Cassville Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cassville, Missouri.
- Location
- 1300 County Farm Road, Cassville, Missouri 65625
- CMS Provider Number
- 265460
- Inspections on file
- 25
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 33 (2 serious)
Citation history
Health deficiencies cited at Cassville Health Care Center during CMS and state inspections, most recent first.
Food and beverages served to residents were found not to be consistently palatable, visually attractive, or maintained at a safe and appetizing temperature, as identified during a survey associated with two complaints.
Surveyors identified multiple deficiencies in food storage, preparation, and sanitation, including unclean kitchen surfaces, improper refrigerator temperatures, expired and improperly labeled food, and condiments left unrefrigerated. Staff failed to consistently log refrigerator temperatures and did not follow facility policies for food safety and sanitation, as confirmed by interviews with the Dietary Manager and Administrator.
A persistent fly infestation was observed throughout the facility, with flies present on residents, in their rooms, and in common areas. Multiple residents complained about flies, and some took steps to keep their doors closed. Several pest control devices were found non-functional, and external doors were left ajar or propped open, allowing flies to enter. Staff and residents reported the issue had been ongoing despite visits from a pest control company, and no effective changes were made to address the problem.
Several residents who required staff assistance did not receive showers according to their preferences or the facility's policy, with some going weeks without bathing. Residents and staff reported that the removal of a designated shower aide, unclear shower schedules, and insufficient staffing led to missed showers and unmet hygiene needs. Staff were often unaware of which residents needed showers and when, resulting in resident complaints and discomfort.
A resident with a colostomy, open abdominal wound, and need for ADL assistance did not have a comprehensive care plan addressing these needs. Staff confirmed that care plan meetings had stopped, and only fall risk was documented in the care plan, leaving critical care interventions unaddressed.
A resident with diabetes and a sulfa allergy suffered a foot injury that was not promptly or adequately assessed or treated by staff. Weekly skin assessments were inconsistently documented, a physician-ordered X-ray was delayed for several days, and staff administered a sulfa-containing antibiotic despite the resident's known allergy. The resident's condition worsened, leading to hospitalization for a toe fracture and infection. Staff interviews revealed confusion about responsibilities for wound care and assessment.
The facility did not have a licensed Administrator present or clearly identified, leading to confusion among staff and a lack of oversight. This resulted in insufficient nursing staff, residents not receiving necessary medications, a staff member under investigation for misappropriation returning to work, and an unlicensed driver transporting residents. Staff were unclear about reporting structures, and the absence of leadership contributed to failures in resident care and safety.
A nurse under investigation for misappropriation of funds and diversion of narcotics was allowed to return to work as the only nurse on duty, despite facility policy requiring suspension during such investigations. A resident with multiple chronic conditions, who had previously reported financial exploitation by the nurse, became fearful and considered leaving the facility due to the nurse's return. Staff interviews confirmed that the nurse's presence caused distress among residents and staff, and that established procedures for protecting residents during investigations were not followed.
A resident with chronic pain and a history of kidney disease did not receive prescribed PRN tramadol before dialysis due to LPNs and a CMT lacking access to the medication dispensing system and EMR. Despite reporting severe pain, only acetaminophen was administered, and staff did not notify management or the physician about the inability to provide the ordered medication. Documentation of the resident's pain and actions taken was incomplete, and leadership was unaware of the access issue until after the incident.
The facility did not maintain adequate nursing staff or a working schedule, resulting in nurses and CNAs working excessive hours, periods with only two staff caring for 44 residents, and times when the building was left unattended. This led to residents being left wet and soiled for extended periods and feeling unsafe, with staff and residents expressing concerns about the lack of care and supervision.
The facility allowed two LPNs to work as charge nurses without completing required pre-employment screenings, including criminal background checks, EDL and NA Registry checks, or verifying nursing licenses. Personnel files were not maintained for these staff, and they did not complete applications, orientation, or education prior to working. Staff interviews confirmed that these checks were not performed, and the Administrator was unaware of who authorized the LPNs to work.
The facility did not post the required daily nurse staffing information in a clear and accessible location for residents and visitors. Multiple staff members, including CNAs, RNs, LPNs, and the Business Office Manager, confirmed that the Nurse Staffing Sheet had not been posted or completed for several months, despite facility policy requiring daily updates and postings.
Facility staff did not ensure that two LPNs received the required two-step TB screening prior to working as charge nurses, as required by policy. The facility could not provide personnel files or TB test documentation for these LPNs, and interviews confirmed that they worked on the floor without the necessary screening.
The facility failed to maintain a fully functional call light system, resulting in two residents with significant care needs experiencing long waits for assistance with incontinence. The call system did not provide visual or audible alerts, and staff were not provided with pagers, requiring them to check a monitor at the nurses' station to identify calls. Staff interviews and resident reports confirmed delays in care, with residents left in soiled conditions for extended periods.
A staff member coerced a resident into providing money over several months and failed to repay damages caused by their child. The same staff member also dispensed large quantities of narcotic medication for another resident without a valid order, failed to document administration or destruction, and forged signatures on destruction logs. These actions were discovered through staff interviews, review of financial and medication records, and were not in accordance with facility policy.
Staff failed to follow physician-ordered monitoring parameters when administering medications to two residents with CHF and blood pressure concerns. Medications were given despite vital signs being outside ordered parameters or without checking and documenting required vital signs. Interviews with staff, including a CMT, LPN, DON, and the Administrator, confirmed inconsistent understanding and implementation of monitoring requirements and documentation practices.
Several residents with diabetes did not receive their ordered insulin or have their blood glucose checked because the assigned LPN lacked access to the EMR and medication dispensing system. Residents reported missed doses and staff interviews confirmed the nurse was unable to administer medications due to access issues and a physical limitation. Documentation was incomplete, and there was no care planning for medication management in some cases.
A facility allowed a Transport Driver with a suspended license, due to legal issues including drug paraphernalia possession, to transport multiple residents to physician appointments. Staff interviews and documentation showed that the driver continued to operate the facility's van after the license suspension, and several staff members were aware of the situation before it was formally addressed. The facility lacked a specific policy or job description for the Transport Driver, and there was confusion among staff about licensure requirements.
The facility did not maintain an effective pest control program, as evidenced by repeated and documented sightings of mice and mouse droppings in resident rooms, hallways, and activity areas. Staff and residents reported ongoing pest activity, but the pest control service only addressed the exterior of the building and was unaware of interior issues. The pest log was not reviewed by the pest control technician, and no interior rodent control measures were documented, resulting in continued pest presence.
Staff identified missing narcotic medications affecting three residents and reported the issue to the Administrator, but the facility did not notify DHSS or law enforcement within the required timeframe. Despite facility policy mandating immediate reporting of such allegations, the Administrator, after consulting with regional leadership, chose not to report the incident, resulting in noncompliance with mandatory reporting regulations.
A resident with multiple chronic conditions and moderate cognitive impairment developed a large, painful hematoma on the left lower leg. Staff did not immediately complete a skin assessment, failed to determine the cause of the injury, and delayed obtaining and documenting physician orders for an ultrasound and x-ray. There was inconsistent monitoring and documentation of the injury, and required notifications and follow-up were not properly recorded, contrary to facility policy.
A resident with multiple complex medical conditions received duplicate doses of Trelegy Ellipta due to two active orders for the same medication at different times on the MAR. Staff administered both doses on several days, despite facility policy requiring review and correction of discrepancies. Interviews revealed that LPNs and CMTs noticed the duplicate orders but did not consistently resolve them, and the DON confirmed that only one daily dose should have been given.
A CNA, who was also a nursing student but not licensed or certified as a medication technician, was allowed by the DON and an RN to administer medications and perform blood sugar checks for multiple residents. The CNA prepared and administered medications, scanned CGM systems, and documented readings in the MAR, actions confirmed by interviews with residents and staff. Facility policy and staff statements indicated that only licensed personnel should perform these tasks, but the CNA was permitted to do so without proper credentials or supervision.
A resident with hemiplegia and frequent incontinence was left wet for 30 to 40 minutes on multiple occasions due to staff failing to respond to call lights within the facility's 15-minute policy. Staff interviews confirmed that response times of up to 51 minutes occurred, with delays attributed to non-functional pagers and reliance on visual monitors at the nurses' station. The resident experienced repeated episodes of incontinence and emotional distress as a result.
