Colonial Springs Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Buffalo, Missouri.
- Location
- 750 West Cooper, Buffalo, Missouri 65622
- CMS Provider Number
- 265245
- Inspections on file
- 16
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Colonial Springs Healthcare Center during CMS and state inspections, most recent first.
A resident with intact cognition and dependence on staff for ADLs, including toileting and use of a sit-to-stand lift, reported that a CNA became frustrated with the lift during bathroom assistance and cursed using the "f" word in the resident’s room. The resident felt the language was inappropriate and reported the incident to an LPN, the Social Service Director, and then the Administrator. Facility policy states residents have the right to be treated with dignity and respect, and in interviews the CNA, other CNAs, the DON, and the Administrator all acknowledged that cursing around residents is disrespectful and not acceptable.
A resident with a hip fracture diagnosis and intact cognition experienced multiple room transfers between different halls, but the facility failed to provide and document required written notice before these room changes. Facility policies required prompt written and advance notice to the resident and, when applicable, the representative for any room or roommate transfer. Registration records showed several room changes, yet only one room/roommate change notice form was found, and staff interviews (including SSD, CNA, LPN, DON, and the Administrator) confirmed that while notification and documentation were expected practices, there was no documentation of notifications for several of the resident’s room moves.
A resident with a history of hip fracture experienced a fall while attempting an independent transfer from a wheelchair to bed. Staff responded, initially noted no injury, and obtained STAT X‑rays of the resident’s right upper extremity, which later showed findings consistent with a radial neck fracture of indeterminate age. Although facility policy required timely notification and documentation of changes in condition, accidents, injuries, and diagnostic results to the physician, resident, and family/responsible party, the medical record contained no documentation that the resident’s family or responsible party was notified of the fall, the X‑ray orders, or the X‑ray results. In interviews, an LPN, an RN, the DON, and the Administrator all confirmed that such notification and documentation were expected but had not occurred in this case.
The facility failed to maintain a complete and timely grievance process for a resident and the resident’s family member, despite multiple complaints about care, use of briefs instead of pullups, missing personal items, and a reported $10 payment to an aide. Although the facility’s policy required escalation of unresolved complaints, maintenance of a grievance log, and written notice of investigation results, staff did not consistently enter grievances on the log, did not document follow-up steps or resolutions, and did not obtain or record confirmation from the complainant. Progress notes and interviews with the SSD, DON, and Administrator showed that some grievances were only partially documented, some were omitted from the log entirely, and outcomes of certain investigations were unknown or not recorded, resulting in an incomplete grievance process for the resident’s concerns.
The facility failed to complete a required baseline care plan within 48 hours of admission for a resident admitted with multiple pelvic fractures who required assistance with toileting, hygiene, bathing, and lower body dressing. Policy required licensed nursing staff to complete admission assessments within 24 hours and initiate a nursing care plan based on identified needs, using an electronic template that includes admission status, responsible party information, and medications. Record review showed no baseline care plan in the resident’s chart, and interviews with the MDS RN, an MDS LPN, RN staff, the DON, and the Administrator confirmed that the admitting or on-duty nurse was responsible for this task, that an admission audit process existed to flag incomplete paperwork, and that staff believed the care plan had been completed when it had not.
Staff failed to maintain safe transfer practices when one resident was jostled in a sit‑to‑stand mechanical lift and another was transferred without a gait belt. In the first case, a cognitively intact resident with prior ankle injury, weakness, and fall risk reported that a CNA became frustrated when a sit‑to‑stand lift got stuck on damaged flooring, repeatedly raising and lowering the lift so the resident swayed and experienced chest soreness and fear. Other staff confirmed the lift frequently got stuck on a notch in the floor, and maintenance reported the floor had sunk after a lift was placed on it too soon, but no work orders had been submitted about the lift wheels locking up. In the second case, a resident with severe cognitive impairment and total dependence for mobility was observed being transferred from bed to wheelchair by a CNA who did not use an available gait belt, instead lifting and pivoting the resident by holding around the back. The CNA believed the resident was care planned not to use a gait belt, while multiple CNAs, therapy staff, nursing staff, the DON, and the Administrator all stated that gait belts should always be used for such transfers and that this resident was not exempt from gait belt use.
