Bentleys Extended Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Overland, Missouri.
- Location
- 3060 Ashby Road, Overland, Missouri 63114
- CMS Provider Number
- 265732
- Inspections on file
- 22
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Bentleys Extended Care during CMS and state inspections, most recent first.
Three residents with cognitive impairment and a history of falls experienced multiple incidents without thorough investigation or consistent implementation of fall prevention interventions. Care plans were not updated to reflect current physician orders, such as the use of soft helmets or floor mats, and staff were often unaware of required interventions due to outdated communication systems. Documentation of falls and follow-up actions was incomplete, and there was no effective process to ensure that new or modified interventions were put in place after each fall.
A resident with multiple medical conditions experienced a broken front tooth and reported pain and difficulty eating, but did not receive timely dental care. After an unsuccessful dental appointment due to transfer issues, no alternative arrangements were made, and the resident later developed a dental abscess treated only with antibiotics. Staff interviews revealed a lack of follow-up and communication, resulting in the resident waiting over a year without appropriate dental intervention.
A resident with Alzheimer's disease and severe cognitive impairment was subjected to alleged physical abuse by a CNA, who was observed yelling and holding the resident against the wall. Despite the incident being reported to the DON, the CNA was not immediately suspended and continued to provide care for several hours. Staff interviews revealed confusion about abuse reporting procedures, lack of timely investigation, and insufficient training on abuse prevention policies.
Staff failed to follow required two-person protocols during Hoyer lift transfers, resulting in a resident being struck in the face and later falling from bed due to missing fall mats, both causing injuries. In addition, staff did not perform required neurological assessments after head injuries, and new aides conducted unsafe transfers without proper training, leading to repeated hazards for a dependent resident with dementia and a history of falls.
A resident with severe cognitive impairment was involved in an incident where a CNA was observed physically restraining the resident and yelling. An RN reported the event to the DON, but the DON did not notify the state agency within the required two-hour timeframe, citing a need for more information and lack of awareness of the policy. Other leadership staff were not informed until hours later, resulting in a failure to promptly report the abuse allegation as required.
The facility did not submit complete and accurate direct care staffing information to CMS for three consecutive fiscal quarters. The Assistant Administrator admitted responsibility for the oversight, acknowledging awareness of the requirement but failing to act. The facility had a census of 47.
The facility failed to maintain resident dignity by allowing staff to use cell phones during care, contrary to policy. Observations showed staff texting while feeding residents and not providing necessary assistance, such as replacing dropped utensils. Residents reported feeling uncomfortable due to staff phone use during care.
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical, physical, and psychosocial needs. One resident's care plan lacked interventions for weight loss and catheter use, another's did not reflect falls and cognitive decline, and a third's did not address dietary needs and preferences.
The facility failed to provide adequate supervision and assistance to prevent accidents, as observed with residents being propelled in wheelchairs without leg rests, leading to discomfort and potential injury. Staff did not consistently use gait belts during transfers, posing a risk of injury. Additionally, a resident with a history of falls was not properly repositioned in their wheelchair, despite being observed leaning and slouched.
The facility did not maintain the required RN coverage for at least eight consecutive hours a day, seven days a week, as per their staffing policy. Staffing sheets showed multiple days without RN coverage, and the ADON acknowledged the difficulty in securing RNs despite posting requests. The Assistant Administrator expected RN staffing to be covered as required.
The facility failed to maintain accurate records for controlled drugs, with numerous shifts lacking the required dual nurse initials on narcotic count sheets. This non-compliance was observed on multiple medication carts, potentially affecting all residents with controlled substance orders. Staff interviews confirmed the expectation for two staff members to sign off on narcotic counts every shift.
The facility failed to maintain proper storage conditions for medications in the medication room refrigerator, as there was no system or temperature log in place. Medications were stored alongside food items, contrary to facility policy. Staff, including a CMT and an LPN, were unaware of the requirements for temperature monitoring and separate storage of medications and food.
Staff at the facility failed to perform proper hand hygiene during meal service, affecting 15 residents. Observations showed that staff, including an LPN and NAs, did not wash hands or use sanitizer before or after assisting residents with meals, contrary to the facility's policy. Interviews confirmed that staff were expected to follow hand hygiene protocols, but observations indicated non-compliance.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with urinary catheters and wounds, as staff did not wear gowns during high-contact care activities. Additionally, infection control standards were not followed during wound care, with an LPN using ungloved hands and uncleaned equipment. The facility also neglected to conduct required TB testing for several residents, as per its policy.
The facility did not offer or administer the pneumococcal vaccine to four residents, despite having a policy requiring assessment and vaccination within thirty days of admission. The ADON confirmed the expectation to offer the vaccine and document refusals, but records showed no documentation of screening or vaccination for residents with conditions like stroke, diabetes, and sepsis.
The facility failed to offer COVID-19 vaccines to four residents, despite having a policy requiring vaccination offers to all eligible individuals. The ADON, responsible for overseeing vaccination documentation, did not ensure that Residents #11, #38, #22, and #14 were screened or vaccinated, as their medical records lacked such documentation. This indicates a lapse in following the facility's vaccination policy.