A resident with severe cognitive impairment and a history of skin issues developed a rash in skin folds, but staff did not document timely application of prescribed Nystatin cream or notify the physician as required by facility policy and the care plan. Interviews confirmed the delay in treatment and lack of documentation, resulting in a deficiency related to failure to provide care according to orders and resident needs.
A resident's right to dignity and respect was violated when two CNAs, following the DON's instructions, entered the resident's room without permission, rearranged items, and discarded personal belongings such as newspapers and meal tray slips. The resident, who was cognitively intact and required significant ADL assistance, was not informed or present during the process and later expressed distress. Multiple staff interviews confirmed that the actions were inappropriate and not in line with facility policy, which requires staff to respect residents' property and obtain consent before handling personal items.
Two residents did not consistently receive prescribed topical medications as ordered, with staff failing to document administration or provide reasons for missed doses. Nursing staff did not always notify the physician or pharmacy when medications were unavailable or not given, and did not consistently follow facility policy for documentation and reporting. The DON and Administrator confirmed that medications were not administered as ordered and that required documentation and notifications were not completed.
The facility failed to maintain sanitation standards in the kitchen, with peeling paint and rust in the microwave posing contamination risks. Additionally, dogs brought by the DON were frequently present in the dining room during meals, against FDA guidelines, causing discomfort among residents and potential health risks.
The facility failed to address and follow up on concerns raised by residents during Resident Council meetings, as documented in meeting minutes from July to September 2024. Issues such as maintenance problems and cleanliness concerns were repeatedly raised without resolution. Interviews revealed that the Activity Director reported issues to morning meetings but did not ensure follow-up, and the Administrator acknowledged the lack of follow-up prior to September 2024.
The facility failed to maintain fire doors, causing mobility issues for residents. Observations showed malfunctioning magnetic hold-open devices, leading staff to prop doors open with chairs. Residents reported difficulties accessing the dining room, and the Maintenance Director acknowledged pending repairs. The Administrator confirmed ongoing issues since April 2024.
The facility failed to conduct necessary pre-employment NA Registry checks for a Dietary Aide, an LPN, and an RN, as required by their abuse prevention policy. This oversight allowed these staff members to begin work and have resident contact without verifying their eligibility to work in a certified LTC facility.
The facility failed to ensure the safety and effectiveness of medications by having expired medications in their carts, affecting at least two residents. An expired Naloxone nasal spray and Nitrostat tablets were found, along with a stock bottle of Geri-kot. The DON attempted periodic checks and audits, but these were not documented, leading to a lapse in medication management.
The facility failed to maintain a clean and comfortable environment, with resident rooms exhibiting floors with wax buildup and a persistent urine smell, and a hallway ceiling showing water damage. Housekeeping and maintenance staff identified issues with cleaning chemicals and delayed repairs, but necessary actions were not completed, compromising the facility's environment.
The facility failed to protect the rights of two residents to have and use their personal possessions during room changes. One resident's belongings were left unsecured in a hallway for two months, while another's items were left in their original room, which was used for storage. Both residents were distressed by the situation, and staff interviews indicated that housekeeping was responsible for moving belongings, but this was not adequately done.
Two residents in a facility with a census of 41 did not receive timely bathing assistance. One resident, with multiple health issues, reported not having a shower since July 2024, except for one instance after family intervention. Another resident, with COPD and diabetes, received infrequent showers, feeling dirty and needing more frequent bathing. Staff interviews revealed issues with shower scheduling and documentation, with CNAs unable to complete showers due to emergencies or staff shortages. The DON acknowledged no audits were conducted to ensure showers were completed.
A facility failed to obtain a physician's order before administering nystatin to a resident with reddened skin and did not timely collect a urine sample for another resident's urinalysis. The first resident, with a history of diabetes and erythema intertrigo, received treatment without an order, while the second resident, showing symptoms like confusion and vomiting, did not have a urine sample collected within the expected timeframe. Staff interviews revealed communication and procedural lapses.
A facility failed to provide adequate dialysis care for a resident with ESRD, resulting in a deficiency due to poor communication with the dialysis center and inconsistent monitoring of fluid intake and dialysis access sites. The resident's care plan included a renal diet and fluid restriction, but staff did not consistently document fluid intake or assess dialysis access sites. Communication between the facility and dialysis center was inconsistent, with reliance on phone calls instead of written forms, leading to a lack of awareness of the resident's laboratory results and dialysis issues.
The facility failed to provide necessary behavioral health services to two residents, one with a history of depression and psychosis and another with multiple sclerosis and depression. Both residents expressed a desire to speak with a psychologist, but the facility did not follow up on these requests. Staff interviews revealed a lack of awareness and procedures for referring residents to psychological services, and there was no psychologist visiting the facility.
The facility exceeded the acceptable medication error rate, reaching 8%, when two residents did not receive their prescribed medications. One resident did not receive pregabalin due to a delay in pharmacy delivery, while another missed a dose of Tylenol 325 mg because it was not in stock. The DON and Administrator indicated that staff should notify them if medications are unavailable, as they might be located elsewhere in the facility or obtained from a local pharmacy.
The facility failed to prevent significant medication errors for two residents. One resident with diabetes did not receive insulin according to physician orders, with nurses administering partial doses without proper documentation or physician notification. Another resident with end-stage renal disease missed multiple doses of medications due to absence and unavailability, with inadequate communication and documentation by staff. The facility's medication administration protocols were not effectively followed, leading to these deficiencies.
Failure to Provide Palatable and Proper-Temperature Food and Drink
Penalty
Summary
The deficiency involves failure to ensure that food and drink provided to residents were palatable, attractive, and maintained at a safe and appetizing temperature. Surveyors identified this concern in connection with complaints #2700845 and #2717249. The cited issues were associated with survey event ID 1D693E-H3, with an exit date of 02/02/26, indicating that during this survey event, observations or findings supported that meals and beverages did not consistently meet required standards for taste, appearance, and temperature.
Deficient Food Storage, Preparation, and Sanitation Practices Identified
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Surveyors observed multiple deficiencies, including unclean food contact and non-food contact surfaces, improper refrigerator temperatures, improper storage and sealing of food, and failure to discard spoiled or contaminated foods. Specifically, food contact surfaces such as the griddle and oven were found with significant grease and food debris, and storage shelves for pots, pans, and cutting boards contained crumbs and trash. Additionally, condiments requiring refrigeration were left at room temperature on dining tables, and a water cooler tray contained brown-stained water. Refrigeration units throughout the kitchen were found to be operating above the required temperature of 41 degrees Fahrenheit, with recorded temperatures ranging from 46 to 51.9 degrees Fahrenheit. Items such as milk, bologna, cheese, and prepared drinks were stored in these refrigerators, some of which were past their expiration or best-by dates. Staff failed to consistently log refrigerator temperatures as required by facility policy, and some food items were not properly sealed or labeled with accurate dates. The Dietary Manager acknowledged issues with staff compliance regarding cleaning and temperature monitoring protocols. The facility's own policies require food to be stored, thawed, and prepared according to sanitary practices, with all products dated and used or discarded within specified timeframes. However, observations revealed that these policies were not followed, as evidenced by expired food, improper labeling, and inadequate cleaning. The Administrator was unaware if temperature logs were being maintained every shift and could not confirm that all refrigerators were functioning within safe temperature ranges.
Failure to Maintain Effective Pest Control Program Resulting in Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in a persistent and widespread fly infestation throughout multiple areas. Observations revealed flies present in resident rooms, on residents' bodies, bedding, and personal items, as well as in common areas such as the dining room. Several residents reported being bothered by flies, with some taking measures such as keeping their doors closed and posting signs to remind staff to do the same. In one instance, a resident with an open wound had flies buzzing around the affected area, and another resident was observed eating while flies were present in the room. Multiple pest control devices, such as bug lights, were found to be non-functional, with bulbs either burnt out, dim, or replaced with inappropriate types. Key entry points, including external doors, were not properly secured; doors were observed to be ajar or propped open, allowing flies to enter the facility. Staff interviews confirmed that the fly problem had been ongoing for an extended period, with residents and staff both expressing frustration. Staff reported that the pest control company had visited, but the issue persisted, and no changes were made to the pest control treatment plan. Maintenance and administrative staff were aware of the problem, with maintenance attributing the fly entry to a broken courtyard door and residents propping doors open. Despite these known issues, there was no evidence of effective intervention or adjustment to the pest control strategy. The facility's failure to ensure operational pest control devices, secure entryways, and responsive pest management led to continued resident discomfort and a failure to meet the standards outlined in the facility's pest control policy.