The facility failed to administer time-sensitive medications as ordered and within policy-defined time frames for two residents. One resident on apixaban and flecainide had BID and Q12H doses that were either undocumented or given at widely varying times, without corresponding nursing notes explaining missed or late doses. Another resident with a sacral pressure ulcer and on anticoagulant therapy had metoprolol ordered for early morning administration but consistently received it several hours later, again without documentation of the variance. Staff interviews, including CMTs, RNs, the NP, the pharmacist, the DON, and the Administrator, showed inconsistent understanding of the liberalized medication pass and which medications were exempt, contributing to inconsistent adherence to ordered administration times.
The facility failed to prevent possible food contamination due to improper storage and preparation practices. The ice machine had microbial growth, a dented can of pumpkin was stored for use, and scoops were improperly left in containers of sugar and cornstarch. Staff were unclear about responsibilities and proper procedures, leading to potential contamination risks.
The facility failed to maintain a sanitary environment by not ensuring the cleanliness of fans in the walk-in refrigerator and freezer, as black and brown substances were observed on the fan casings. There was no policy or clear responsibility for cleaning these fans, leading to confusion among dietary and maintenance staff about their roles in maintaining cleanliness.
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon transfer to a hospital, affecting five residents. Despite the policy requiring notification upon admission and within 24 hours of an emergency transfer, documentation was lacking. Interviews revealed inconsistent practices and a lack of awareness among staff regarding the distribution of the bed hold policy.
The facility failed to document physician orders for catheter placement and care for two residents, leading to deficiencies in catheter management. One resident had severe cognitive impairment and an indwelling catheter without documented orders, while another returned from the hospital with a catheter but lacked documented orders until days later. Staff interviews revealed inconsistencies in the process of obtaining and documenting these orders.
The facility failed to ensure proper pharmacy services for controlled substances, as staff did not consistently document medication counts and administration on controlled drug record logs. Instances included single staff signing shift count sheets and discrepancies in tablet counts for residents. Interviews revealed non-compliance with policy, as some staff did not perform counts with another member and occasionally passed narcotics without verification.
The facility failed to maintain a medication error rate below 5%, with errors involving the improper timing of levothyroxine administration for two residents. The medication was given after breakfast and with other medications, contrary to orders for it to be taken at 6:00 A.M. on an empty stomach. Staff interviews confirmed awareness of the issue, but cited challenges in adhering to the schedule due to the number of residents.
A resident with a history of subarachnoid hemorrhage and diabetes required tube feeding, but the facility failed to administer it consistently as ordered. Observations showed the feeding was often not attached or running, and staff interviews revealed confusion about the feeding schedule. The facility's policy required adherence to physician orders, but unclear orders led to inconsistent feeding administration.
Facility staff failed to complete quarterly MDS assessments for two residents within the required 92-day timeframe due to a glitch in the tracking system. The MDS Coordinator, who was primarily responsible for assessments, and the Assistant MDS Coordinator, who recently began assisting, confirmed the oversight. The Administrator was unaware of the tracking system and the untimely assessments.
A facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or a denial letter to a resident upon discharge from Medicare Part A services. The resident, who needed to stay in the facility for further care, did not receive documentation of estimated costs for non-covered services and had to research these costs independently. The Social Services Director and Administrator acknowledged the oversight, as the SNFABN was not issued due to a misunderstanding of the requirements.
A facility failed to report an incident of inappropriate touching between two residents to the state agency within the required timeframe. The incident involved a resident with cognitive impairment and another with a history of bipolar disorder and dementia. Staff interviews revealed inconsistencies in understanding reporting requirements, with some staff unsure if the incident constituted abuse. The DON and Administrator provided conflicting views on the necessity of reporting, leading to the facility's failure to comply with its abuse/neglect policy.
The facility failed to investigate an incident where a resident was found touching another resident's genitalia, contrary to its abuse/neglect policy. Despite the policy requiring immediate investigation and documentation, no formal investigation was conducted, and the incident was not reported to the DHSS. Interviews revealed staff uncertainty in handling such situations, and the facility did not verify consent from the involved residents.
