Butler Rehab And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Butler, Missouri.
- Location
- 416 S High Street, Butler, Missouri 64730
- CMS Provider Number
- 265275
- Inspections on file
- 13
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Butler Rehab And Healthcare Center during CMS and state inspections, most recent first.
A resident with diabetes and traumatic brain injury, who wished to remain in LTC, was discharged to a homeless shelter after being sent to the hospital, with immediate discharge paperwork citing behavioral concerns. The discharge process lacked proper documentation, the resident's signature, and staff clarity on appropriate procedures.
A contracted PTA did not adequately explain therapy procedures or obtain informed consent before providing treatments to several residents, resulting in confusion and discomfort. Multiple residents with various medical conditions reported that the PTA initiated physical contact, including touching near the chest and abdomen, without prior explanation, causing them to feel uneasy or distressed. Interviews confirmed that proper communication protocols were not followed, leading to a deficiency in upholding residents' rights.
The facility failed to update care plans for several residents, including those with pressure ulcers, smoking supervision needs, and pain management. Observations and interviews revealed inconsistencies and lapses in accurately reflecting residents' current conditions and needs.
The facility failed to ensure proper TB screening for both residents and new employees. Four residents did not receive timely or documented TB tests, and two new employees started working without completing the required TB tests. Interviews revealed systemic issues in the administration and documentation of TB tests.
The facility failed to provide the required 12 hours of training and in-services, including behavior and dementia training, abuse and neglect prevention, and resident rights, for three CNAs. Despite attending various in-services, the specific required topics were not covered, and the total training hours did not meet the mandated 12 hours from April 2023 to April 2024.
The facility failed to develop a spend-down plan for two residents who maintained balances exceeding the Missouri Medicaid limit in their Resident Trust Fund accounts for more than one month. The Business Office Manager informed the residents of their excess balances but did not assist in creating a plan to manage the funds, risking the loss of Medicaid benefits.
The facility failed to accurately document a resident's advance directives, resulting in conflicting Full Code and DNR orders in the care plan. Interviews with staff revealed inconsistencies in updating and verifying the resident's code status, despite the resident's guardian providing verbal consent for Full Code.
The facility failed to follow its policy to conduct CBC and check the NA Registry for new employees before hiring. Employee B started work without a completed NA registry check, and Employee F's NA registry check was completed two days after their hire date. The BOM/HR and DON confirmed that these checks should be completed before new employees start working.
A resident with a history of cerebral infarction and hemiplegia did not receive necessary ROM treatment and services, including a previously ordered splint and therapy. The resident's left hand was observed to be contracted without any devices to maintain a neutral position, and interviews with staff confirmed the lack of appropriate interventions.
The facility failed to ensure that a physician reviewed and acted upon a pharmacist's monthly Drug Regimen Review (DRR) recommendations for a resident with a complex medical history. Despite the pharmacist identifying irregularities and making recommendations, no physician responses were found in the resident's medical record for two months, and a critical recommendation was not fully addressed in a third month.
The facility failed to ensure that two residents received necessary dental services for broken teeth. Both residents had significant dental issues, including missing and broken teeth, and expressed a desire to see a dentist. However, no dental appointments were made, and their care plans did not reflect any dental concerns. Staff interviews revealed systemic issues in handling dental care, including inadequate documentation and lack of follow-up.
Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident who was sent to the hospital and subsequently discharged with paperwork indicating a return to a homeless shelter. The resident, who was cognitively intact and had a history of diabetes and traumatic brain injury, had expressed a desire to remain in long-term care according to their care plan. Despite this, the discharge paperwork listed a homeless shelter as the destination, and the discharge was marked as immediate due to the resident being considered a danger to self and others, with the notice lacking the resident's signature. Interviews with facility staff revealed a lack of clarity and documentation regarding the discharge process. The Social Services Director stated the resident did not request discharge, and the DON was unaware if the discharge packet was completed or if discharging to a homeless shelter was appropriate. The Administrator confirmed that the resident was told not to return to the facility and that the discharge was considered immediate, citing behavioral concerns such as inappropriate comments and alcohol use. However, there was no documentation of significant behavioral incidents in the medical record, aside from a single report of inappropriate comments. The facility was unable to provide a discharge policy when requested, and staff interviews indicated uncertainty about proper discharge procedures and documentation. The discharge notice was delivered to the hospital along with the resident's belongings, but the process lacked clear documentation and did not include the resident's agreement or signature. The actions taken did not align with the resident's expressed wishes or ensure a safe and appropriate discharge destination.