Failure to Provide Showers According to Resident Preference and Facility Policy
Penalty
Summary
The facility failed to honor and facilitate resident choice regarding showering for five residents who required staff assistance. Multiple residents, including those with significant physical limitations, cognitive impairments, and at risk for skin issues, did not receive showers according to their preferences or the facility's stated policy. Documentation and interviews revealed that some residents received only one shower in a 30-day period, with gaps of up to three weeks or more between showers, despite expressing a desire for more frequent bathing and reporting discomfort such as itching and feeling unclean. Residents reported that when they requested showers, staff often told them there was not enough time or that there was no designated shower aide available. Staff interviews confirmed that the facility had recently removed the designated shower aide position, leaving CNAs responsible for showers in addition to their other duties. Staff were unclear about which residents needed showers, when showers were last provided, and how to access or use a shower schedule. Several staff members indicated that the workload was too heavy to complete all required showers, and that management had not provided adequate support or clear direction regarding shower scheduling and documentation. The lack of a consistent shower schedule, insufficient staffing, and poor communication among staff led to residents not receiving showers as per their preferences or care plans. Residents and staff both reported frustration with the situation, and the issue was brought to the attention of nursing and administrative leadership. Despite the facility's policy to provide showers per resident request or schedule, the failure to maintain a system for tracking and ensuring showers resulted in unmet hygiene needs for multiple residents.
Failure to Develop Comprehensive Care Plan for Resident with Colostomy and Wound
Penalty
Summary
Facility staff failed to develop and implement a comprehensive care plan for a resident with significant medical needs, including a colostomy, an open abdominal wound, and requirements for assistance with activities of daily living (ADLs). The only care plan in place addressed fall risk, with interventions limited to therapy referrals. No care plan interventions were documented for the resident’s colostomy care, wound management, or ADL support, despite these needs being clearly identified in the resident’s Minimum Data Set (MDS) and through direct observation. Observations revealed that the resident had a colostomy bag with feces present and an open abdominal wound with thick, yellow drainage, both of which were not addressed in the care plan. The resident reported that their abdominal bandage needed changing, and staff confirmed that care plans should include such interventions. Multiple staff interviews indicated that care plan meetings had ceased several months prior due to the former DON’s refusal to participate, resulting in care plans not being updated or developed for residents with new or ongoing needs. Staff, including the Social Service Director, LPN, and CMT, acknowledged that care plans were incomplete and not reflective of residents’ current care requirements. The Administrator and Senior Director of Regulatory Affairs confirmed that care plan meetings were not being held and that there was no clinical staff available to participate in the process. As a result, the resident’s care needs for colostomy management, wound care, and ADL assistance were not addressed in the care planning process.
Failure to Timely Assess, Treat, and Document Resident's Foot Injury and Allergy
Penalty
Summary
Facility staff failed to provide timely and adequate assessment and treatment for a resident who sustained a toe and skin injury. The resident, who had a history of chronic kidney disease, diabetes, and allergies to sulfa antibiotics, reported that their right foot was run over by another resident in a wheelchair. Despite physician orders for weekly skin assessments, documentation showed that these assessments were not consistently completed, with only one assessment documented in the month following the injury. Progress notes also lacked documentation of skin assessments during the critical period after the injury. When the resident reported pain and swelling in the right foot, staff contacted the physician and received a verbal order for a mobile X-ray. However, the X-ray was not obtained until four days after the order was placed, despite repeated requests from the resident and their family. During this period, the resident's condition worsened, with increased swelling, redness, and the development of an open, necrotic area on the toe. Staff interviews revealed confusion about responsibility for wound and skin assessments, and delays in both assessment and treatment were noted. Additionally, staff administered Bactrim DS, an antibiotic containing sulfa, to the resident despite a documented allergy to sulfa antibiotics. The medication was given on multiple occasions before being held after the resident's family raised concerns. The resident ultimately required hospitalization for evaluation and treatment of the foot injury, which was later diagnosed as a toe fracture with infection. Throughout the incident, there were multiple failures in timely assessment, documentation, communication, and adherence to physician orders and resident-specific allergies.
Failure to Maintain Licensed Administrator and Oversight Resulting in Lapses in Care and Safety
Penalty
Summary
The facility failed to ensure a licensed Administrator was available and actively involved in daily operations, resulting in significant lapses in care and oversight. The Administrator position was filled by an individual who did not possess a Missouri Administrator license, and there was confusion among staff regarding who the Administrator was. Staff were unable to identify the current Administrator, and the individual serving as Administrator was unaware of key events, such as ongoing investigations into misappropriation. The facility did not have a policy related to the Administrator role, and there was no Temporary Emergency Administrator License issued. Due to the lack of effective administrative oversight, the facility did not maintain sufficient nursing staff to meet resident needs, leading to residents being left wet for extended periods and nurses working excessive shifts. Staff did not have access to necessary medications, including insulin and pain medications, resulting in residents not receiving ordered treatments. Additionally, a staff member under investigation for misappropriation was allowed to return to work, causing at least one resident to feel unsafe and consider leaving the facility. The facility also allowed an unlicensed driver to transport residents to appointments, as there was no Administrator available to address the issue when it was discovered. Interviews with staff, including the Business Office Manager, LPNs, and the Medical Director, confirmed the absence of a licensed Administrator and the resulting confusion and lack of leadership. Staff were unclear about reporting structures and who to contact in the event of issues, such as the discovery of a suspended driver's license. The lack of administrative presence and oversight directly contributed to failures in resident care, medication administration, staffing, and resident safety.
Failure to Protect Resident During Investigation of Staff Misappropriation
Penalty
Summary
The facility failed to protect residents from potential abuse, neglect, exploitation, or mistreatment during an ongoing investigation of misappropriation involving a registered nurse (RN). Despite the facility's policy requiring immediate suspension and removal of any staff member accused of mistreatment pending investigation, the RN under investigation for both diversion of narcotics and misappropriation of resident funds was allowed to return to work as the only nurse on duty. This action was taken after the facility owner personally contacted the RN and requested their return, despite the ongoing investigation and the RN's prior termination for substantiated allegations. A resident with chronic obstructive pulmonary disorder, congestive heart failure, and an irregular heartbeat, who was cognitively intact, reported that the RN had solicited and received money from them on multiple occasions, both in cash and through a mobile payment app. The resident also reported that the RN's child broke their tablet. The resident only felt safe to report the financial exploitation after the RN was initially suspended. However, when the RN returned to the facility, the resident experienced significant fear and mental anguish, packed their belongings, and considered leaving the facility due to fear of retaliation. The RN attempted to contact and speak with the resident after returning to work, further exacerbating the resident's distress. Multiple staff members, including nurses and certified nurse aides, expressed concern and stated that the RN should not have been allowed to return to the facility while under investigation. Staff interviews confirmed that the RN was the only nurse on duty during their return and that the resident was visibly upset and fearful. The facility's own policies and staff statements indicated that accused employees should be suspended and removed from resident care areas pending investigation, but these procedures were not followed, resulting in the resident not being protected from further potential harm.