Failure to Maintain Resident Dignity When CNA Used Profanity During Care
Penalty
Summary
The deficiency involves a failure to ensure a resident’s right to be treated with dignity and respect when a CNA used disrespectful and profane language in the resident’s presence. The facility’s Resident Rights policy, revised 10/01/21, states that residents have the right to be treated with dignity and respect. The affected resident had been admitted with a diagnosis including dislocation of the right ankle joint and, per the quarterly MDS dated 02/20/26, had intact cognitive skills, no documented behaviors, was dependent for toileting and personal hygiene, and required substantial/maximal assistance with showering. The resident’s care plan, reviewed 02/26/26, documented that the resident required extensive to total assistance with one to two staff for all ADLs and directed staff to use a calm, reassuring approach. On the evening of 02/14/26 at approximately 9:30 P.M., the resident reported that while being assisted to the bathroom with a sit-to-stand lift that was hard to turn, CNA F became frustrated with the equipment and cursed, using the “f” word, in the resident’s room. The resident stated they did not feel the CNA’s language was appropriate and felt the CNA used inappropriate language. The resident reported the incident to an LPN and the Social Service Director, who told the resident to inform the Administrator; the resident then went to the Administrator’s office and reported that the CNA was mad at the sit-to-stand lift and cursed. In interviews, the Administrator acknowledged receiving a delayed report that the resident thought the CNA was unprofessional and did not appreciate the language. CNA F stated that cursing around a resident is not respectful and is a form of abuse, and other staff, including another CNA, the DON, and the Administrator, all stated that staff should not curse around residents and that staff are expected to be respectful.
Failure to Provide and Document Written Notice of Room Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide and document written notice to a resident before multiple room changes, contrary to its own policies on room and roommate transfers and notification guidelines. The facility’s policies required prompt written notification to the resident and, when applicable, to the resident’s representative for any change in room or roommate assignment, as well as advance notice of such transfers. Resident #1, admitted with a diagnosis including a fracture of the neck of the left femur and assessed as cognitively intact on the MDS, experienced several room changes between different halls. Registration records showed the resident was admitted to a room on the 100 hall, then transferred to the 200 hall, later moved back to the 100 hall for quality-of-care purposes, and then again transferred to the 200 hall. Record review showed only one room/roommate change notice form dated 04/18/25 for a move to the 100 hall, and no documented room/roommate change notices for the other room changes. The Social Service Director reported that staff typically call the family or speak with the resident regarding room changes, provide a room/roommate change request card, and do not move residents if they do not want to move, but she could not find documentation of notifications for the resident’s moves back to the 200 hall. CNA and nursing staff interviews indicated that social services are responsible for informing residents of room changes and that staff should document room changes and consent in progress notes, but such documentation was absent in this case. The DON and Administrator both stated that staff are expected to document room changes and resident/family notification in the progress notes, yet this was not done for Resident #1, resulting in noncompliance with the requirement to provide written notice before room changes.
Failure to Notify Family/Responsible Party of Fall and X‑ray Results
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of a resident’s family or responsible party of a change in condition following a fall and subsequent diagnostic findings. Facility policy revised in January 2025 required that physicians, residents, and families be notified in a timely manner of clinical and environmental changes, including accidents or injuries, and that such notifications be documented. Resident #1, admitted with diagnoses including a left femur neck fracture, experienced a fall when attempting to transfer independently from a wheelchair to bed. A CNA heard a crash, found the resident sitting on the floor, and staff assessed the resident with no injuries initially noted. A nurse obtained a STAT order from a nurse practitioner for X‑rays of the resident’s right shoulder, humerus, elbow, forearm, and wrist, and the X‑rays were completed as ordered. X‑ray reports from the same day documented soft tissue swelling and changes along the radial neck suggesting a fracture of indeterminate age, with an impression of an abnormal radial neck region. A later progress note described that after the fall the resident complained of right arm pain, an X‑ray showed a radial neck fracture of indeterminate age, and that the medical director and orthopedic physician were aware and ordered a sling. However, there was no documentation that the resident’s family or responsible party was notified of the fall, the X‑ray orders, or the X‑ray results. During interviews, an LPN, an RN, the DON, and the Administrator each stated that staff are expected to notify the resident and/or responsible party of falls, injuries, and X‑ray results and to document this notification in the progress notes, but they acknowledged that such documentation was not present for this resident.
