in the facility, as it hindered the facility's ability to effectively identify and address quality issues.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff members, which had the potential to affect all staff and residents. The facility did not provide a training program policy, records of completed training, nor performance evaluations for required training programs, including abuse, neglect, and exploitation prevention, dementia management, QAPI, required in-service training for Nurse Aides, and Behavioral Health training. During interviews, the Assistant Director of Nursing (ADON) admitted that they could not find the in-services from the last Director of Nursing (DON), and the previous DON had destroyed paperwork when they quit. The ADON was temporarily in charge of training until a new DON could be hired. The Administrator confirmed that the facility should have documentation of all required trainings and policies in place for those programs.
Failure to Ensure Staff Training in Abuse Prevention and Dementia Management
Penalty
Summary
The facility failed to ensure all staff participated in an abuse, neglect, and exploitation prevention program and a dementia management training program, with a process in place to track attendance. This deficiency had the potential to affect all residents, with a facility census of 96. The facility could not provide records of the required training. The Assistant Director of Nursing (ADON) admitted that they could not find the in-services from the previous Director of Nursing (DON), and that the DON before that had destroyed paperwork upon quitting. The ADON, who was in charge of training until a new DON could be hired, was unaware of when the last training sessions for abuse, neglect, and exploitation prevention and dementia management had been conducted. The Administrator confirmed that the facility should have documentation of the abuse and neglect training for all staff.
Failure to Conduct Mandatory QAPI Training for Staff
Penalty
Summary
The facility failed to conduct mandatory training for all staff on the Quality Assurance and Performance Improvement (QAPI) program. The QAPI program is designed to establish data-driven processes to improve the quality of care, quality of life, and clinical outcomes for residents. The facility's policy outlined the importance of leadership accountability, tracking and monitoring adverse events, and implementing action plans to prevent recurrence. However, the facility did not provide any records of staff receiving training on the QAPI program, and interviews with staff confirmed that none had received such training. During the survey, the Assistant Director of Nursing (ADON) mentioned that the facility currently does not have a Director of Nursing (DON), and the ADON has had to assume many of the DON's duties, including responsibilities related to the QAPI program. The ADON was unable to locate any training records regarding QAPI. The Administrator also confirmed the absence of training records for all staff members on the QAPI program. This deficiency had the potential to affect all residents and staff in the facility, which had a census of 96 at the time of the survey.
Failure to Implement Effective Nurse Aide Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective nurse aide (NA) in-service training program as determined by performance reviews and the facility assessment. The facility did not provide a policy regarding NA training or performance reviews, nor did it provide any training records or performance reviews. The facility assessment, dated 02/12/23, was not reviewed annually and contained inaccuracies regarding the number of residents with intellectual or developmental disabilities and behavioral healthcare needs. Additionally, the competencies required by the facility did not include essential areas such as catheter care, falls, communication, behavioral health, or meeting the needs of individuals with mental illness or intellectual/developmental disabilities. Interviews with staff revealed that several CNAs had not received performance evaluations, with some stating they had not heard about them or had not received one in over a year. The Assistant Director of Nursing (ADON) admitted to not knowing about the documentation of the training and mentioned that previous Directors of Nursing (DON) had either lost or destroyed paperwork. The ADON is currently handling many of the DON's responsibilities due to the absence of a current DON. The Administrator confirmed that performance reviews for nurse aides had not yet been initiated.
Failure to Implement Effective Behavioral Health Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all staff, including behavioral health care and services training, as determined by staff need and the facility assessment. This deficiency affected two sampled employees hired within the last year. The facility census was 96. The facility did not provide a policy regarding behavioral health training, and the facility assessment had not been reviewed annually since 2023. Additionally, there was no documentation showing that the Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee reviewed the facility assessment. The number of residents with intellectual and/or developmental disabilities was inaccurately reported, and the behavioral healthcare needs, including trauma and PTSD, were also inaccurately documented. The competencies required by the facility did not include essential areas such as catheter care, falls, communication, behavioral health, or meeting the needs of individuals with mental illness or intellectual/developmental disabilities. Review of the medical diagnoses of the 96 residents present during the on-site survey revealed a significant number of residents with various mental health conditions, including schizophrenia, bipolar disorder, anxiety, depression, schizoaffective disorder, history of suicide attempts or suicidal ideations, personality disorder, PTSD, and psychosis. Despite this, there was no documentation of behavioral health training for two Certified Nurse Aides (CNAs) hired within the last year. During interviews, the Assistant Director of Nursing (ADON) admitted that they could not find the in-services from the previous Directors of Nursing (DON) and that the specific training for behavioral residents was unknown. The Administrator acknowledged the need for behavioral health training in the facility.