Failure to Provide Timely Pain Management Due to Medication Access Issues
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for a resident with chronic kidney disease, low blood pressure, and heart disease, who required pain control, particularly before dialysis treatments. The resident had physician orders for both scheduled pain assessments and as-needed (PRN) analgesics, including acetaminophen and tramadol. Despite these orders, staff did not administer the prescribed tramadol prior to dialysis, even when the resident reported severe pain rated at 8 out of 10. Instead, only acetaminophen was given, which the resident stated was less effective. Documentation showed that staff did not record the reasons for not administering tramadol, nor did they notify the physician or management about the inability to access the medication. Multiple interviews revealed that several LPNs and a Certified Medication Tech (CMT) were unable to access the medication dispensing system or the electronic medical records (EMR) due to lack of system access, especially for staff who did not regularly work at the facility. As a result, they could not administer PRN pain medications, including tramadol, as ordered. Staff were aware of the resident's pain and the usual practice of administering tramadol before dialysis, but were unable to fulfill this due to access issues. The resident repeatedly reported severe pain and distress, both verbally and through nonverbal cues, over the course of two days. Facility leadership, including the Social Services Director, Medical Director, and Administrator, confirmed that nurses should have had access to the medication dispensing system prior to starting their shifts. However, the Administrator was not aware of the access issues until after the events occurred. Staff interviews indicated that, in the absence of access, they did not escalate the issue to management or the physician in a timely manner, nor did they document the lack of access or the resident's ongoing pain in the medical record. This resulted in the resident not receiving prescribed pain management consistent with professional standards of practice and the resident's care plan.
Failure to Maintain Sufficient Nursing Staff and Scheduling
Penalty
Summary
The facility failed to maintain sufficient nursing staff to meet the needs of all residents, resulting in significant lapses in care and resident safety. Multiple interviews and record reviews revealed that the facility did not provide any working nursing staffing sheets or schedules when requested, and staff reported that no one was actively making the schedule. Staff were left to call each other for coverage, and there was no consistent use of agency staff despite a contract being in place. On several occasions, nurses and CNAs worked for over 30 consecutive hours without relief, and at one point, the building was left with only two staff members to care for 44 residents overnight. There were also periods when the building was left unattended for short durations. Staff interviews indicated that the lack of adequate staffing led to residents being left wet and soiled for extended periods, with some residents not being changed since early morning hours. Residents expressed concerns for their safety and well-being, reporting that they were unable to get assistance when needed and felt unsafe due to the absence of staff. The police were called to the facility after residents made multiple calls regarding their safety, and the police subsequently contacted the Department of Health and Senior Services. Staff also reported that the facility had not maintained staffing sheets for a long time, and the only time a staffing sheet was seen was during a state complaint investigation. The deficiency was further corroborated by statements from the facility's medical director and physician, who both indicated that two staff members were not sufficient to care for the resident census and that they expected the facility to have a working schedule and staffing sheet. The business office manager and other staff confirmed that the facility only had two nurses employed at the time and that the lack of a schedule had persisted for weeks. The administrator acknowledged the staffing shortages and the inappropriateness of leaving only one staff member in the building, as well as the absence of a working schedule prior to their arrival.
Failure to Complete Pre-Employment Screening and License Verification for Nursing Staff
Penalty
Summary
The facility failed to implement and follow its own policies and procedures designed to prevent abuse, neglect, and exploitation of residents by not completing required pre-employment screenings for two Licensed Practical Nurses (LPNs) before they began working with residents. Specifically, the facility did not conduct Criminal Background Checks (CBC), Employee Disqualification List (EDL) checks, Nurse Aide (NA) Registry checks, or verify nursing licenses for these staff members prior to their shifts. The facility also did not have personnel files for these LPNs, and there was no evidence that they completed employment applications, orientation, or required education before working. Interviews with staff and the Business Office Manager confirmed that the necessary background and licensure checks were not performed for the two LPNs. The LPNs themselves stated that they were not subjected to the required screenings or onboarding processes before working their shifts, and one LPN indicated they had not worked at the facility since earlier in the year. Observations confirmed that both LPNs worked as charge nurses without the facility having completed the mandated checks or maintaining their personnel files. Further interviews with other staff, including a Certified Medication Technician and the Medical Director, reinforced that the facility's standard practice was to complete all background and registry checks before allowing new staff to work with residents. The Administrator acknowledged that the required checks were not completed for the two LPNs and was unaware of who authorized them to work. The failure to follow established policies and procedures resulted in staff working with residents without proper vetting, as required by facility policy and regulatory standards.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the current daily nurse staffing information in a clear and readable format and in a prominent place readily accessible to residents and visitors, as required by its own policy. Multiple observations over several days confirmed that the Nurse Staffing Sheet was not displayed in the entry hall, at the nurses' station, or by the time clock. Staff interviews revealed that several employees, including CNAs, RNs, and LPNs, were unaware of the location of the Nurse Staffing Sheet or reported that it had not been posted for several months. The former DON, who was responsible for posting the sheet, admitted to not having posted it for at least four months. Further interviews with other staff, including the Business Office Manager and the Administrator, confirmed that the Nurse Staffing Sheet had not been completed or posted for an extended period, and no copies were available for review. The facility's policy required daily posting of the staffing sheet, including up-to-date information on licensed and unlicensed nursing staff, but this was not followed, resulting in a lack of accessible staffing information for residents and visitors.
Failure to Ensure Timely TB Screening for Staff
Penalty
Summary
Facility staff failed to fully implement their infection prevention and control program by not ensuring that two LPNs received the required two-step tuberculosis (TB) screening test prior to working on the floor, as mandated by facility policy. The policy required all new employees to receive a two-step PPD skin test upon hire and an annual one-step TB test thereafter, with documentation kept in employee files. However, the facility was unable to provide personnel files or TB test documentation for the two LPNs in question. One LPN confirmed during interview that they had worked on the floor without a TB test, and the Business Office Manager stated that neither LPN was an employee of the corporation or a staffing agency, and no TB test records were available for them. Multiple staff interviews, including with the facility physician and Medical Director, confirmed that staff should have a negative TB test prior to working with residents. The Administrator acknowledged that staff should have their first TB skin test read before working on the floor but was unaware of who authorized the LPNs to work or their employment status. Both LPNs worked as charge nurses without the required TB screening, and the facility census at the time was 44.
Failure to Maintain Functional Call Light System Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide a fully functional call light system for residents, as required by policy and state regulations. The call light system did not illuminate outside resident rooms or make an audible sound when activated, and staff were not provided with pagers to receive notifications of call lights. Instead, staff had to physically check a monitor at the nurses' station to determine if any call lights were on, which led to significant delays in response times, especially for staff assigned to areas distant from the nurses' station. The facility's previous exception to use a wireless call system with pagers had expired, and the required pagers were not available or functional for an extended period. Two residents were directly affected by these deficiencies. One resident, with diagnoses including COPD, stroke, diabetes, depression, and anxiety, required assistance with activities of daily living and was frequently incontinent. This resident reported waiting 15 to 30 minutes, and sometimes up to an hour, for staff to respond to call lights at night, resulting in urinating in bed and experiencing skin discomfort and embarrassment. Another resident, with chronic respiratory failure, depression, anxiety, and diabetes, also required substantial assistance and was frequently incontinent. This resident reported waiting up to an hour for staff to respond, resulting in having to lie in feces, which caused feelings of indignity and anger. Staff interviews confirmed the lack of functional pagers and the absence of visual or audible alerts from the call light system. Staff described the need to walk to the nurses' station to check for call lights, with some reporting that pagers had not been available for months and that residents had complained about delayed responses. Observations by surveyors corroborated that the call light system did not function as intended, with no lights or sounds activating when tested in resident rooms.
Misappropriation of Resident Funds and Controlled Substances by Staff Member
Penalty
Summary
A deficiency occurred when a staff member, specifically the former DON/RN, engaged in misappropriation of resident property and funds. One resident, who was cognitively intact and had diagnoses including COPD and CHF, reported that the DON/RN repeatedly requested and received money from them over several months. The staff member was aware of the resident's financial situation and coerced the resident into providing funds, both in cash and through a mobile payment app. The resident also reported that the staff member's child broke their tablet, and the staff member promised repayment, which did not occur. The resident only felt safe to report the incident after the staff member was suspended for a separate issue. Another deficiency involved the same staff member's handling of controlled substances for a different resident with severe cognitive impairment and diagnoses including dementia and Alzheimer's disease. The staff member dispensed significant quantities of hydrocodone/acetaminophen from the medication dispensing system for this resident, despite the absence of a corresponding physician order in the resident's medical record or medication administration record. There was no documentation of administration or proper destruction of these narcotics, and destruction logs were either missing or contained forged signatures. The staff member claimed to have destroyed the medications but failed to follow required documentation procedures and did not ensure a second nurse was present for destruction, as required by policy. Interviews with other staff confirmed that the staff member's actions were not in line with facility policy or standard practice. The discrepancies in medication dispensing and lack of proper documentation were discovered by other nurses, who reported the findings to administration. The staff member was found to have forged signatures and failed to document communications with the pharmacy or physician regarding the medication orders. The deficiencies were substantiated through review of witness statements, bank records, medication dispensing logs, and interviews.