The facility failed to ensure CNAs received the required 12 hours of annual education, with no training records available for sampled CNAs and CMTs. Interviews revealed a lack of formal tracking or documentation of in-service training, and the ADON admitted to not maintaining a system for tracking these trainings.
A facility failed to promptly notify a physician of a resident's abnormal lab results indicating a UTI, resulting in delayed antibiotic treatment. The resident and their representative were not informed about the UTI diagnosis or new medication orders. Interviews with staff revealed inadequate processes for handling lab results, especially on weekends, and a lack of documentation in the resident's EMR.
The facility failed to provide written notices of transfer/discharge to two residents transferred to the hospital for acute medical reasons, as required by their policy. Interviews with staff, including an LPN and the ADON, confirmed that while other paperwork is sent with residents, the practice of sending transfer/discharge notices had lapsed. The ADON and Assistant Administrator acknowledged the lack of documentation for these notices.
The facility failed to provide written bed hold policy notices to two residents transferred to the hospital, as required by its policy. Interviews with staff revealed that the practice of sending these notices had lapsed, despite expectations from the ADON and Assistant Administrator that they should be provided.
A resident in an LTC facility experienced significant unplanned weight loss and had unhealed pressure ulcers that were not accurately documented in their MDS assessment. The ADON misinterpreted the weight loss question and failed to record the pressure ulcers, focusing instead on the resident's bullous pemphigoid wounds. This resulted in an inaccurate assessment of the resident's health status.
The facility failed to maintain comprehensive care plans for four residents, despite changes in their care needs. Diagnosed with various conditions, these residents did not have updated care plans in the EMR, contrary to facility policy. Staff interviews revealed reliance on verbal instructions due to missing care plans, with the ADON citing an error in care plan creation.
The facility failed to ensure that all CPR-certified staff received training with hands-on practice and in-person skills assessment. Three staff members, including an RN and the ADON, obtained their CPR certification through an online provider, which does not meet regulatory requirements. The facility's policy lacked guidance on this issue, and staffing records showed these staff were often the only CPR-certified personnel scheduled. Interviews revealed a lack of awareness about the specific requirements for CPR certification.
A facility failed to provide proper care by not assessing the appropriate wheelchair size for a resident, resulting in skin irritation and indentations. The resident, with multiple health conditions, was left in the wheelchair for six hours without repositioning, despite complaints of pain. Additionally, another resident's dressing was not dated, leading to uncertainty about when it was applied. These actions reflect a failure to meet acceptable standards of practice in resident care.
Two residents in the facility experienced inadequate foot care, resulting in long nails and dry skin. One resident, with diabetes, had not seen a podiatrist in eight months, while another resident with severe cognitive impairment had refused podiatry care. Staff interviews revealed inconsistencies in documenting and addressing foot care needs, with both CNAs and LPNs responsible for this aspect of care.
The facility failed to follow physician orders for continuous oxygen usage for a resident with respiratory issues, as the resident was observed not wearing the nasal cannula despite the order. Additionally, the facility did not ensure proper storage of oxygen masks and routine changing of oxygen tubing for infection control, as observed with another resident receiving nebulizer treatments. Staff interviews confirmed expectations for monitoring and storage were not met.
The facility did not ensure that NAs employed for over four months were certified, affecting five NAs. Despite being enrolled in a 16-hour online course, delays in testing and lack of oversight by the ADON contributed to the issue. Some NAs faced challenges in finding testing sites, prolonging the certification process.
A resident was prescribed Haldol without proper documentation to support its clinical need, leading to an increase in falls and continued behavioral issues. The facility failed to monitor for adverse effects or medication effectiveness, and did not document the resident's ongoing obsession with dying. Staff interviews revealed a lack of behavior charting and follow-up with the psychiatrist, highlighting deficiencies in medication management and resident care.
The facility failed to maintain RN coverage for eight consecutive hours per day, seven days a week, and did not have a full-time Director of Nursing (DON). The ADON, an LPN, assumed DON responsibilities and consulted with a DON from a sister facility. Despite efforts to recruit, the facility did not meet regulatory requirements for RN coverage, as confirmed by staff interviews and record reviews.
Failure to Investigate Falls and Update Care Plans for Fall Prevention
Penalty
Summary
The facility failed to thoroughly investigate and evaluate each resident fall to determine the cause and did not implement new or modify existing interventions to prevent future falls or reduce the risk of injury. Additionally, the care plans for residents with a history of falls were not updated to reflect current fall interventions, and there was no effective system in place to communicate these interventions to staff. These deficiencies were identified in three residents with a history of falls, all of whom experienced multiple incidents without adequate follow-up or documentation of interventions. One resident with severe cognitive impairment and a history of dementia experienced several falls, some resulting in injuries such as lacerations and hematomas. Despite physician orders for interventions like a soft helmet and floor mats, these were not consistently documented in the care plan or implemented by staff. Observations revealed that required safety equipment was sometimes missing or not used as ordered, and staff were unaware of current interventions due to outdated or missing communication tools. Interviews with CNAs indicated confusion about when and how to use fall prevention measures, and the Director of Nursing confirmed that interventions were not always added to care plans or communicated effectively. Another resident with moderately impaired cognition and a diagnosis of cancer experienced multiple falls, including incidents where the resident fell from bed or a wheelchair, sometimes sustaining injuries. Documentation of these events was inconsistent, and interventions such as fall mats were not always present or documented in the care plan. A third resident with severe cognitive impairment and mobility limitations also experienced a fall, but there was insufficient documentation regarding the circumstances of the fall or the use of safety equipment like side rails. The facility lacked a consistent process for post-fall investigation and failed to ensure that all staff were informed of and implemented appropriate fall prevention interventions.
