Belleview Valley Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Belleview, Missouri.
- Location
- 23144 Highway 32, Belleview, Missouri 63623
- CMS Provider Number
- 265258
- Inspections on file
- 27
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Belleview Valley Nursing Home during CMS and state inspections, most recent first.
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.
The facility failed to ensure that a resident with severe cognitive impairment received adequate assistance with ADLs, specifically showers and shaving. Despite being scheduled for showers twice a week, the resident missed multiple scheduled showers and shaves over several months. Observations and staff interviews confirmed lapses in the resident's personal hygiene and overall care.
The facility failed to provide timely and proper care for a resident with a suprapubic catheter, including not changing the catheter on time, improper catheter care, and not maintaining hygiene practices. The resident, who has multiple sclerosis, also experienced issues with a leaking colostomy that soaked the catheter dressing. The facility did not follow its urinary catheter care policy, and the Assistant Director of Nursing and the Administrator were unaware of the missed catheter change.
The facility failed to assess the use of bed rails, review risks and benefits with residents or their representatives, and obtain informed consent for three residents. Observations showed residents with bed rails in the raised position despite documentation indicating they were not required. Care plans did not address bed rail use, and staff were unaware of the presence of bed rails.
The facility failed to provide necessary behavioral health care and services to a resident with multiple mental health conditions, resulting in numerous incidents of self-harm and aggression. The facility lacked a crisis plan, specific interventions, and adequately trained staff to manage the resident's needs.
The facility failed to limit PRN orders for psychotropic medications to 14 days for three residents and did not ensure one resident was free from unnecessary antipsychotic medication. Additionally, one resident had no documented appropriate diagnosis for a quetiapine dose and no attempts for a gradual dose reduction for several medications. Interviews with the ADON and Administrator confirmed these deficiencies.
The facility staff failed to conduct regular inspections of bed frames, mattresses, and side rails for three residents, leading to potential safety hazards. Observations showed residents with raised bed rails and no documented maintenance assessments. Interviews revealed a lack of awareness and documentation regarding bed rail inspections.
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.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to ensure that Resident #68 received adequate assistance with activities of daily living (ADLs), specifically showers and shaving. The resident, who has severe cognitive impairment and multiple diagnoses including Alzheimer's disease, Parkinson's disease, and major depressive disorder, was documented to require substantial to maximal assistance for various ADLs. Despite being scheduled for showers twice a week, the resident missed multiple scheduled showers and shaves over a period of several months. Observations confirmed that the resident often had unshaven facial hair and disheveled hair, indicating a lack of proper grooming and hygiene care. Interviews with staff, including a CNA, the MDS Coordinator, the Administrator, and the Assistant Director of Nursing, revealed inconsistencies in the understanding and implementation of the resident's shower and shaving schedule. The facility did not provide a policy regarding ADLs or showers, further contributing to the deficiency. The resident's care plan did not address ADLs, and the shower schedule was not consistently followed, leading to significant lapses in the resident's personal hygiene and overall care.
Failure to Provide Timely and Proper Suprapubic Catheter Care
Penalty
Summary
The facility failed to ensure timely and proper care for a resident with a suprapubic catheter. The resident's catheter was not changed on the first day of the month as ordered by the physician, and there was no documentation of catheter care on several occasions. The catheter was eventually changed 11 days late. Additionally, the facility did not provide a suprapubic catheter policy, and the urinary drainage bag was observed touching the floor and not covered with a dignity bag. The resident reported that staff did not change the catheter on time due to a lack of supplies, although a 22 French catheter was found in the supply closet during a later inspection. The Assistant Director of Nursing and the Administrator were unaware of the missed catheter change and stated that any soiled dressing should be replaced immediately and the area cleansed, which was not done in this case. The resident, who has multiple sclerosis, also experienced issues with a leaking colostomy that soaked the suprapubic catheter dressing. During care, staff did not cleanse the catheter properly or apply a new dressing. The facility's policy on urinary catheter care was not followed, as staff failed to perform catheter and perineal care after each bowel movement and did not maintain proper hygiene practices. The facility census was 96 at the time of the survey.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to appropriately assess the use of bed rails, review the risks and benefits with the resident or resident representative, and obtain informed consent prior to using bed rails for three residents. Resident #3, who had severe cognitive impairment and was dependent for bed mobility, was observed with bed rails in the raised position despite documentation indicating bed rails were not required. The resident's care plan did not address the use of bed rails, and there was no informed consent on file explaining the risks and benefits of bed rail use. Resident #13, who had severe cognitive impairment and required substantial assistance for all activities of daily living, was found with bed rails in the raised position. The resident's medical record showed no documentation of informed consent, and the care plan did not address the use of bed rails. Additionally, the resident was found with their arm stuck between the bed and the bed rail, indicating a failure to assess and mitigate safety risks associated with bed rail use. Resident #20, diagnosed with Huntington's disease and severely cognitively impaired, was observed with both upper bed rails in the raised position. The resident's medical record indicated the use of bed rails for positioning and safety, but there was no informed consent on file. The resident's care plan lacked documentation of additional interventions, and the resident was observed with their foot caught between the bed rail bars, requiring assistance from a CNA to remove it. Interviews with facility staff revealed a lack of awareness regarding the presence and use of bed rails for these residents.