Failure to Follow Physician-Ordered Monitoring Parameters During Medication Administration
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications by not following physician-ordered monitoring parameters during medication administration. For one resident with diagnoses of congestive heart failure (CHF) and high blood pressure, staff administered metoprolol tartrate despite physician orders to hold the medication if the resident’s systolic blood pressure was 110 mm/Hg or less or if the heart rate was below 65 beats per minute. Documentation showed that the medication was given multiple times when the resident’s heart rate was below the ordered threshold, with recorded heart rates as low as 42 beats per minute. Another resident with CHF and orthostatic hypotension had a physician order for Entresto, with instructions to hold the medication if the standing systolic blood pressure was less than 100 mm/Hg. Staff administered this medication twice daily over a period of several weeks without consistently checking or documenting the resident’s blood pressure prior to administration, as required by the order. The vital sign summary indicated that blood pressure was only recorded once during this period, and staff interviews confirmed a lack of awareness and compliance with the monitoring requirements. Interviews with facility staff, including a Certified Medication Technician, an LPN, the Director of Nursing, and the Administrator, revealed inconsistent understanding and implementation of the policy regarding medication administration with vital sign parameters. Staff acknowledged that vital signs should be checked and documented on the medication administration record (MAR) when required by physician orders, but there was no designated place on the MAR for this documentation, and the required monitoring was not consistently performed.
Failure to Administer Insulin Due to Lack of Staff Access
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors when staff did not administer insulin as ordered for three residents with diabetes. The residents had physician orders for specific types and dosages of insulin, including scheduled and sliding scale doses, as well as orders for regular blood glucose monitoring. On the morning in question, documentation showed that blood sugar checks and insulin administrations were not completed or recorded for these residents. Progress notes did not provide explanations for the missed doses, and residents reported not receiving their insulin or having their blood sugar checked. Interviews with the affected residents revealed that they were aware of the missed insulin doses and expressed concern about their blood sugar levels. One resident was observed to be flushed and worried, another reported not receiving insulin or having blood sugar checked, and a third appeared fatigued and unable to hold a conversation. All three residents stated that staff informed them the nurse on duty did not have access to administer insulin or check blood sugar levels. The Medication Administration Records (MARs) and progress notes corroborated the lack of documentation and administration for the scheduled insulin doses and blood glucose checks. Staff interviews confirmed that the nurse assigned to administer medications that morning did not have access to the electronic medical records (EMR) or the medication dispensing system, and was therefore unable to provide the required insulin. The nurse also reported having a broken hand, further limiting their ability to administer medications. Other staff members and facility leadership acknowledged that access to the medication system should have been provided prior to the start of the shift, and that residents should receive medications as ordered. The deficiency was further substantiated by the lack of care planning for medication management in some residents' records and the absence of communication to the physician regarding missed doses.
Unlicensed Transport Driver Provided Resident Transportation
Penalty
Summary
The facility failed to comply with Federal, State, and local laws and professional standards by allowing a Transport Driver with a suspended driver's license to transport four residents to physician appointments. Documentation and interviews revealed that the Transport Driver's license was suspended due to legal issues, including charges for driving while license suspended/revoked and unlawful possession of drug paraphernalia. Despite the facility's policy requiring verification and maintenance of valid licensure for personnel, the Transport Driver continued to operate the facility's van and transport residents on multiple occasions after the suspension of their license. Staff interviews indicated that several employees, including a CNA, NA, and the Business Office Manager, were aware of the Transport Driver's suspended license, with some learning about it through direct communication or by checking online records. The Business Office Manager confirmed that the driver continued to transport residents until the issue was brought to their attention by other staff. The facility did not provide a policy or job description specific to the Transport Driver, and there was confusion among staff regarding the licensure requirements for operating the facility's van. The Medical Director stated that it would not be expected for anyone with a suspended license to serve as the transport driver.
Failure to Implement Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in multiple reported and observed sightings of mice and mouse droppings in various areas, including resident rooms and common areas. The pest control policy required a written agreement with an outside pest service for regular and comprehensive pest control, including both interior and exterior measures, and a system for reporting and addressing pest issues between scheduled visits. Despite this, the pest control service only provided rodent control measures for the exterior of the facility, and no interior rodent pest control actions were documented, even after repeated reports of mice inside the building. Staff and residents reported frequent sightings of mice and mouse droppings in resident rooms, hallways, and activity areas over a period of several weeks. Specific observations included mouse droppings in residents' clothing drawers and closets, mice running in hallways and rooms, and mice jumping out of a resident's wardrobe drawer. Staff consistently documented these sightings in a pest log, but the pest control technician was unaware of these reports and had not reviewed or signed the logbook. Residents and staff reported that traps placed in rooms were ineffective, and the issue persisted nightly, particularly in the back hall and specific resident rooms. Interviews with staff, including housekeepers, CNAs, and the DON, confirmed ongoing pest activity and a lack of effective response. The pest control technician stated that he was only responsible for exterior rodent control and was not made aware of interior pest issues until the surveyor's inquiry. The administrator was unsure if the pest control company reviewed the pest logbook and acknowledged that the company had not signed it. The facility's failure to coordinate and implement interior pest control measures, despite ongoing reports and documentation of pest activity, led to the uncorrected deficiency.
Failure to Timely Report Medication Misappropriation Allegation
Penalty
Summary
The facility failed to report an allegation of misappropriation of medications to the Department of Health and Senior Services (DHSS) and law enforcement within the required twenty-four hour timeframe. Staff discovered missing narcotic medications for three residents and reported the issue to the Administrator. The facility's policy requires immediate reporting of all allegations of abuse, neglect, exploitation, or misappropriation to the appropriate agencies, including the state agency, within prescribed timeframes. Despite this, documentation showed that the facility did not notify DHSS regarding the misappropriation allegation. The investigation revealed that a possible diversion of medications was identified when staff noticed unaccounted-for narcotic medications and discrepancies in the medication dispensing records. Specifically, more hydrocodone/acetaminophen tablets were dispensed than ordered, and destruction logs provided by the implicated nurse appeared altered. The nurse in question was suspended pending investigation, but there was no evidence that the incident was reported to DHSS as required by policy and regulation. Interviews with various staff members, including LPNs, CNAs, and CMTs, indicated that they understood the requirement to report allegations of misappropriation to the Administrator and that the Administrator was responsible for reporting to DHSS within two hours. However, the former Administrator stated that after consulting with regional leadership, it was decided not to report the incident to DHSS, resulting in a failure to comply with mandatory reporting requirements.
Failure to Monitor, Assess, and Document Bruising and Delayed Diagnostic Orders
Penalty
Summary
Facility staff failed to provide care according to standards of practice for a resident with multiple diagnoses, including congestive heart failure, high blood pressure, expressive aphasia, and depression. The resident, who had moderate cognitive impairment and was independent with activities of daily living, reported a large, painful bruise on the left lower leg. The nurse observed a significant hematoma and bruising but did not immediately determine the cause, question staff about possible injury or falls, or complete a skin assessment at the time of discovery. The nurse notified the DON, physician, and family, but there was a delay in obtaining and documenting physician orders for diagnostic tests. Physician orders for an extremity ultrasound and a tibia/fibula x-ray were not obtained until three days after the bruise was discovered. There was also a delay in completing the ordered tests due to an error in the order and equipment brought by the technician. Staff failed to document the process and results related to the ultrasound and x-ray in the resident's progress notes. Additionally, there was no documentation of a fall on the date the bruise was discovered, and staff did not consistently monitor or document the resident's condition or the status of the bruise in subsequent progress notes and skin assessments. Interviews with nursing staff and the DON confirmed that the nurse should have completed a skin assessment upon discovery of the bruise, monitored the bruise every shift, and documented all notifications and results. The DON was unaware of the delay in entering the diagnostic orders and noted that the nurse incorrectly documented a fall. The facility's policy required prompt notification and documentation of changes in condition, but these procedures were not followed, resulting in a lack of timely assessment, monitoring, and documentation for the resident's injury.