Failure to Provide Timely Dental Care Following Tooth Injury
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for a resident who experienced a chipped front tooth while at the facility. The resident, who was cognitively intact but dependent for transfers, dressing, and wheelchair locomotion, had multiple diagnoses including diabetes, hemiplegia, stroke, seizures, and malnutrition. The resident's oral/dental status was left blank on the Minimum Data Set, and there was no documentation regarding oral care in the care plan. After the tooth broke, the resident reported pain and difficulty eating, and repeatedly communicated these issues to staff, but did not receive timely dental care. The resident's dental needs were not addressed promptly. Although a dental appointment was scheduled, the resident was unable to be seen due to an inability to transfer to the dental chair. No alternative arrangements were made, and the resident continued to experience pain and embarrassment about the appearance of the tooth. Staff interviews revealed a lack of follow-up and communication regarding the resident's ongoing dental issues, with the social worker and nursing staff each assuming the other was responsible for arranging care. The resident and family made several requests for dental care, but these were not acted upon in a timely manner. The resident eventually developed a dental abscess, for which a physician prescribed antibiotics. However, there was no evidence of further dental intervention or resolution of the underlying dental problem. Staff were unaware of the resident's ongoing pain and the need for dental care, and there was no documentation of follow-up or reassessment after the initial failed dental appointment. The lack of coordination and follow-through resulted in the resident waiting over a year without appropriate dental care.
Failure to Protect Resident from Abuse and Delay in Investigation
Penalty
Summary
The facility failed to protect a resident from abuse when an allegation of physical abuse was made against a CNA. A registered nurse heard yelling, banging, and a loud slap coming from a resident's room, followed by the CNA holding the resident against the wall. The nurse reported the incident to the DON, who instructed the nurse not to send the CNA home due to staffing shortages. The CNA continued to provide care to other residents for over five hours after the allegation was reported, and no immediate investigation was initiated. The resident involved had Alzheimer's disease, severe cognitive impairment, and required substantial assistance with activities of daily living. The care plan indicated the resident could be resistive to care and potentially physically aggressive, but interventions were in place to de-escalate situations and avoid physical confrontation. Despite these interventions, staff interviews revealed that some staff believed it was necessary to use a loud voice or physical restraint, and the CNA admitted to raising their voice and physically holding the resident against the wall during care. Interviews with facility staff, including the DON, ADON, and other personnel, revealed a lack of timely notification, investigation, and adherence to abuse prevention policies. The DON did not immediately suspend the accused CNA or begin an investigation, and several staff members were unclear about their responsibilities in reporting and responding to abuse allegations. Additionally, some non-nursing staff had not received recent training on abuse policies and were uncertain about their role in reporting suspected abuse.
Failure to Ensure Safe Mechanical Lift Transfers and Accident Prevention
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision to prevent accidents, specifically during mechanical lift (Hoyer) transfers. In one incident, a Certified Nurse Aide (CNA) performed a Hoyer lift transfer for a resident without the required assistance of a second staff member. During this transfer, the lift struck the resident in the face, resulting in a laceration, bruising, and swelling. The CNA did not report the incident to the nurse on the evening shift, and neurological assessments were not performed for 72 hours following the injury, contrary to facility policy. The resident involved had a history of repeated falls, muscle weakness, dementia, and was dependent for transfers, with physician orders for fall mats and a low bed, but these interventions were not consistently implemented or documented in the care plan. In a separate event, a Certified Medication Technician (CMT) also performed a Hoyer lift transfer for the same resident without a second person and failed to ensure that physician-ordered fall mats were in place at the bedside. After the transfer, the resident fell from bed, sustained a head injury, and required stitches. The CMT admitted to not following the two-person transfer protocol and not placing the fall mats before leaving the room. The care plan did not include the use of fall mats and a low bed as interventions, despite physician orders and the resident's high fall risk status. Additionally, direct observation revealed that staff did not consistently use proper Hoyer lift techniques during transfers. Two nurse aides, both new to the facility, attempted a two-person Hoyer transfer without adequate training, resulting in the lift tilting multiple times and the resident being bumped and dropped rapidly onto the bed. The aides reported not receiving hands-on training at the facility and relied on previous experience or observation. These failures in supervision, adherence to policy, and staff training led to multiple incidents where the resident was exposed to significant accident hazards.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Survey Agency within the required timeframe. According to the facility's policy, all alleged violations involving abuse must be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury. On the day of the incident, a registered nurse (RN) heard yelling, threatening language, and a loud slap coming from a resident's room. Upon entering, the RN observed a certified nurse aide (CNA) physically holding the resident against the wall. The resident, who had severe cognitive impairment, was unable to provide clear information about the incident. The RN reported the observation to the Director of Nurses (DON) shortly after the event. Despite being informed of the situation, the DON did not report the allegation to the Department of Health and Senior Services (DHSS) within the required two-hour window, stating that more details were needed before making a report and expressing a lack of awareness of the reporting requirement. Other facility leaders, including the Assistant Director of Nurses (ADON) and Assistant Administrator, were not made aware of the allegation until several hours later. The facility's failure to promptly report the abuse allegation as required by policy and regulation constituted the deficiency.