Failure to Maintain Complete and Timely Grievance Documentation for Resident and Family Complaints
Penalty
Summary
The deficiency involves the facility’s failure to implement a complete and consistent grievance process, including timely documentation of grievances, follow-up steps, and resolutions for a resident and the resident’s family member. The facility’s grievance policy states that residents or their representatives may register complaints or grievances without fear of reprisal, and that grievances include complaints about care, abuse or neglect, and other issues that are not resolved at the time of the complaint by staff present. The policy further requires that unresolved complaints be escalated to supervisors, the Patient Advocate, and the Administrator as needed, and that the Patient Advocate maintain a log of complaints and grievances, with written notice to the complainant at the completion of the investigation, including steps taken, results, and date of completion. The resident involved had been admitted with a diagnosis including a fracture of the neck of the left femur and had intact cognitive skills, requiring partial to moderate assistance with toileting, showering, bathing, and personal hygiene. A nurse’s progress note documented that the resident’s family member complained to a CNA that the resident had not received breathing treatments that day and objected to the resident wearing a brief instead of a pullup. The nurse noted that management and social services were not available in the building at that time, and when the nurse later asked the family member if there were any issues needing resolution, the family member stated that everything was fine. Subsequently, the Social Services Director (SSD) documented receiving an email from the family member expressing concerns about the resident’s care, including breathing treatments and use of briefs, as well as missing personal items such as lotion, Kleenex, a turquoise ring, and a watch. The SSD shared the email with the Administrator and DON and noted that a staff member reported the family member had thrown wipes at them, and that the plan was to remove that staff member from providing care to the resident and to offer moving the resident to another hall. The facility’s complaint/concerns log recorded a complaint from the resident’s family member about missing rings, lotion, and a watch, and noted that replacement items were provided, but did not document any discussion with, or signature of, the resident or the family member who filed the grievance. A later progress note by the SSD, created weeks after the event date, described responding to another email from the family member about missing items and documented that the facility replaced multiple rings, lotion, and a watch, and informed the resident and family, but again did not reflect complete grievance documentation as required by policy. Another progress note by the DON described contacting the family member regarding concerns from the prior night, with the family member referring the DON to staff and a formal grievance before hanging up; however, this grievance was not entered on the facility’s grievance log. Interviews with the CNA, SSD, DON, and Administrator confirmed that the SSD was responsible for grievances, that staff were expected to report complaints to her, and that grievance forms and logs existed, but also revealed that the SSD did not document resolutions on the grievance log, did not have a form with a written resolution to return to complainants, and did not know the outcome of an investigation into a reported $10 payment from the resident to an aide. The DON acknowledged that resolutions of grievances were not documented, and the Administrator stated he expected documentation of who was spoken to, whether the grievance was resolved, and the response to the complainant, but these elements were missing, demonstrating the facility’s failure to maintain a complete grievance process for the resident’s grievances. Additional information from interviews further supports the incomplete grievance process. The SSD stated that if residents spoke with staff about complaints, staff should email or inform her, and that she reported grievances to the Administrator and DON and attempted to respond within 24 hours. She also reported receiving an email from the resident’s family member about an aide receiving $10 from the resident and said she informed the Administrator, but she did not document the resolution on the grievance log and did not know the results of that investigation. The DON described that grievances should be taken to social services, that grievance forms were available in a binder, and that staff discussed grievances in morning meetings with department heads, but she admitted she did not document grievance resolutions even though she believed they probably should be documented. The Administrator indicated that SSD should document who she talked with, whether the grievance was resolved, and the date, and that staff should document the response to the person who filed the grievance, yet he was not aware of the reported $10 payment. These documented omissions and inconsistencies in logging grievances, documenting follow-up steps, and recording resolutions for the resident’s and family member’s complaints constitute the identified deficiency in the facility’s grievance process. Overall, the events show that multiple complaints and concerns from the resident’s family member regarding care issues, missing personal items, and a possible financial concern were not consistently or fully documented as grievances in accordance with the facility’s own policy. The grievance log lacked entries for at least one formal grievance referenced by the family member, and existing entries did not include documentation of discussions with the complainant or confirmation of resolution. Staff interviews confirmed that there was no standardized form with a documented resolution returned to the complainant and that outcomes of certain investigations were unknown or not recorded. These actions and inactions demonstrate that the facility did not have a complete grievance process in place for this resident, as required by its policy and regulatory expectations.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and complete a baseline care plan within 48 hours of admission for one resident. Facility policy titled "Assessments in Long Term Care" required licensed nursing staff to initiate an admission assessment upon the resident’s arrival and complete nursing and screening assessments within 24 hours, with the nursing care plan initiated based on identified needs from that assessment. The facility’s initial care plan form was to include admission status, identification of the responsible party or resident offered a copy of the initial care plan, and information on resident medications. For the resident in question, the face sheet showed an admission date of 01/26/26 with diagnoses including multiple pelvic fractures, and progress notes documented arrival from the hospital that afternoon. The admission MDS dated the same day showed intact cognitive skills and a need for partial/moderate assistance with toileting and personal hygiene, and substantial/maximal assistance with showering, bathing, and lower body dressing. Despite these documented needs, review of the medical record showed no documentation that a baseline care plan was completed for this resident. The MDS Coordinator/RN stated that the admitting charge nurse is responsible for completing the baseline care plan upon admission, using a computer template, and that it should be completed within 24 hours along with admission notes; however, the RN confirmed there was no baseline care plan for this resident. Another MDS Coordinator/LPN reported that they perform an admission audit within 48 hours, circling incomplete items and returning them to the nurses’ desk, and acknowledged that staff did not complete the baseline care plan, though they believed it had been done and that the next nurse should complete any missing items. RN C stated nursing staff should complete the baseline care plan upon admission. The DON and the Administrator both indicated that the admitting nurse or nurse on duty is expected to complete the baseline care plan, including assessments and offering a copy to the resident and/or family, but this did not occur for the resident involved.