Failure to Protect Resident Privacy During Showers
Penalty
Summary
The facility failed to protect residents' right to privacy by not ensuring other residents did not enter the shower room during showers. This deficiency affected three sampled residents and five additional residents. Observations showed that the shower room had a toilet with a curtain and a shower with a curtain, but residents frequently entered the shower room without knocking, even when another resident was showering. This lack of privacy was confirmed through multiple resident interviews, where residents expressed discomfort and concern about others entering the shower room and using the toilet while they were showering. Certified Nurse Assistants (CNAs) also reported that despite their efforts to stop other residents from entering, many residents would still walk in to use the toilet. During interviews, residents consistently reported that their privacy was compromised during showers, with others entering the shower room without knocking and using the toilet. The Assistant Director of Nursing (ADON) and the Administrator were unaware of these privacy concerns until the survey. The facility did not provide a policy regarding the protection of privacy during bathing, indicating a systemic issue in ensuring residents' privacy rights were upheld during personal care activities.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for its residents. Observations revealed a strong, unidentifiable musty odor in A and B Halls, grime and debris beneath beds in multiple rooms, excessive dust buildup on a fan, missing light fixture covers, and damaged surfaces on doors and furniture. Specific rooms had missing drawer fronts on wooden clothing cabinets, and the men's shower rooms had significant damage, including a hole in the wall and separated caulking. Interviews with residents and staff indicated that cleaning was not consistently performed under beds, and maintenance issues were not adequately reported or addressed. The facility lacked a maintenance policy and had no maintenance requests logged after a certain date, contributing to the ongoing issues with cleanliness and repair. Additionally, there were reports of mice and roaches, exacerbated by unclean conditions and residents storing food in drawers. The housekeeping supervisor and other staff acknowledged the problems but indicated that the process for reporting and addressing maintenance issues was not effectively managed. The facility's failure to maintain a clean and safe environment was further evidenced by observations of the dining room and nurses' office, which had missing cabinet doors, drawer fronts, and baseboards, as well as a black substance below a window. Interviews with the Interim Maintenance Director and other staff revealed that maintenance requests were supposed to be submitted via forms, but there was no logbook available, and the past Maintenance Director had managed these tasks. The Administrator confirmed that maintenance issues should be reported using request forms and addressed by the Interim Maintenance Director, but acknowledged that better cleaning methods were needed and that the building and furniture should be kept in good repair.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement individualized comprehensive care plans with specific interventions for several residents. For instance, Resident #3, who was admitted with diagnoses of cerebral palsy and dementia, had severe cognitive impairment and was dependent for bed mobility. Despite observations showing the use of bed rails, the resident's care plan did not address this intervention. Similarly, Resident #13, who had a stroke and severe cognitive impairment, was observed with bed rails in use, but this was not reflected in the care plan either. Resident #20, diagnosed with Huntington's Disease and severe cognitive impairment, was observed using bed rails, but the care plan only mentioned the use of a bed rail for positioning and safety without additional interventions. Resident #57, with multiple mental health diagnoses including PTSD, had a care plan that did not address the identification of triggers or specific interventions related to PTSD. Resident #59, who had multiple diagnoses including PTSD and used tobacco, had no smoking assessment completed and the care plan did not address tobacco use, fall risks, or PTSD triggers. Resident #61, who used tobacco and had balance problems, was observed smoking without a protective apron, and the care plan did not address smoking safety or specific interventions. Lastly, Resident #68, with severe cognitive impairment and multiple diagnoses, had a care plan that did not address activities of daily living (ADLs) or incontinence of bowel and bladder. Interviews with the Administrator and Assistant Director of Nursing confirmed that these aspects should have been included in the care plans.
Failure to Follow Physician's Orders and Ensure Medical Appointments
Penalty
Summary
The facility failed to follow physician's orders for six residents, leading to missed medication administrations and a missed medical appointment. Resident #37, diagnosed with multiple mental health disorders, did not receive their scheduled Invega Sustenna injection on the due date of 04/16/24. Similarly, Resident #40, with similar diagnoses, missed their Invega Sustenna injection on 04/11/24. Resident #43, who has severe intellectual disability and other mental health conditions, did not receive their medroxyprogesterone injection on 04/13/24 because it was not available in the facility. Resident #50, diagnosed with schizoaffective disorder and other behavioral conditions, did not receive their Haldol Decanoate injection on 04/15/24 as it was not in the facility. Resident #91, with multiple mental health diagnoses, continued to receive incorrect dosages of Effexor and prazosin for 40 days due to a failure to update medication orders following discharge instructions from a behavioral health hospitalization. The facility staff did not clarify or follow the most current medication orders. Resident #89, diagnosed with COPD, missed a cardiologist appointment scheduled for 04/15/24 due to a failure in securing a confirmation number from Medicaid transport. The transportation scheduler did not receive a confirmation number, resulting in the resident not being picked up for the appointment. The facility staff acknowledged the error but did not ensure the resident was transported to the necessary medical appointment.