Failure to Submit Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for three consecutive fiscal quarters preceding the annual survey. The specific quarters in question were fiscal year quarter 1, 2024 (October 1 to December 31), fiscal year quarter 2, 2024 (January 1 to March 31), and fiscal year quarter 3, 2024 (April 1 through June 30). During an interview, the Assistant Administrator acknowledged that it was his responsibility to submit the Payroll Based Journal (PBJ) report to CMS and admitted that he was aware of the requirement but had not fulfilled it. The facility had a census of 47 at the time of the survey.
Failure to Maintain Resident Dignity Due to Staff Cell Phone Use
Penalty
Summary
The facility failed to uphold the dignity of its residents by allowing staff to use cell phones during care, which was against the facility's policy. Multiple observations were made where staff members, particularly Nurse Aide (NA) E, were seen using their phones while attending to residents. For instance, NA E was observed texting while feeding a resident with severe cognitive impairment, not paying attention to the resident's needs. Another resident with moderate cognitive impairment felt uncomfortable when NA E entered their room and used their phone without interacting with them. Additionally, a cognitively intact resident reported feeling uneasy when NA E was on a phone call during their care. The facility also failed to ensure that staff were appropriately seated while feeding residents, which is essential for maintaining dignity and respect. Observations showed that NA C stood over residents with severe cognitive impairments while feeding them, rather than sitting at their level. This practice was noted during multiple instances, indicating a lack of adherence to the facility's dignity policy. Furthermore, the facility did not ensure that residents received necessary assistance during meals. A resident with severe cognitive impairment and dystonia was observed struggling to eat with their hands after dropping their spoon, without receiving help from staff to replace the utensil. This lack of assistance persisted throughout the meal, highlighting a failure to provide dignified care. Interviews with staff and residents confirmed that cell phone usage during care was a common issue, despite the facility's policy prohibiting it.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive care plans with resident-specific interventions for five residents, leading to deficiencies in addressing their medical, physical, and psychosocial needs. For one resident, the care plan did not include specific interventions for significant weight loss, use of an indwelling catheter, and active wounds, despite the resident having multiple medical conditions such as stroke, diabetes, and pressure ulcers. Observations and interviews revealed that the resident had a catheter, was on a pureed diet, and had unplanned weight loss, yet these were not reflected in the care plan. Another resident with severe cognitive impairment and a history of falls, including a hip fracture, had a care plan that was not updated to reflect these incidents or the resident's current use of a wheelchair. The resident also exhibited ongoing thoughts about death and dying, which were not addressed in the care plan. Staff interviews indicated that the resident's condition had declined, and the resident frequently expressed anxiety and confusion about dying, yet the care plan lacked specific interventions to manage these behaviors. A third resident, who was underweight and had significant weight loss, had a care plan that failed to address the resident's dietary needs and preferences, such as eating with hands and refusing assistance. Despite receiving dietary supplements and having a divided plate to aid in eating, these interventions were not documented in the care plan. Observations showed the resident eating with hands and dropping food, while staff interviews confirmed the resident's refusal of assistance and significant weight loss.
Inadequate Supervision and Transfer Protocols
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for several residents. Two residents were observed being propelled in wheelchairs without leg rests, causing their feet to drag on the floor. This occurred despite the residents' difficulty in keeping their legs elevated, leading to discomfort and potential injury. Staff members were aware of the issue but did not consistently use leg pedals or other appropriate measures to prevent the residents' feet from dragging. Additionally, the facility staff did not use gait belts during assisted transfers for three residents, which is a standard safety protocol. Observations showed staff lifting residents by their arms or clothing, which is inappropriate and poses a risk of injury. Interviews with staff and the Assistant Director of Nursing confirmed that gait belts should be used during transfers, yet this practice was not consistently followed. Furthermore, a resident with a history of falls was not appropriately repositioned in their wheelchair, despite being observed leaning and slouched in the chair on multiple occasions. Staff interviews revealed an expectation for frequent rounds and repositioning to ensure the resident's safety, but these measures were not adequately implemented. The lack of a written policy regarding transfer protocols further contributed to these deficiencies.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. The facility's staffing policy, revised in April 2007, mandates adequate staffing to meet the care and service needs of the resident population, including the availability of licensed RN and nursing staff to provide and monitor resident care services. However, a review of staffing sheets from October 1 to October 21, 2024, revealed multiple days without RN coverage, specifically on October 1, 2, 3, 4, 6, 8, 10, 11, 13, 14, and 19. During interviews, the Assistant Director of Nursing acknowledged the requirement for RN coverage and cited difficulties in securing RNs to work, despite posting requests on the agency website. The Assistant Administrator also expressed an expectation for RN staffing to be covered as required.