Failure to Provide Adequate Behavioral Health Care
Penalty
Summary
The facility failed to provide the necessary behavioral health care and services to a resident diagnosed with multiple mental health conditions, including PTSD, borderline personality disorder, and oppositional defiant disorder. The resident exhibited a range of behaviors such as self-harm, aggression, and suicidal ideation. Despite these behaviors, the facility did not have a policy regarding behaviors and failed to implement a crisis plan, Individual Support Plan (ISP), Individualized Treatment Plan (ITP), or Behavioral Support Plan (BSP) as required by the resident's Preadmission Screening and Resident Review (PASRR). The resident's care plan was also inadequate, lacking specific triggers to avoid and interventions for suicidal ideations, elopements, or self-harm behaviors. The resident's medical record showed multiple incidents of self-harm and aggressive behavior from January to April, including cutting themselves with various objects, throwing furniture, and attempting to elope from the facility. Despite these incidents, the facility did not provide the necessary supervision or interventions to prevent harm to the resident or others. The staff was not adequately trained to handle the resident's behavioral needs, and the facility did not have the resources to provide one-to-one care. Interviews with the Assistant Director of Nursing (ADON), Administrator, and Medical Director revealed that the facility staff felt they could not adequately care for the resident. The ADON admitted to not knowing the specifics of the training provided for behavioral residents, and the Administrator acknowledged the lack of staff to provide the necessary care. The Medical Director also expressed doubts about the facility's ability to manage residents with such complex behavioral needs.
Failure to Limit PRN Psychotropic Medication Use and Ensure Appropriate Diagnoses
Penalty
Summary
The facility failed to limit the use of PRN orders for psychotropic medications to 14 days for three residents and did not ensure one resident was free from unnecessary antipsychotic medication. Specifically, Resident #38 had an order for Haldol without a 14-day stop date. Resident #59 had an order for lorazepam without a 14-day stop date. Resident #92 had orders for lorazepam and Risperdal without 14-day stop dates and was administered an olanzapine injection without attempting PRN medications first. Additionally, Resident #51 had no documented appropriate diagnosis for a quetiapine dose and no attempts for a gradual dose reduction (GDR) for several medications. Resident #38 had multiple diagnoses, including schizoaffective disorder, dementia, major depressive disorder, and obsessive-compulsive personality disorder. The resident had an order for Haldol IM for agitation without a 14-day stop date. Resident #59, diagnosed with encephalopathy, PTSD, autistic disorder, anxiety, and schizoaffective disorder, had an order for lorazepam PRN for anxiety without a 14-day stop date. Resident #92, with diagnoses including alcohol dependence with alcohol-induced dementia, dementia with behavioral disturbance, insomnia, and anxiety, had PRN orders for lorazepam and Risperdal without 14-day stop dates and was given an olanzapine injection for aggression without prior use of PRN medications. Resident #51, admitted with diagnoses of anxiety disorder, major depressive disorder, and bipolar disorder, had multiple psychotropic medication orders, including nortriptyline, duloxetine, and quetiapine. There was no documentation of an appropriate diagnosis for a quetiapine dose and no attempts for GDR for the medications. The facility did not provide policies for the limited use of PRN medications, unnecessary antipsychotic medication use, appropriate diagnosis, use of psychotropic medication, and GDRs. Interviews with the ADON and Administrator confirmed the deficiencies in medication management and the lack of adherence to regulatory requirements.
Failure to Conduct Regular Bed Safety Inspections
Penalty
Summary
The facility staff failed to conduct regular inspections of bed frames, mattresses, and side rails for three residents, leading to potential safety hazards. Resident #3 was observed multiple times lying in a low bed with raised bed rails, but there was no documentation of a maintenance assessment for the side rails. Similarly, Resident #13 was observed with raised bed rails on both sides of the bed, but again, no maintenance assessment was documented. Resident #20 was found with their foot trapped between the bars of the raised bed rail, requiring assistance from a CNA to remove it, and there was no documentation of a maintenance assessment for the side rails. During interviews, the MDS Coordinator was unaware of the presence of side rails and mentioned that hospice might have brought new beds. The Administrator confirmed that no assessments or inspections had been completed on the bed rails and that there was no documentation available. This lack of regular maintenance and inspection poses a significant risk to the residents, especially those who are frail, confused, or have uncontrolled body movements.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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