Unsafe Mechanical Lift Use and Failure to Use Gait Belt During Resident Transfers
Penalty
Summary
The deficiency involves the facility’s failure to keep residents free from accident hazards and to provide adequate supervision during transfers, specifically in the use of a sit‑to‑stand mechanical lift and a gait belt. Facility policy on patient/resident handling, revised April 2025, states that safe procedures for providing care are a high priority, that handling incidents are to be analyzed for trends with appropriate follow‑up, and that employees are encouraged to report hazards and make safety suggestions. Despite this, staff actions during two separate transfer situations did not align with safe handling practices described by facility leadership and other staff. In the first incident, a cognitively intact resident with a history of right ankle dislocation, generalized weakness, dependence on staff for transfers and ADLs, pain related to a previous fracture, and risk for falls reported that a CNA became frustrated while using a sit‑to‑stand lift during a bathroom transfer. The resident stated that the lift was hard to turn and that the CNA raised and lowered the lift, letting it hit the floor while the resident hung by the arms and swayed, causing upper chest soreness and fear. The resident reported having to yell at the CNA to calm down. Interviews with the CNA confirmed that two wheels on the lift locked up when attempting to roll the resident out of the bathroom, that the lift was stuck, and that the resident began swinging in the lift, causing concern the resident might fall. Other staff, including another CNA and nursing staff, reported that the floor in the resident’s room and bathroom was “horrible,” that the lift frequently got stuck on a notch or damaged area of the floor, and that the resident had reported being jostled and scared when the CNA shook the lift to get it unstuck. The Maintenance Supervisor reported that a new floor had been installed in the resident’s room about a year earlier and that staff placed a sit‑to‑stand lift on it before the 24‑hour curing period, causing the floor to sink. He stated he had not received a work order or complaint about the lift wheels locking up, and that staff had previously indicated the lift was usable and were transporting residents across the bathroom floor. The DON and Administrator both stated that staff were expected to report issues with floors and equipment, including lift wheels locking up, and the DON acknowledged that rocking a lift back and forth to free it from a floor notch created safety issues. The CNA involved stated he was not aware whether maintenance had been informed of the lift getting stuck during the incident. In the second incident, a resident with dementia, severely impaired cognitive skills, and total dependence on staff for mobility and ADLs was observed being transferred from bed to wheelchair by a CNA without the use of a gait belt, despite a gait belt hanging on the wall next to the bed. The CNA rolled the resident to a sitting position, sat the resident on the edge of the bed, then placed both hands around the resident’s back, stood the resident, pivoted, and seated the resident in a wheelchair. In interview, the CNA stated that he or she normally used a gait belt for all residents but believed this resident was care planned not to use one due to potential resistance, and therefore did not use a gait belt during the observed transfer, even though the resident was not combative or resistant at that time. Multiple staff, including other CNAs, OT staff, an LPN, the DON, and the Administrator, stated that staff should always use a gait belt during one‑person transfers when a lift is not used, that gait belts are the safest way to transfer, and that there was nothing in this resident’s care plan indicating a gait belt should not be used. These events demonstrate that, in both cases, staff actions during transfers did not follow the safe handling expectations described by facility leadership and other staff, and that known environmental and equipment issues with the sit‑to‑stand lift and flooring were not effectively reported or addressed through the facility’s established hazard reporting processes.