Deficiency in Controlled Drug Reconciliation
Penalty
Summary
The facility failed to establish a system of record for all controlled drugs with sufficient detail to enable accurate reconciliation on two out of three medication carts reviewed. This deficiency was identified during a review of the facility's Controlled Substances policy, which mandates compliance with laws and regulations related to the handling, storage, disposal, and documentation of controlled substances. The policy requires nursing staff to count controlled medications at the end of each shift, with both the nurse coming on duty and the nurse going off duty participating in the count. However, the review of Narcotic Count Sheets from 10/1 through 10/19/24 revealed significant non-compliance, with numerous shifts lacking the required dual nurse initials on the shift change count. Specifically, on the 400 and 500 medication carts, 22 out of 57 shifts had no nurse initial, and 28 shifts had only one nurse initial. Similarly, on the 100, 300, and 600 medication carts, 23 out of 57 shifts had no nurse initial, and 28 shifts had only one nurse initial. Interviews with staff, including a Certified Medicine Technician and a Licensed Practical Nurse, confirmed that the expected practice was for two staff members to sign the narcotic book and complete the count every shift. The Assistant Director of Nursing also stated that she expected narcotics to be counted and documented by two different staff members every shift. This failure in documentation and procedure had the potential to affect all residents with controlled substance orders, with the facility census being 47.
Improper Storage of Medications and Lack of Temperature Monitoring
Penalty
Summary
The facility failed to ensure that drugs and biologicals stored in the medication room refrigerator were maintained at the proper temperature, as there was no system or temperature log in place. During an observation, it was noted that the refrigerator contained a thermometer hanging on the inside of the door, but there was no record of temperature monitoring. Certified Medication Technician (CMT) F and Licensed Practical Nurse (LPN) A both confirmed the absence of a temperature log and were unaware of who was responsible for checking the refrigerator's temperature. Additionally, the facility did not adhere to the policy of storing medications separately from food items. The medication room refrigerator contained not only medications such as insulin vials, tuberculin testing serum, and Ativan but also several cartons of nutritional supplements like Nepro, Boost, and Med Pass, as well as a clear plastic bowl of applesauce. The Assistant Administrator and the Assistant Director of Nursing (ADON) admitted that they were not aware of the requirement to store medications separately from food items and confirmed the lack of a system to monitor the refrigerator's temperature.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by staff during meal service, affecting 15 residents. Observations during breakfast and lunch revealed that staff members, including a Licensed Practical Nurse (LPN) and Nurse Aides (NAs), did not perform hand hygiene before or after assisting residents with meals, handling food, or touching residents and their belongings. This was contrary to the facility's hand hygiene policy, which mandates handwashing or the use of an alcohol-based hand rub before and after direct contact with residents and handling food. During breakfast, a Nurse Aide was observed assisting multiple residents with their meals and personal items without performing hand hygiene. The aide repositioned residents, handled their silverware, and assisted with feeding without washing hands or using hand sanitizer. Similar observations were made during lunch, where another Certified Nursing Assistant (CNA) and a Nurse Aide were seen assisting residents with their meals and personal items without adhering to hand hygiene protocols. Interviews with staff members, including a CNA, a Certified Medication Technician (CMT), and a Licensed Practical Nurse (LPN), confirmed that the expectation was for staff to perform hand hygiene before entering the dining room, after passing each plate, and after touching any items. The Assistant Director of Nursing (ADON) and the Administrator also stated that they expected all staff to follow the hand hygiene policy. Despite these expectations, the observations indicated a failure to comply with the facility's hand hygiene procedures, leading to the deficiency.
Infection Control and TB Testing Deficiencies
Penalty
Summary
The facility failed to implement proper infection prevention and control practices, particularly in the use of Enhanced Barrier Precautions (EBP) for residents with urinary catheters and wounds requiring treatment. Specifically, staff did not adhere to the Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for EBP, which require gown and glove use during high-contact resident care activities. Observations revealed that staff did not wear gowns while providing care to residents with urinary catheters and wounds, and there was no EBP signage outside the residents' rooms. Interviews with staff, including CNAs, LPNs, and the Assistant Director of Nursing (ADON), indicated a lack of awareness and training regarding EBP. In addition to the failure to implement EBP, the facility did not follow acceptable infection control standards during wound care procedures. For instance, an LPN was observed using ungloved hands to handle unpackaged dressings and scissors that were not cleaned before use. The LPN also failed to label or date the wound dressing after application. These actions were contrary to the facility's wound care policy, which requires hand hygiene, the use of gloves, and the cleaning of equipment before use. Furthermore, the facility did not conduct tuberculosis (TB) testing for several residents as required by its TB policy. The policy mandates TB screening for all residents upon admission, with a two-step tuberculin skin test (TST) or a blood assay for Mycobacterium tuberculosis (BAMT). However, records showed that five residents had no documentation of TB screening or testing. The ADON acknowledged the oversight and stated that TB screening and testing should be completed for all residents upon admission and annually thereafter.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer and administer the pneumococcal vaccine to four out of five sampled residents, despite having a policy in place that mandates offering the vaccine to eligible residents. The policy, revised in August 2016, requires that residents be assessed for vaccine eligibility upon or prior to admission and be offered the vaccine within thirty days unless contraindicated or previously vaccinated. However, the medical records for Residents #12, #11, #38, and #22 showed no documentation of screening or vaccination, despite their various medical conditions, including stroke, diabetes, heart failure, sepsis, and respiratory failure. The Assistant Director of Nursing (ADON), responsible for screening and checking vaccine status, confirmed that residents should be offered the vaccine if eligible and that refusals should be documented. Additionally, education about the vaccine's benefits and potential side effects should be provided to residents or their representatives, with documentation in the medical record. The lack of documentation and action regarding the pneumococcal vaccine for these residents indicates a failure to adhere to the facility's vaccination policy.