Duplicate Medication Orders Result in Administration Errors
Penalty
Summary
The facility failed to ensure proper pharmaceutical services and medication administration systems, resulting in a resident receiving duplicate doses of Trelegy Ellipta, an inhaled medication intended for once-daily use. Staff entered two separate orders for the same medication for the same resident, one at 7:00 A.M. and another at 9:00 A.M., and subsequently administered both doses on multiple days as documented in the Medication Administration Record (MAR). The facility's policy required staff to review the MAR, administer medications as ordered, and correct any discrepancies, but these procedures were not followed. The resident involved had significant medical conditions, including stage 4 kidney disease, general anxiety disorder, major depression, hypertension, blindness in one eye, and impaired thought processes related to metabolic encephalopathy. The care plan specified that staff should administer medications as ordered and monitor for side effects and effectiveness. Despite this, the MAR contained duplicate orders for Trelegy Ellipta, and staff administered the medication twice daily on several occasions, contrary to the physician's order for once-daily administration. Interviews with staff revealed that both LPNs and Certified Medication Technicians were aware of duplicate orders appearing on MARs but did not consistently take action to resolve the issue. Some staff attempted to discontinue extra orders when errors were found, while others were unsure why duplicate orders existed. The Director of Nursing confirmed that only one dose per day should have been administered and that staff should have recognized and reported the duplicate order. The administrator stated that nursing should verify that the MAR matches the prescription before administering medication.
Unlicensed Personnel Administered Medications and Performed Blood Sugar Checks
Penalty
Summary
The facility failed to ensure that only appropriately licensed personnel administered medications and performed blood sugar checks for residents. According to the facility's own policy, only individuals licensed or permitted by the state are allowed to prepare, administer, and document medication administration. However, a certified nurse aide (CNA), who was also a nursing student but not yet licensed or certified as a medication technician, was permitted by the Director of Nursing (DON) to administer medications and perform blood sugar checks for multiple residents. The CNA was observed by residents and staff administering medications and conducting blood glucose monitoring without direct supervision in resident rooms. Interviews revealed that the DON called the CNA to the facility specifically to allow the CNA to practice medication administration and blood sugar checks, despite the CNA not having completed the required clinical check-offs or holding the necessary certification. The DON and a registered nurse (RN) prepared medications and provided them to the CNA, who then administered them to residents. The DON initially observed and assisted the CNA but later left the facility, leaving the RN to oversee the CNA. The CNA administered medications to 22 residents and performed blood sugar checks on three residents during a single shift, including scanning continuous glucose monitoring (CGM) systems and documenting readings in the medication administration record (MAR). Other staff, including a certified medication technician (CMT), LPN, and RN, confirmed that medication administration and blood sugar checks were not within a CNA's scope of practice and that only nurses or CMTs should perform these tasks. The administrator also acknowledged that CNAs should not administer medications or perform blood sugar checks or CGM scans. The facility's failure to adhere to its own policy and state regulations resulted in unlicensed personnel administering medications and performing clinical tasks reserved for licensed staff.
Failure to Respond Timely to Call Light Results in Prolonged Incontinence Episode
Penalty
Summary
A deficiency occurred when staff failed to respond to a resident's call light in a timely manner, resulting in the resident being left wet for an extended period. The facility's policy required staff to respond to all call lights within 15 minutes, with incontinence needs considered high-priority. However, documented call light response times for the resident ranged from approximately 28 to 51 minutes over several days, far exceeding the facility's policy and expectations. Multiple staff interviews confirmed that these response times were not appropriate and that staff should not wait 30 minutes or longer to answer a call light. The resident involved had significant medical needs, including a history of stroke with right-sided hemiplegia, frequent urinary incontinence, and dependence on staff for toileting and personal hygiene. The resident was cognitively intact and able to communicate needs, activating the call light before needing to use the restroom. Despite this, the resident reported being left wet for 30 to 40 minutes while waiting for assistance, leading to episodes of incontinence and emotional distress. The resident also filed a grievance regarding the delayed call light response, stating that the issue persisted and had not been addressed. Staff interviews revealed that the call light system relied on visual monitors at the nurses' station, and pagers intended to alert staff were not operational or missing. Staff acknowledged that any team member could answer a call light, but delays were common, especially during shift changes or when staffing was low. The charge nurse and DON were identified as responsible for ensuring timely responses, but the lack of functional pagers and inconsistent monitoring contributed to the prolonged response times experienced by the resident.
Failure to Timely Treat and Document Skin Rash in Resident
Penalty
Summary
Staff failed to provide timely treatment and care for a resident who developed a rash, as required by facility policy and the resident's care plan. The resident, who had diagnoses including dementia, schizophrenia, and anxiety, was identified as being at risk for impaired skin integrity and had a history of moisture-associated skin damage in the abdominal folds. Weekly skin observation tools documented redness and yeast under the resident's breasts and abdominal folds, but there was no documentation of physician notification or timely application of prescribed Nystatin cream during multiple periods when the rash was observed. The resident's care plan required weekly skin assessments, physician notification of new skin impairments, and implementation of treatment orders. Despite this, staff did not document applying the as-needed Nystatin cream to the affected areas from the time the rash was first observed until several weeks later. Additionally, there was no documentation in the progress notes explaining why the treatment was not administered, nor was there evidence that the physician was notified of the change in the resident's skin condition during this period. Interviews with staff, including an LPN and the DON, confirmed that the resident frequently developed yeast rashes and had an as-needed order for Nystatin cream, which later became a scheduled treatment. However, the DON was unaware of the delay in treatment, and the Administrator stated that staff should assess, document, and notify the physician when new skin issues are identified. The lack of timely treatment and documentation constituted a failure to follow facility policy and the resident's care plan.
Failure to Honor Resident's Right to Dignity and Personal Possessions
Penalty
Summary
Two certified nursing assistants (CNAs) entered a resident's room without the resident's knowledge or permission and proceeded to rearrange items and remove personal belongings. The CNAs discarded newspapers, meal tray slips, and possibly magazines, and moved the resident's food to a different location. The resident, who was cognitively intact but required significant assistance with activities of daily living, was not present during this process and was not informed beforehand. The resident later expressed distress, stating that the items removed were important and that staff should have sought permission before handling personal property. Interviews with the involved CNAs confirmed that they did not ask the resident for permission before rearranging the room or discarding items. The CNAs stated they were acting on instructions from the Director of Nursing (DON), who cited safety and fire hazard concerns. However, both CNAs acknowledged that it was inappropriate to remove or rearrange a resident's belongings without consent, recognizing that the resident's room is their home and their property should be respected. Other staff members, including additional CNAs, a certified medication technician, an LPN, the business office manager, the social services director, and the housekeeping supervisor, all agreed that the actions taken did not treat the resident with dignity and respect, and that staff should not handle residents' belongings without their knowledge or permission. The DON admitted to instructing the CNAs to remove newspapers and acknowledged that permission from the resident was not obtained. The DON, along with the administrator and other staff, agreed that the resident was not treated with dignity and respect, and that the resident's right to retain and use personal possessions was not honored. Facility policies reviewed during the investigation emphasized the importance of treating residents with dignity and respect, including respecting their private space and property, and ensuring residents are informed and procedures are explained before being performed.