Failure to Ensure Complete Hospice Coordinated Plan of Care
Penalty
Summary
The facility failed to ensure that four residents receiving hospice services had a complete hospice coordinated plan of care. Specifically, the medical records for Residents #3, #13, and #20 showed no facility staff signatures for the coordinated plan of care. Additionally, Resident #37 had no hospice care documentation at all, despite being admitted to hospice services. The facility's hospice binder lacked essential documentation, including hospice orders, the name of the hospice nurse, specific days of hospice nurse and aide visits, medical supplies, and durable medical equipment provided by hospice. During interviews, the Assistant Director of Nursing (ADON) and the Administrator confirmed the absence of a coordinated plan of care signed by both hospice and facility staff. The ADON mentioned being informed about another hospice binder by the hospice company but was unable to locate it. The Administrator acknowledged that the ADON had searched for any hospice information for Resident #37 but found nothing in the building. The facility census was 96 at the time of the survey.
Failure to Ensure Smoking Safety for Residents
Penalty
Summary
The facility failed to ensure the environment remained free of accident hazards by not appropriately assessing four residents who were identified as smokers to ensure they were able to smoke safely. Resident #13, who had a stroke affecting the left non-dominant side and hemiplegia, had not been assessed for smoking safety since 10/10/22. Despite being identified as unable to light, hold, or extinguish a cigarette safely, the resident was observed smoking without a smoking apron, resulting in ashes falling on their clothing and wheelchair. Staff were unaware of the need for a smoking apron, and it was not offered or encouraged to the resident. Resident #59, diagnosed with encephalopathy, PTSD, autistic disorder, and other conditions, had no documentation of a smoking assessment. The resident was observed smoking with significant ash accumulation on their clothing and wheelchair, and although a smoking apron was available, it was inconsistently used. Staff failed to provide the smoking apron even when it was needed, and the resident's care plan did not address smoking safety or supervision. Resident #61, with diagnoses including diabetes mellitus, CHF, and psychotic disorder, had not been assessed for smoking safety since 02/20/23. The resident was observed smoking without a smoking apron, resulting in ashes and burn holes on their clothing. The resident's care plan did not address smoking safety or supervision. Similarly, Resident #89, diagnosed with schizoaffective disorder, PTSD, and COPD, had not been assessed for smoking safety since 08/24/23. The resident was observed smoking without a smoking apron, and their care plan did not address smoking safety. Staff interviews revealed a lack of awareness and adherence to the facility's smoking policy and assessment requirements.
Failure to Address PTSD in Residents
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for seven residents diagnosed with PTSD. These residents included individuals with complex mental health conditions such as major depressive disorder, schizoaffective disorder, anxiety disorder, and bipolar disorder. Despite their diagnoses, there was no documentation of PTSD assessments or care plans addressing their past trauma or triggers that could cause behaviors. For instance, Resident #33 had multiple mental health diagnoses and medications prescribed but lacked a PTSD assessment and care plan addressing their triggers and interventions. Similarly, Resident #38, who had schizoaffective disorder and PTSD, also had no PTSD assessment or care plan addressing their triggers and interventions. The report highlights that the facility's failure extended to other residents, such as Resident #57, who had a history of physical and sexual abuse and exhibited behaviors like verbal threats and suspicion of others. Despite these indicators, there was no PTSD assessment or care plan addressing their trauma and triggers. Resident #59, diagnosed with PTSD and other mental health conditions, also lacked a PTSD assessment and care plan. The same pattern was observed with Resident #78, who had PTSD and homicidal ideations, and Resident #89, who had PTSD and insomnia. Both residents had no PTSD assessments or care plans addressing their triggers and interventions. The facility's staff, including the Social Service Designee, Medical Records Director, LPN, MDS Coordinator, and Administrator, acknowledged the lack of PTSD assessments and care plans. They confirmed that residents with PTSD should have assessments upon admission and individualized care plans addressing their triggers and interventions. The absence of a PTSD policy and proper documentation of PTSD-related concerns in care plans was a significant oversight, leading to inadequate care for residents with PTSD. The facility's census was 96 at the time of the survey, indicating a broader issue affecting multiple residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices during colostomy and suprapubic catheter care for a resident. Staff members did not perform hand hygiene upon entering the room, between glove changes, or after removing gloves. Additionally, the catheter bag was placed on the resident's abdomen, allowing urine to flow back towards the