Failure to Offer COVID-19 Vaccines to Eligible Residents
Penalty
Summary
The facility failed to offer COVID-19 vaccines to four out of five residents sampled for immunizations, despite having a policy in place that mandates offering the vaccine to all eligible residents. The policy, revised in May 2023, requires that each resident be offered the COVID-19 vaccine unless medically contraindicated or already fully vaccinated. The Assistant Director of Nursing (ADON) is responsible for overseeing the education, documentation, and reporting of vaccination status. However, the medical records of Residents #11, #38, #22, and #14 showed no documentation of screening or vaccination, indicating a lapse in following the facility's policy. Resident #11, admitted with diagnoses including sepsis and acute respiratory failure, had no documentation of being screened or offered the vaccine. Similarly, Resident #38, with conditions such as adult failure to thrive and diabetes, and Resident #22, with sepsis and long-term antibiotic use, also lacked documentation of screening or vaccination. Resident #14, who had received initial doses of the COVID-19 vaccine in early 2021, had no further documentation of additional vaccinations or screenings. The ADON confirmed during an interview that it was expected for residents to be offered the vaccine and for refusals to be documented, highlighting a deficiency in the facility's adherence to its vaccination policy.
Deficiency in CNA Training Documentation
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required minimum of 12 hours of ongoing education annually. This deficiency was identified for five out of five sampled CNAs, with a facility census of 47. The facility was unable to provide a policy related to the 12-hour training requirement for CNAs. Employee files for CNAs and Certified Medication Technicians (CMTs) showed no records of in-service training. Interviews revealed that the facility provides in-services, but there is no formal tracking or documentation system in place. The Assistant Director of Nursing (ADON) acknowledged that it is her responsibility to maintain a system for tracking in-service training but admitted to not doing so, and could not provide any documentation of completed in-services.
Failure to Notify Physician and Resident of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the physician of abnormal lab results for a resident diagnosed with a urinary tract infection (UTI). The resident's urinalysis and culture results, which indicated the presence of Citrobacter farmeri bacteria, were collected and reported to the facility but were not communicated to the physician until two days later. This delay in communication resulted in a delay in receiving new orders for antibiotic treatment. Additionally, the facility did not inform the resident or the resident's representative about the abnormal lab results and the new medication orders. The resident reported experiencing intense burning and was unaware of the UTI diagnosis until after starting the antibiotic treatment. The resident's power of attorney (POA) was also not informed about the UTI diagnosis or the new medication orders. Interviews with facility staff, including an LPN, the Assistant Director of Nurses (ADON), and the Assistant Administrator, revealed that there were expectations for timely lab collection and communication of results. However, the facility's process for handling lab results, especially those received on weekends, was inadequate, leading to a lack of timely notification to the physician and the resident. Documentation of communication with the physician, resident, and responsible party was also lacking in the resident's electronic medical record (EMR).
Failure to Provide Written Notices of Transfer/Discharge
Penalty
Summary
The facility failed to provide emergency written notices of transfer or discharge to two residents who were transferred to the hospital for acute medical reasons. The facility's policy, revised in December 2016, requires that residents and/or their representatives receive a 30-day written notice of an impending transfer or discharge, or as soon as practicable in cases of urgent medical needs. However, for Resident #31, there was no documentation of written notice for transfers to the hospital on two occasions, and for Resident #19, there was no documentation of written notice for a transfer to the hospital. Interviews with facility staff, including an LPN and the Assistant Director of Nurses (ADON), revealed that while paperwork such as the resident's face sheet and medication list is sent with the resident to the hospital, the practice of sending a notice of transfer/discharge had lapsed. The ADON confirmed the absence of documentation for the required notices for the residents in question. The Assistant Administrator also stated the expectation that residents and/or their representatives should receive a notice of transfer/discharge when a resident is transferred to the hospital.
Failure to Provide Bed Hold Policy Notices
Penalty
Summary
The facility failed to provide written information on its bed hold policy to residents and/or their representatives at the time of transfer to a hospital for two residents. The facility's policy, revised in March 2017, mandates that residents or their representatives be informed in writing about the bed-hold and return policy prior to any transfers or therapeutic leaves. However, for two residents who were transferred to the hospital for acute medical reasons, there was no documentation indicating that they or their representatives received the required written notice. Specifically, Resident #31 was transferred to the hospital on two occasions, and Resident #19 was transferred once, with no evidence of the bed hold policy being communicated in writing during these transfers. Interviews with facility staff revealed a lapse in the process of providing bed hold notices. An LPN mentioned that while paperwork such as the resident's face sheet and medication list is sent with the resident to the hospital, the practice of including a bed hold notice had ceased some time ago. The Assistant Director of Nurses confirmed the absence of documentation for the bed hold notices for the two residents in question and expressed an expectation that such notices should be provided. Similarly, the Assistant Administrator stated that residents and/or their representatives should receive a bed hold notice upon hospital transfer, indicating a discrepancy between expected procedures and actual practice.