Failure to Accurately Administer and Document Topical Medications
Penalty
Summary
The facility failed to ensure accurate administration and documentation of topical medications as ordered by physicians for two residents. For one resident with diagnoses including COPD, asthma, and diabetes, there were multiple instances where triamcinolone acetonide cream was not documented as administered on both day and evening shifts, with some entries lacking reasons for missed doses or simply noting the resident was sleeping. The resident's care plan required medication administration per physician's orders and reporting of any adverse effects, but the medication administration records (MAR) and progress notes showed repeated omissions and insufficient documentation. Another resident, with severe cognitive impairment and a history of diabetes and bullous pemphigoid, also experienced missed and undocumented doses of both triamcinolone and clobetasol creams. Orders required these topical medications to be applied twice daily to specific areas, but the MAR and progress notes revealed several days where applications were not documented, reasons were not provided, or the medication was noted as unavailable. Staff interviews confirmed that nurses were responsible for applying these medicated creams and that any missed doses or unavailable medications should have been documented, with the physician and pharmacy notified as per facility policy. Interviews with the DON and Administrator confirmed that the residents did not receive their medications as ordered and that staff failed to document reasons for missed doses or notify appropriate parties. The DON also identified issues with staff not properly checking both the MAR and TAR for medication orders, contributing to the missed applications. Facility policy required immediate reporting and documentation of any discrepancies in medication administration, which was not consistently followed in these cases.
Sanitation and Animal Control Deficiencies in Dining and Kitchen Areas
Penalty
Summary
The facility failed to maintain proper sanitation and safety standards in the kitchen, leading to potential food contamination. Observations revealed a significant area of peeling paint on the ceiling above the food preparation table, which had been in that condition since at least June 2024. Additionally, a gap was noted between a repair material and the ceiling, and the microwave had a discolored and rusted area due to peeling paint. Interviews with staff, including a Dietary Aide and the Dietary Manager, confirmed awareness of these issues, but they had not been addressed, posing a risk of contamination to food being prepared. Furthermore, the facility allowed dogs in the dining room during meal times, which is against the FDA Food Code 2022 due to the risk of disease transmission from animals. The Director of Nursing (DON) regularly brought two dogs to the facility, and these dogs were observed in the dining room during resident meals. Residents expressed discomfort with the presence of dogs during meals, and staff confirmed that the dogs occasionally urinated and defecated in the facility, including the dining room. Interviews with various staff members, including the Dietary Manager and the Housekeeping Supervisor, indicated that the presence of dogs in the dining room was a known issue. Despite attempts to keep the dogs out, they frequently entered the dining area during meal times. The Administrator acknowledged that the dogs should not be in the dining room during meals, but the issue persisted, contributing to the deficiency in maintaining a safe and sanitary dining environment.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to provide a fully functioning Resident Council Group by not addressing and providing feedback on concerns expressed by residents during council meetings. The facility's policy supports residents' rights to organize and participate in the Resident Council, which serves as a forum for residents to voice concerns and suggestions for improvement. However, the review of Resident Council Meeting Minutes from July to September 2024 revealed that various issues raised by residents, such as missing personal items, maintenance problems, and cleanliness concerns, were not documented as resolved or followed up on in subsequent meetings. Interviews with residents and staff further highlighted the lack of follow-up on issues raised during council meetings. Residents expressed frustration that their concerns, such as broken doors and spider webs, were not addressed over several months. The Activity Director admitted to taking notes and reporting issues to morning meetings but acknowledged that there was no additional follow-up or resolution of the concerns. The Administrator confirmed that prior to September 2024, there was no follow-up on issues from previous months, and staff were expected to address concerns but failed to report back to the Resident Council.
Failure to Maintain Fire Doors Causes Resident Mobility Issues
Penalty
Summary
The facility failed to maintain the fire doors, resulting in difficulties for residents moving about the facility. Observations during the survey period revealed that the smoke barrier doors were not functioning properly, with magnetic hold-open devices failing to operate as intended. This issue was noted on the 200 hall, where a smoke door was held open due to a sticky or warped floor. Residents reported that the magnetic hold-open devices had been non-functional since July 2024, leading staff to prop open the doors with chairs. This situation was documented in Resident Council Meeting Minutes from July and August 2024, where residents expressed concerns about the fire/smoke doors being closed and not working. Several residents, including those with mobility challenges, reported difficulties in accessing the dining room due to the malfunctioning doors. Interviews with residents and staff confirmed that the doors had been propped open with chairs, and some residents had to wait for assistance to pass through the smoke barrier doors. The Maintenance Director acknowledged the issues with the magnetic holders and stated that repairs were pending. The Administrator confirmed that the problem had been ongoing since April 2024 and that an in-service was conducted to address the issue of doors being propped open. However, the Administrator was unaware of specific issues with the Cardinal hall smoke doors.
Failure to Conduct Pre-Employment NA Registry Checks
Penalty
Summary
The facility failed to fully implement its abuse prevention policy by not conducting necessary pre-employment checks on three staff members before they began working and having contact with residents. Specifically, the facility did not perform a Nurse Aide (NA) Registry check, which is crucial to ensure that potential employees do not have a history of abuse, neglect, or misappropriation of property that would disqualify them from working in a certified long-term care facility. This oversight affected a Dietary Aide, a Licensed Practical Nurse, and a Registered Nurse, all of whom were hired without the required registry checks. During interviews, the Business Office Manager admitted to not conducting the NA Registry check for the Dietary Aide because it was their first job, and acknowledged that the checks for the LPN and RN were overlooked. The Administrator confirmed that it was expected for staff to check the NA Registry for all new employees to ensure no federal indicators were present. The facility's policy clearly outlined the necessity of these checks as part of the pre-employment screening process, which includes criminal history, background, and misconduct registry checks.
Expired Medications Found in Facility's Medication Carts
Penalty
Summary
The facility failed to ensure the safety and effectiveness of physician-ordered medications by having expired medications in their medication carts, affecting at least two residents. During an observation, it was found that the facility had an expired box of Naloxone nasal spray, used for treating narcotic overdose, with a manufacturer's expiration date of June 2024, intended for one resident. Additionally, an expired bottle of Nitrostat sublingual tablets, used for treating chest pain, with an expiration date of February 2024, was found in the nurse medication cart for another resident. Furthermore, a stock bottle of Geri-kot, used to treat constipation, with an expiration date of March 2024, was also found in the medication cart. Interviews with the Director of Nursing (DON) revealed that there was an attempt to periodically check the medication carts and medication room for expired medications. The DON mentioned that audits of the medication room were conducted every two weeks, and night nurses were supposed to start auditing the medication carts for expired medications in September 2024, but these audits were not documented. The DON also suspected that the expired Naloxone might have been mistakenly left on the crash cart and not returned to the pharmacy for replacement, indicating a lapse in the medication management process.
Environmental Deficiencies in Resident Rooms and Hallway
Penalty
Summary
The facility failed to maintain a functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by the condition of the floors and ceilings. Observations revealed that several resident rooms had floors with a buildup of a black, gummy substance, chipped tiles, and a tacky texture due to wax buildup. The floors were not cleanable, and there was a persistent urine smell in some rooms. Interviews with housekeeping staff indicated that the cleaning chemicals used were ineffective and contributed to the wax buildup, making it difficult to clean the floors properly. Maintenance had not stripped or re-waxed most of the rooms, despite identifying the issue months prior. Additionally, the facility had a ceiling in disrepair in the Cardinal Hall, with a large dried brown stain, sagging sheetrock, and exposed drywall tape. This damage was attributed to a water leak that occurred months earlier, which had not been repaired. Interviews with residents and staff confirmed the presence of the ceiling damage and expressed concerns about the potential for further deterioration. The Administrator acknowledged the issue but had delayed repairs pending further plumbing work. The facility's failure to address these environmental deficiencies compromised the cleanliness and safety of the living environment. Despite identifying the issues and discussing potential solutions, the necessary maintenance and housekeeping actions were not completed, leading to ongoing concerns about the facility's ability to provide a homelike and sanitary environment for its residents.
Failure to Protect Residents' Personal Possessions During Room Changes
Penalty
Summary
The facility failed to protect the rights of two residents to have and use their personal possessions when they were moved to different rooms. Resident #3 was moved due to water issues in their room, and their belongings, including personal items and furniture, were placed in an unsecured area at the end of the hall. This situation persisted for almost two months, causing frustration and distress to the resident, who repeatedly inquired about returning to their original room. Resident #27 was relocated to allow for air conditioner replacement in their room. Some of their personal items, such as pictures and crafts, were left in the original room, which was subsequently used for storage by maintenance. The resident was not informed about when they could return to their room, and staff did not assist in moving their belongings, leading to the resident feeling upset about the situation. Interviews with staff, including the Certified Medication Tech, Certified Nurse Aide, Social Services Director, and Housekeeping Supervisor, revealed that housekeeping was responsible for moving residents' belongings during room changes. However, in both cases, not all belongings were moved with the residents, and the residents were left uncertain about the status of their original rooms and their personal items.