bladder, and fecal material was cleansed towards the suprapubic catheter site instead of away from it. These actions were observed during the care of a resident who was lying in bed and later transferred to a wheelchair by a hoyer lift. The facility also failed to maintain proper infection control practices during blood sugar checks and insulin administration for three residents. Staff members did not perform hand hygiene before or after putting on gloves, and used lancets were improperly disposed of in regular trash containers instead of sharps containers. These deficiencies were observed during blood sugar checks and insulin administration for three residents, with staff members failing to follow proper procedures for hand hygiene and disposal of used medical equipment. Interviews with staff members, including the Assistant Director of Nursing and the Administrator, confirmed that hand hygiene should be performed between glove changes and when moving from dirty to clean care. They also confirmed that catheter bags should remain below the bladder, and lancets should be disposed of in biohazard containers. Despite these policies, the observed practices did not align with the facility's infection control protocols, leading to the identified deficiencies.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program to control the insect population, specifically flies, within the facility. Observations over several days revealed the presence of flies in critical areas such as the kitchen food prep area, dry food storage room, dining room, a resident's room, and the nurses' office. The facility's pest control invoices for the year 2024 did not include services targeting flies, which contributed to the ongoing issue. Interviews with staff, including the Assistant Dietary Manager, Licensed Practical Nurse, Interim Maintenance Director, and the Administrator, confirmed the presence of flies and acknowledged that the problem had worsened recently, particularly with the warming weather. The staff reported that despite contacting corporate and pest control services, the issue persisted, indicating a lack of effective measures to address the fly infestation. The resident in room A17 reported difficulty sleeping due to the presence of flies, highlighting the impact on residents' well-being. The Assistant Dietary Manager and LPN noted that flies were a common issue in their respective areas, and the Interim Maintenance Director admitted that the insect problem had escalated with the change in weather. The Administrator acknowledged the deficiency and mentioned ongoing efforts to find solutions, such as spraying outside windows and doors. However, the lack of a specific policy on pest control and the absence of targeted measures for flies in the pest control invoices indicate a significant gap in the facility's pest management program.
Failure to Provide Appropriate Assistive Device
Penalty
Summary
The facility failed to evaluate and provide an appropriate assistive device for a resident who had a stroke affecting the left non-dominant side and hemiplegia. The resident required substantial to maximal assistance for all activities of daily living and used a wheelchair. Observations over several days showed the resident sitting in a wheelchair with a thick concave pad on the left armrest, which raised the resident's left shoulder to an uncomfortable height. The resident reported discomfort and pain due to this positioning. Interviews with staff revealed that the wheelchair was provided by hospice, and facility staff were not able to modify it. The Assistant Director of Nursing and Restorative Aide acknowledged the issue but indicated uncertainty about whether the facility would provide a different wheelchair if hospice could not. The Medical Director stated that the resident should have a chair that suited and protected them. Despite these acknowledgments, the facility did not provide a policy regarding assistive devices, and the resident continued to experience discomfort.
Inconsistent Documentation of Code Status for Two Residents
Penalty
Summary
The facility failed to consistently document the code status for two residents out of a sample of 20. For Resident #37, the medical record showed conflicting information: the facesheet and Physician's Order Sheet (POS) indicated a full code status, while a Do Not Resuscitate (DNR) form was signed by the resident, responsible party, and physician. Resident #37 had recently been admitted to hospice, which contributed to the inconsistency. For Resident #89, the care plan indicated a DNR status, while the POS showed a full code status. The resident expressed a preference for a full code status, and a green tag indicating full code was placed on the door, despite the initial request for a DNR status. Interviews with staff revealed that the facility used colored dots to indicate code status, with green for full code and red for DNR. The Assistant Director of Nursing (ADON) and the Minimum Data Set (MDS) Coordinator both acknowledged that the code status should be documented consistently throughout the medical record and that the indicator dot should match the chart. The facility did not have a Director of Nursing (DON) at the time, and the MDS Coordinator admitted to missing the inconsistency in Resident #37's care plan. The Administrator also confirmed that the code status should be consistently documented and matched with the indicator dot.