Inaccurate Resident Assessment Leads to Oversight of Health Issues
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident, resulting in the oversight of significant health issues. The resident experienced an unplanned significant weight loss of 18.48% over six months, dropping from 147.2 pounds to 120.0 pounds. Despite this, the resident's Minimum Data Set (MDS) inaccurately indicated that the weight loss was part of a physician-prescribed regimen. Additionally, the resident had a Stage II pressure ulcer on the left buttock and a Stage IV pressure ulcer on the sacrum, which were not documented in the MDS. Instead, the focus was incorrectly placed on the resident's bullous pemphigoid wounds, leading to the omission of these critical skin conditions. The Assistant Director of Nurses (ADON), responsible for completing the MDS assessments, admitted to misinterpreting the weight loss question and failing to accurately document the resident's pressure ulcers. The ADON's focus on the bullous pemphigoid areas contributed to the oversight of the pressure ulcers. The Assistant Administrator also expressed an expectation for accurate resident assessments, highlighting a lapse in the facility's assessment process for this resident.
Failure to Maintain Comprehensive Care Plans
Penalty
Summary
The facility staff failed to review and revise the care plans for four residents, despite changes in their care needs. The facility's policy mandates that a comprehensive, person-centered care plan be developed within seven days of the comprehensive assessment and revised as the resident's condition changes. However, the review of the electronic medical records (EMR) for Residents #38, #46, #22, and #32 revealed that they did not have comprehensive care plans, which is a violation of the facility's policy. Resident #38, diagnosed with cerebral aneurysm, diabetes, high blood pressure, depression, and seizures, was admitted on a specified date, but the EMR review showed no comprehensive care plan. Similarly, Resident #46, with diagnoses including depression, dementia, and anxiety, also lacked a comprehensive care plan in the EMR. Resident #22, with moderately impaired cognition and diagnoses of type two diabetes mellitus and depression, and Resident #32, diagnosed with depression, dementia, weakness, high blood pressure, and anemia, were also found without comprehensive care plans in their EMRs. Interviews with facility staff, including LPNs and CNAs, revealed that while they have access to the EMR and are expected to view care plans, they often rely on verbal instructions from charge nurses due to the absence of care plans in the EMR. The Assistant Director of Nursing (ADON) acknowledged that the care plans were not in the EMR due to an error during their creation, and confirmed that care plans should be completed within the appropriate time frame as per the facility's policy.
Deficiency in CPR Certification Training
Penalty
Summary
The facility failed to ensure that all staff certified in cardiopulmonary resuscitation (CPR) received their certification through a provider whose training includes hands-on practice and in-person skills assessment. Out of 10 CPR-certified staff, three were found to have obtained their certification through an online provider, which does not meet the regulatory requirements for CPR training. This deficiency was identified during a review of the facility's CPR certification records and interviews with staff, including the Assistant Director of Nurses (ADON) and a Registered Nurse (RN). The facility's Advance Directives policy lacked guidance on ensuring CPR certification included hands-on practice and in-person skills assessment. The review of nurse staffing sheets revealed that on multiple occasions, the only CPR-certified staff scheduled were those with online certifications. Interviews with the ADON and Assistant Administrator confirmed that they expected CPR-certified staff to have received training that includes hands-on practice, but they were unaware of the specific regulatory requirements. The facility had 22 residents with full code status, indicating the importance of having properly certified staff available.
Inadequate Wheelchair Assessment and Undated Dressing
Penalty
Summary
The facility failed to provide services consistent with acceptable standards of practice for a resident when staff did not accurately assess the appropriate wheelchair size, leading to skin irritation and indentations on the resident's legs. The resident, who had a diagnosis of dementia, depression, high blood pressure, high cholesterol, peripheral vascular disease, and was overweight, was observed sitting in a wheelchair that was not their property. The resident complained of pain in their bottom, back, and legs, and was unable to reposition themselves. Staff failed to reposition the resident for six hours, despite the resident's repeated requests to be moved to bed. Observations revealed indentations and reddened areas on the back of the resident's calves and thighs, attributed to the wheelchair's foot pedal brackets applying pressure. Additionally, the facility failed to date a dressing for another resident, who had a diagnosis of diabetes, high blood pressure, high cholesterol, kidney disease, amputation, and dementia. The resident was observed with a dressing on their right lower leg that was not dated on multiple occasions. Staff were unable to identify when the dressing was applied, and it was later noted that the abrasion occurred on a specific date. The Assistant Director of Nursing expected the nursing staff to date the dressing when the treatment was performed. These deficiencies highlight the facility's failure to adhere to acceptable standards of practice in assessing and addressing residents' needs, particularly in ensuring appropriate equipment and documenting care procedures. The lack of proper assessment and documentation led to discomfort and potential harm to the residents involved.