Failure to Provide Timely Bathing Assistance
Penalty
Summary
The facility failed to provide timely assistance with bathing for two residents, Resident #28 and Resident #14, in a facility with a census of 41. Resident #28, who has multiple diagnoses including multiple sclerosis and end-stage renal disease, required extensive assistance for showers. Despite this, the resident reported not having a shower or bed bath since July 2024, except for one shower on September 23, 2024, after a family member intervened. The Director of Nursing (DON) was unaware of the extent of missed showers and did not receive any complaints from the resident's family. Resident #14, with diagnoses including COPD and Type II diabetes, also experienced infrequent showers. The resident reported feeling dirty and expressed a need for more frequent showers, ideally at least two per week. However, the facility's records showed that the resident received only three showers in August 2024 and two in September 2024. The resident noted that staff often did not have time to assist with showering, leading to infrequent bathing. Interviews with staff revealed systemic issues in the facility's shower scheduling and documentation processes. Certified Nurse Aides (CNAs) were responsible for completing showers, but often could not fulfill this duty due to emergencies or staff shortages. The DON acknowledged that no audits were conducted to ensure showers were completed, and there were issues with the electronic documentation system. The facility lacked a dedicated shower aide every day, and the DON was expected to ensure residents received their scheduled showers.
Failure to Obtain Physician Orders and Timely Urine Sample Collection
Penalty
Summary
The facility failed to adhere to standards of practice by not obtaining a physician's order before administering treatment to a resident with reddened skin. Resident #1, who had a history of diabetes, morbid obesity, and erythema intertrigo, was observed with moist, reddened skin under the abdominal fold. Despite the facility's policy requiring physician orders for treatments, staff applied nystatin to the resident's skin without an order. Interviews with staff revealed a lack of awareness about the need for an order and the presence of redness under the resident's skin fold. Additionally, the facility did not timely obtain a urine sample for a urinalysis ordered for Resident #11, who had diagnoses including diabetes, dementia, and stroke. The resident exhibited symptoms such as increased confusion and vomiting, prompting a physician to order a urinalysis. However, the facility failed to collect the urine sample within the expected timeframe. Interviews indicated a breakdown in communication and procedure, as staff were unsure if the sample had been collected and did not follow up with the physician or other staff members. The deficiencies highlight issues in communication and adherence to protocols within the facility. Staff interviews revealed inconsistencies in following procedures for obtaining physician orders and collecting necessary samples. The Director of Nursing and Administrator acknowledged the lapses, emphasizing the need for staff to follow orders and communicate effectively to ensure timely and appropriate care for residents.
Inadequate Dialysis Care and Communication Deficiency
Penalty
Summary
The facility failed to provide adequate dialysis care and services for a resident with end-stage renal disease (ESRD), leading to a deficiency in communication and collaboration with the dialysis center. The facility did not consistently monitor the resident's fluid intake as per the care plan, nor did they implement necessary interventions to manage dialysis treatment effectively. The resident's care plan included a renal diet and a 1500 ml fluid restriction, but staff did not consistently document fluid intake during meals, and the resident reported that staff did not monitor their fluid intake, relying instead on the resident to self-monitor. The facility also failed to maintain effective communication with the dialysis center. The communication process between the facility and the dialysis center was inconsistent, with the facility relying on phone calls rather than written communication forms, which had been discontinued. The resident's dialysis book, which was supposed to contain communication forms and laboratory results, was not regularly checked by facility staff, leading to a lack of awareness of the resident's current laboratory results and dialysis-related issues. The resident experienced multiple issues with a clogged shunt, requiring hospital visits and shunt revisions, yet there was no consistent documentation or communication regarding these events. Additionally, the facility did not adequately assess and monitor the resident's dialysis access sites. The resident reported that nurses did not check their ports or shunts for bruits and thrills, and staff interviews confirmed that the assessment of these sites was not consistently performed. The facility's failure to weigh the resident before and after dialysis, as previously done, further contributed to the deficiency in monitoring the resident's condition. The lack of consistent documentation and communication between the facility and the dialysis center, along with inadequate monitoring of the resident's fluid intake and dialysis access sites, led to a deficiency in providing safe and appropriate dialysis care for the resident.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to ensure that two residents received necessary behavioral health services to maintain their highest practical psychosocial well-being. Resident #24, who had a history of depression, psychosis, and anxiety, expressed a desire to see a psychologist following a recent amputation. Despite this, the facility did not update the resident's care plan to include non-pharmacological interventions or a referral to a psychologist. Observations revealed that the resident remained in a dark room, feeling depressed and expressing a willingness to talk to a psychologist if available. Interviews with staff indicated a lack of awareness and follow-up regarding the resident's psychological needs. Resident #28, diagnosed with multiple sclerosis, diabetes, and depression, also exhibited signs of depression and expressed a desire to speak with a psychologist. The resident's care plan included provisions for psychological services if requested, but no such services were offered. Interviews with staff revealed that the resident's mood had recently worsened, yet there was no follow-up on the resident's request for psychological support. The Social Services Designee (SSD) and other staff members did not routinely ask residents if they wanted to speak with a psychologist, and there was no psychologist visiting the facility. The facility lacked a systematic approach to addressing the behavioral and mental health needs of its residents. Staff interviews highlighted a general unawareness of the procedures for referring residents to psychological services. The Director of Nursing (DON) acknowledged the absence of a visiting psychologist and the challenges in scheduling appointments due to residents' other medical commitments. The facility was in the process of developing a system to address these needs but had not yet implemented it effectively.
Medication Error Rate Exceeds 5% Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate during a medication pass observation. This deficiency was identified when staff failed to administer ordered medications to two residents. One resident, diagnosed with diabetes mellitus type II, diabetic neuropathy, and chronic pain, did not receive their prescribed pregabalin due to the medication not being available at the facility. The LPN responsible for administering the medication indicated that the pharmacy was awaiting a new physician's prescription before dispensing the medication. Another resident, diagnosed with unspecified osteoarthritis, did not receive their prescribed Tylenol 325 mg tablets. The CMT responsible for administering the medication noted that the facility did not have the medication in stock. Despite searching the medication cart and storage room, the CMT could not locate the Tylenol and documented it as unavailable. The DON later purchased the medication from a store but was unaware that the resident had missed their dose. Interviews with the DON and Administrator revealed that staff were expected to notify the DON if a medication was unavailable, as it might be located elsewhere in the facility. The facility's pharmacy was located out of town, necessitating a backup plan for obtaining medications locally if needed. The failure to administer the ordered medications was considered a medication error, and staff were expected to follow physician orders and notify the pharmacy and physician if medications were unavailable.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, particularly in the administration of insulin and other medications. For one resident with diabetes, the nursing staff did not administer insulin according to the physician's sliding scale orders. The resident often requested partial doses of insulin, which the nurses administered without notifying the physician or documenting the partial doses in the medical records. The resident's care plan lacked specific interventions related to blood glucose and insulin usage, and there were no documented instructions for insulin dosage for certain blood glucose levels. Another resident with end-stage renal disease and dependence on dialysis did not receive multiple doses of medications prescribed to manage chronic kidney disease. The resident frequently missed doses of Veltassa and Auryxia due to being absent from the facility or medication unavailability. The facility's process for ordering and administering these medications was inconsistent, and there was a lack of communication between the staff and the pharmacy regarding medication delivery. The resident's care plan did not accurately reflect the current medications or dietary recommendations necessary for managing elevated phosphorus levels. Interviews with staff revealed a lack of adherence to medication administration protocols and insufficient documentation of medication errors. The facility's Director of Nursing (DON) and other staff members acknowledged the issues with medication administration and documentation but failed to take appropriate actions to rectify the situation. The facility's policies and procedures for medication orders were not effectively implemented, leading to significant medication errors and potential harm to the residents.
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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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