Failure to Inform Residents of Therapy Procedures Leads to Discomfort
Penalty
Summary
Contracted Physical Therapy Assistant (PTA) A failed to adhere to residents' rights by not adequately informing residents about the care and treatments being provided prior to initiating therapy sessions. Multiple residents reported that PTA A did not explain the procedures or the reasons for physical contact during therapy, such as muscle palpation or massage-like actions. This lack of communication led to confusion and discomfort among several residents, some of whom were unfamiliar with therapy or had not previously received such treatments from PTA A. The deficiency involved seven residents, most of whom were cognitively intact and had various medical conditions including post-surgical weakness, stroke, muscle wasting, and spondylosis. Residents described instances where PTA A entered their rooms, began therapy or massage-like activities without prior explanation, and in some cases, touched areas near the chest or abdomen. While no residents reported pain or physical injury, several expressed feeling uncomfortable, nervous, or "creepy" after the interactions. Some residents did not immediately report the incidents, only disclosing their discomfort when later questioned by facility staff. Interviews with facility staff and the contract therapy agency director confirmed that proper protocol required PTA A to explain all procedures and obtain informed consent before touching residents, especially in sensitive areas. The director acknowledged that certain therapy techniques might require contact with the chest or inner thigh, but emphasized the necessity of clear communication to prevent misunderstanding. The lack of explanation and failure to ensure residents understood the nature of the therapy led to the deficiency, as residents' rights to be informed and to refuse care were not upheld.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the care plans for several residents were updated to reflect their current medical conditions and needs. Resident #29's care plan did not include information about an unstageable pressure ulcer, despite the resident having a physician's order for wound care treatment and a documented risk for pressure ulcers. The MDS Coordinator confirmed that the resident should have had a care plan for any type of wound, indicating a lapse in updating the care plan to reflect the resident's current condition. Resident #18's care plan was not updated to reflect the resident's need for assistance and supervision while smoking. Despite assessments indicating the resident required supervision, observations showed the resident smoking without proper assistance, leading to unsafe situations where other residents had to help. Interviews with staff revealed inconsistencies in the supervision and assistance provided to the resident, highlighting a failure to ensure the care plan accurately reflected the resident's needs and the facility's policies. Resident #38's care plan lacked documentation related to the resident's current pain status, including frequency, type, and location of pain, as well as non-pharmacological pain interventions. The resident had multiple orders for pain medications and reported constant pain that affected daily activities. Similarly, Resident #47's care plan did not document all pressure ulcers, missing information about a pressure ulcer on the right heel. The DON confirmed that care plans should be updated quarterly and as needed, indicating a failure in the facility's process for maintaining accurate and comprehensive care plans.
Failure to Properly Screen for Tuberculosis
Penalty
Summary
The facility failed to ensure proper screening for Tuberculosis (TB) for both residents and new employees. Four residents were not screened according to the facility's TB policy, which mandates a two-step TB test upon admission and annual testing thereafter. For instance, Resident #29 had multiple instances where TB tests were either not read or not documented, and similar issues were observed with Residents #38, #47, and #50. The Infection Preventionist (IP) and Director of Nursing (DON) acknowledged that many residents' TB tests were not done timely or documented correctly, attributing the lapses to previous staff not keeping track of the tests properly. Additionally, the facility failed to properly screen new employees for TB before they started working. Employee G and Employee J did not have their TB tests completed and documented as required. Employee G's second TB test was administered but not read, while Employee J started working before the first TB test was administered. The Assistant Director of Nursing (ADON) and the Business Office Manager (BOM)/Human Resources (HR) Director confirmed these lapses, with the ADON admitting that new employees were usually hired directly after the interview and started working once the first TB test was read with a negative result. Interviews with the IP, DON, ADON, and BOM/HR Director revealed systemic issues in the administration and documentation of TB tests for both residents and employees. The IP and DON were responsible for ensuring timely TB tests for residents, while the ADON was responsible for tracking employee TB tests. However, the lack of proper documentation and adherence to protocols led to significant deficiencies in the facility's infection prevention and control program.