Failure to Issue SNF ABN and Obtain Signed NOMNC
Penalty
Summary
The facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and did not have the resident's Notice of Medicare Non-Coverage (NOMNC) signed by the resident representative for one resident out of three sampled residents who remained in the facility when benefits were not exhausted. Specifically, Resident #33 was discharged from skilled services with skilled Medicare days remaining and continued to stay in the facility. The resident's representative provided verbal consent but did not sign the NOMNC. The facility also did not provide a SNF ABN to the resident or the representative. Interviews with the Social Services Designee (SSD), Minimum Data Set (MDS) Coordinator, and the Administrator revealed that staff changes and confusion led to the forms not being completed and signed appropriately. The facility's census was 96 at the time of the survey.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to notify the state survey agency regarding an allegation of staff-to-resident abuse when a staff member grabbed a resident by the arm and wrist, resulting in a bruise. The incident involved a resident with multiple diagnoses, including PTSD, autistic disorder, and borderline personality disorder. The resident reported the incident to an LPN, who took a picture of the bruise and notified the ADON. However, the ADON did not conduct a thorough investigation, as she did not interview the staff or resident, nor did she complete a skin assessment. The ADON also failed to report the incident to the state agency, despite receiving a text containing a picture of the bruise from the LPN. The Administrator was informed of the incident but did not view the video footage herself and relied on the ADON's assessment that the incident was not reportable. The facility's policy mandates that all alleged violations involving abuse must be reported immediately, but not later than 2 hours after the allegation is made. In this case, the ADON and Administrator did not adhere to this policy. The ADON's investigation was incomplete, and the Administrator did not ensure that the incident was reported to the state agency. The failure to report the incident and conduct a thorough investigation led to a deficiency in the facility's handling of abuse allegations, compromising the resident's safety and well-being.
Failure to Notify Residents and Representatives Before Hospital Transfers
Penalty
Summary
The facility failed to notify the resident, the resident's representative, and the Missouri State Long-Term Care Ombudsman in writing before transferring three residents to the hospital. Resident #78 was transferred to the hospital for medical evaluation and readmitted to the facility without any documentation of written notifications to the resident or their representative. Similarly, Resident #91 was transferred to the hospital and readmitted without any written notifications to the resident, their representative, or the Ombudsman. Resident #97 experienced multiple transfers to the hospital, with no documentation of written notifications to the resident, their representative, or the Ombudsman for several of these transfers. Interviews with facility staff revealed inconsistencies and confusion regarding the responsibility for completing and following up on transfer/discharge notifications. The Social Service Designee (SSD) indicated that nurses were supposed to fill out the transfer/discharge forms and fax them to guardians, but there was no follow-up to ensure they were mailed. The Minimum Data Set (MDS) Coordinator mentioned that the Director of Nursing (DON) used to handle follow-ups, but the facility no longer had a DON. Licensed Practical Nurse (LPN) A confirmed that nurses completed the forms and faxed them to guardians, with the SSD responsible for follow-up. The Administrator expected transfer/discharge forms to be issued and signed when residents were transferred to the hospital, but this was not consistently done.
Failure to Provide Written Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of their bed-hold policy to residents and/or their representatives at the time of transfer for three residents. Resident #78 was transferred to the hospital on 01/13/24 and readmitted on a later date, but there was no written documentation of the bed-hold policy notification. Similarly, Resident #91 was transferred to the hospital on 03/01/24 and readmitted later without any written notification of the bed-hold policy. Resident #97 experienced multiple transfers to the hospital on 01/30/24, 03/01/24, and 03/07/24, but no documentation of the bed-hold policy notification was provided for any of these transfers. The facility census was 96 at the time of the survey, and the deficiency was identified in three out of seven sampled residents' records reviewed by the surveyors. Interviews with facility staff revealed a lack of clarity and consistency in the process of issuing bed-hold notifications. The Social Service Designee (SSD) mentioned that nurses were responsible for filling out the bed-hold paperwork and faxing it to guardians, but the SSD did not follow up on these notifications. The Minimum Data Set (MDS) Coordinator indicated that the Director of Nursing (DON) previously handled bed-hold follow-ups, but the facility no longer had a DON. The MDS Coordinator attempted to email the paperwork to guardians. Licensed Practical Nurse (LPN) A confirmed that nurses were responsible for the transfer/discharge and bed-hold notices. The Administrator expected the bed-hold notification to be issued and signed when a resident was transferred to the hospital, but this expectation was not met in the cases reviewed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 17 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Belleview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Baptist Homes Of Arcadia Valley | 12.4 mi | — | 0 | 0 |
| Potosi Manor | 14.4 mi | ★★★★★ | 0 | 0 |
| Gardens Health And Rehab, The | 15 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Desloge | 16.8 mi | ★★★★★ | 0 | 0 |
| Country Meadows | 18.1 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.