Inadequate Foot Care for Residents
Penalty
Summary
The facility failed to provide adequate foot care for two residents, resulting in long nails and dry feet. Resident #44, who is cognitively intact and has diabetes, reported having dry, flaky skin and excessively long toenails, which caused discomfort and difficulty wearing shoes. Despite being at the facility for eight months, Resident #44 had not yet seen a podiatrist, and the issue was not documented in the resident's most recent skin evaluation. Resident #21, who has severe cognitive impairment and multiple diagnoses including dementia and COPD, also exhibited long, jagged toenails and dry, flaky skin. The resident's care plan included interventions for nail care, but the most recent shower sheets and skin evaluation did not document any concerns. Although the resident refused podiatry care at the last appointment, family members expressed concern about the condition of the resident's nails. Interviews with facility staff, including CNAs and LPNs, revealed that both groups are responsible for foot care, with nurses specifically tasked with trimming nails for diabetic residents. Documentation of foot care issues should occur on shower sheets or skin assessments, but this was not consistently done. The Assistant Director of Nursing acknowledged the oversight in ensuring residents' foot care needs were met and noted that Resident #44 was on the list to see the podiatrist but was not seen during the last visit.
Failure to Follow Oxygen Therapy Orders and Infection Control Protocols
Penalty
Summary
The facility failed to ensure physician orders were followed for a resident with an order for continuous oxygen usage. Resident #44, who was cognitively intact and diagnosed with anxiety, asthma, and acute respiratory failure, had a physician's order for continuous oxygen at 2 liters via nasal cannula. However, observations over several days showed the resident in bed with the oxygen concentrator on but not wearing the nasal cannula. Interviews with staff, including a CNA, LPN, and the ADON, revealed that the resident frequently removed the nasal cannula, and there was an expectation for frequent monitoring to ensure the resident wore it. The care plan did not address the resident's behavior of removing the nasal cannula. Additionally, the facility failed to ensure proper storage of oxygen masks and routine changing of oxygen tubing for infection control purposes. Resident #14, who had severe cognitive impairment and diagnoses including wheezing and dementia, had an order for nebulizer treatments. Observations showed the nebulizer mask uncovered on a side table, contrary to staff expectations that it should be stored in a plastic bag when not in use. Interviews with staff confirmed the expectation for proper storage of the nebulizer mask, but the care plan did not include the resident's nebulizer use.
Failure to Certify Nursing Assistants Within Required Timeframe
Penalty
Summary
The facility failed to ensure that Nursing Assistants (NAs) employed for more than four months were certified, affecting five NAs in total. The facility's assessment, reviewed in July 2023, indicated that staff training and education, including certification and licensure requirements, were necessary to provide the required level of care. However, a review of the hire dates for the NAs showed that none of them were certified within the required four-month period. Interviews with the NAs revealed that they were either waiting to test out or waiting for approval to retake the test, indicating a delay in the certification process. The Assistant Director of Nursing (ADON) stated that all NAs were enrolled in a 16-hour online course and were responsible for completing the program and the test. Some NAs had failed their tests and needed to retake the course. The ADON mentioned that she could not track the progress of the NAs' online training and was unaware of any requirement to sign off on their completion. Additionally, some NAs faced challenges in finding a testing site, leading to a prolonged period between finishing the course and taking the test.
Inadequate Documentation and Monitoring of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, as evidenced by the prescription of Haldol without appropriate documentation to support its clinical need. The resident, who had a history of major depressive disorder and anxiety disorder, was prescribed Haldol despite the absence of documented behaviors or symptoms that would justify its use. The facility's policy on antipsychotic medication use requires thorough documentation and evaluation of a resident's behavior and symptoms before such medications are prescribed, which was not adhered to in this case. The resident experienced an increase in falls following the adjustment of psychotropic medications, including the addition of Haldol, yet there was no documentation of monitoring for adverse consequences or medication effectiveness. The resident's medical record showed multiple falls and hospitalizations for a fractured femur, but there was no evidence of follow-up visits with the psychiatrist after the medication changes. The facility's care plan for the resident did not include documentation related to the resident's expressed thoughts or anxiety about dying, which was a significant behavior noted by staff. Observations and interviews with staff revealed that the resident was frequently confused and obsessed with thoughts of dying, a behavior that had been ongoing since the resident's admission. Despite the prescription of Haldol, the resident continued to exhibit these behaviors, indicating a lack of effectiveness of the medication. The facility did not utilize behavior charting, which could have provided valuable insights into the resident's condition and the impact of the medication. The lack of documentation and monitoring highlights a deficiency in the facility's management of psychotropic medications and resident care.
Failure to Maintain RN Coverage and Designate a 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 have a Director of Nursing (DON) on a full-time basis. This deficiency had the potential to affect all residents, with a census of 50. The facility's list of Department Heads showed no DON employed, and daily assignment sheets indicated no RN coverage on several days. Interviews with staff, including a Certified Nursing Assistant (CNA), Licensed Practical Nurse (LPN), and the Assistant Director of Nursing (ADON), confirmed the absence of a DON for several months and inconsistent RN coverage. The ADON, who is an LPN, assumed the responsibilities of the DON and consulted with a DON from a sister facility as needed. The ADON acknowledged the requirement for RN coverage and the facility's ongoing search for a DON and full-time RNs. The Assistant Administrator also confirmed the lack of a DON and stated that the facility used staffing agencies to meet RN needs. Despite these efforts, the facility did not meet the regulatory requirement for RN coverage, as confirmed by multiple staff interviews and record reviews.
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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