Failure to Provide Required CNA Training
Penalty
Summary
The facility failed to provide the required 12 hours of training and in-services, including behavior and dementia training, abuse and neglect prevention, and resident rights, for three Certified Nursing Assistants (CNA B, C, & D). The review of the training records for these CNAs showed that they did not receive the necessary training in critical areas such as abuse and neglect, behavior and dementia training, resident rights, and care of cognitively impaired residents. Despite attending various in-services, the specific required topics were not covered, and the total training hours did not meet the mandated 12 hours from April 2023 to April 2024. During an interview, the Director of Nursing (DON) confirmed that CNAs should receive 12 hours of in-service training annually, with monthly in-services covering essential topics like abuse and neglect safety, dementia and Alzheimer's safety, and other resident needs. The DON also mentioned that in-services were typically an hour long and conducted by the DON, ADON, or other department heads. However, the facility failed to provide documentation of a policy for the required training, and the Human Resource staff did not adequately monitor the in-service hours for the CNAs, including those working on a PRN basis.
Failure to Develop Spend-Down Plan for Resident Trust Funds
Penalty
Summary
The facility failed to develop a spend-down plan for two residents who maintained a balance exceeding the Missouri Medicaid limit of $5,726.00 in their Resident Trust Fund (RTF) accounts for more than one month. Resident #13's RTF balance consistently exceeded the legal limit from September 2023 to March 2024, reaching as high as $11,044.75. Similarly, Resident #18's RTF balance also remained above the legal limit during the same period, with a peak balance of $10,944.75. Despite these excessive balances, the facility did not take appropriate action to assist the residents in managing their funds to avoid losing Medicaid benefits. During an interview, the Business Office Manager (BOM) acknowledged responsibility for the RTF accounts and admitted to informing the residents that their balances were over the legal limit. However, the BOM did not inform the residents of the potential loss of Medicaid benefits due to the excess funds, nor did they assist in creating a plan to spend down the RTF money. The BOM's approach was limited to advising the residents to spend their money without providing further guidance or support, leading to the deficiency in managing the residents' funds effectively.
Failure to Accurately Document Resident's Advance Directives
Penalty
Summary
The facility failed to properly and accurately document a resident's advance directives, resulting in conflicting information regarding the resident's code status. The resident, who was diagnosed with Chronic Obstructive Pulmonary Disease (COPD), chronic kidney disease, and major depressive disorder, had both a Do Not Resuscitate (DNR) order and a Full Code order documented in their care plan. This discrepancy was found during a review of the resident's electronic health record (EHR) and care plan, which showed conflicting information about the resident's wishes for life-saving measures. Interviews with facility staff, including a Certified Nurse's Assistant (CNA), a Registered Nurse (RN), the MDS coordinator, and the Director of Nursing (DON), revealed a lack of clarity and consistency in documenting and updating the resident's code status. The resident's guardian had provided verbal consent for Full Code, but the care plan still contained both Full Code and DNR orders. The MDS coordinator acknowledged the error and stated that the care plan would be revised immediately. The DON confirmed that the code status should be clearly documented and consistent across all records, and that the resident's wishes should be accurately reflected in the care plan and physician orders.
Failure to Conduct Timely Background Checks and NA Registry Checks for New Employees
Penalty
Summary
The facility failed to follow its policy to conduct Criminal Background Checks (CBC) and check the Nurses Aide (NA) Registry for new employees before hiring. Specifically, the facility did not complete a NA registry check for Employee B before their hire date and completed the NA registry check for Employee F two days after their hire date. The Business Office Manager (BOM)/Human Resources (HR) admitted that sometimes background checks slipped through the cracks, and employees were not supposed to start working until all background screenings, including NA Registry checks, were completed. Despite having a checklist to ensure all backgrounds were completed before employees started working, the facility allowed Employee B to start work immediately without completing the background process, and Employee F started working before their NA registry check was completed. During interviews, the BOM/HR and the Director of Nursing (DON) confirmed that the NA registry check should be completed before new employees start working. The BOM/HR was responsible for completing the NA registry and background checks for new hires. The facility's failure to adhere to its policy resulted in two employees starting work without the necessary background checks, which is a deficiency in the facility's hiring process and compliance with regulatory requirements.
Failure to Provide Necessary ROM Treatment and Services
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain and improve the range of motion (ROM) and mobility for a resident with significant medical conditions. The resident, who had a history of cerebral infarction, hemiplegia, and muscle weakness, was observed to have a contracted left hand without any devices or equipment to maintain a neutral hand position. Despite having an order for a left arm splint from a previous facility, the splint was never provided, and the resident did not receive any physical or occupational therapy or restorative therapies during the assessment period. Interviews with the Director of Rehabilitation (DOR) and the Director of Nursing (DON) revealed that the resident was not on therapy services and had not been evaluated or treated by the therapy department upon admission. The DOR acknowledged that the resident would have benefited from a splinting device or restorative therapies to prevent worsening of contractures. The DON confirmed that orders from the previous facility should have been reviewed and continued if appropriate, and that the resident should have received treatment to maintain or improve ROM. The lack of appropriate interventions and equipment led to the resident's continued contractures and limited mobility.
Failure to Act on Pharmacist's Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that the monthly pharmacy Drug Regimen Review (DRR) recommendations for Resident #29 were reviewed and acted upon by the physician. The pharmacist's notes from 3/22/23, 4/27/23, and 9/1/23 indicated that there were irregularities and recommendations that needed to be addressed. However, no reports or physician responses were found in the resident's medical record for the notes from 3/22/23 and 4/27/23. On 9/1/23, the pharmacist recommended evaluating the necessity of two blood-thinning medications and monitoring for abnormal bleeding or bruising. Although the physician discontinued one of the medications, there was no order to monitor for abnormal bleeding or bruising as recommended by the pharmacist. The facility's policy requires that the physician respond to the pharmacist's recommendations within 30 days, but this was not done for Resident #29's DRR recommendations. Resident #29 had a medical history that included cerebral infarction, hemiplegia and hemiparesis following a stroke, bipolar disorder, anxiety disorder, and major depressive disorder. The DON confirmed that the pharmacist reviewed medications monthly and emailed the recommendations, which were then given to the physician for review and sign-off. The DON also stated that the physician should respond to the pharmacist's recommendations within 30 days and that follow-up would be done if no response was received. Despite these procedures, the facility did not ensure that the physician reviewed and acted upon the pharmacist's recommendations for Resident #29, leading to a deficiency in the resident's care.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to ensure that two residents received necessary dental services for broken teeth. Resident #25, who was admitted with moderate protein-calorie malnutrition, had most of their teeth missing or broken and had not seen a dentist since admission. Despite the resident's complaints of pain and requests to see a dentist, no dental appointments were made, and the resident's care plan did not address any dental issues. Observations confirmed the resident's poor dental condition, and interviews with staff revealed a lack of awareness and action regarding the resident's dental needs. Resident #51, admitted with a need for assistance with personal care, also had significant dental issues, including missing and broken teeth. The resident expressed a desire to see a dentist and have their teeth pulled and replaced with dentures. However, similar to Resident #25, no dental appointments were made, and the resident's care plan did not reflect any dental concerns. Staff interviews indicated that there was no proper documentation or follow-up on the resident's dental needs, and the facility's new computer system lacked a place to chart oral care or dental issues. Interviews with various staff members, including the Certified Medication Technician, Assistant Director of Nursing, Certified Nursing Assistant, Social Service Director, and Director of Nursing, highlighted systemic issues in the facility's handling of dental care. There was confusion about responsibilities, inadequate documentation, and a lack of follow-up on residents' dental needs. The facility's policy required regular dental assessments and care, but these were not consistently implemented, leading to the deficiency in providing necessary dental services to the residents.
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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