Failure to Administer Time-Sensitive Medications as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that met residents’ needs by not administering medications as ordered and not adhering to specified administration times. The facility’s own Medication Administration and Documentation policy allowed a liberalized medication pass with a three-hour window before and after scheduled times for certain oral medications, but it also stated that medications with a narrow therapeutic index, such as anticoagulants, should not be liberalized if ordered at a specific time on the MAR. The policy further indicated that medications are considered late if given more than three hours after their scheduled time and that missed doses require provider consultation. Despite this, staff did not consistently follow ordered times or document missed or late doses. For one resident admitted with multiple pelvic fractures and on anticoagulant therapy, physician orders included apixaban 5 mg PO BID and flecainide 25 mg PO every 12 hours. The MAR for a ten-day period showed missing documentation for both the morning and evening doses on certain days and administration times that varied widely from the expected BID schedule, including doses given at 7:00 A.M., 8:01 P.M., 10:17 A.M., 6:29 P.M., 12:14 P.M., 7:10 P.M., 10:00 A.M., 6:58 P.M., 10:55 A.M., and 7:15 P.M. Nurses’ notes for this period did not contain documentation explaining missed doses or doses given outside the ordered time frame. The NP stated that apixaban should be given eight hours between doses and that giving it earlier would be a medication error, while the pharmacist indicated it was typically scheduled at 9:00 A.M. and 9:00 P.M. due to its half-life. For another resident with a diagnosis including a sacral pressure ulcer and on anticoagulant medication, there was an order for metoprolol succinate 12.5 mg to be given daily at 6:00 A.M. The MAR showed that during the same review period, this medication was consistently administered much later in the morning, with times ranging from 9:20 A.M. to 11:10 A.M. Nurses’ notes contained no documentation related to these administrations occurring outside accepted time frames. Interviews with multiple staff, including CMTs, RNs, the NP, the pharmacist, the DON, and the Administrator, revealed inconsistent understanding of the liberalized medication pass, with varying descriptions of allowable time windows and which medications were considered time-specific, contributing to the failure to administer medications within the ordered or policy-defined time frames for these residents.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a manner that prevents possible contamination. Observations revealed that the ice machine's deflector shield had multiple black spots, indicating microbial growth. Despite the facility's policy requiring regular cleaning of ice machines, there was confusion among staff about who was responsible for cleaning the inside of the machine. The Maintenance Director, who was responsible for cleaning, was unaware of the black spots, and the Administrator was also not informed about the issue. Additionally, a large dented can of pumpkin was found on the shelf, which contradicts the FDA's guidelines that dented cans may present a serious potential hazard. Staff interviews revealed inconsistent practices regarding the handling of dented cans. Furthermore, scoops were found partially submerged in containers of sugar and cornstarch, which could lead to contamination. Staff members had differing opinions on whether this practice was acceptable, indicating a lack of clear guidelines or training on proper food storage practices.
Sanitation Deficiency in Walk-in Refrigerator and Freezer
Penalty
Summary
The facility failed to maintain a sanitary environment for residents and staff by not ensuring the cleanliness of fans located in the walk-in refrigerator and freezer. Observations on two separate occasions revealed black and brown substances on the plastic casings of the refrigerator and freezer fans. The facility did not have a policy addressing the maintenance of these fans, and the weekly cleaning schedule did not list staff responsible for cleaning them. Interviews with various staff members, including dietary aides, the Assistant Dietary Manager, the Maintenance Director, and the Administrator, revealed a lack of clarity and communication regarding responsibility for cleaning the fans. Dietary staff were unsure of their role in cleaning the fans, and the Maintenance Director admitted to not knowing when the fans were last cleaned, although he acknowledged that they should not have black or brown substances on them. The Administrator confirmed that maintenance was responsible for cleaning the fans, but there was no evidence of a structured process to ensure this task was completed regularly.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon transfer to a hospital or during therapeutic leave. This deficiency was identified for five residents who were transferred to the hospital. The facility's policy requires that residents and their families be informed of the bed hold policy in writing upon admission and within 24 hours of an emergency transfer. However, the facility did not adhere to this policy, as evidenced by the lack of documentation showing that the bed hold policy was provided to the residents or their representatives. For Resident #32, the medical record did not contain a copy of the bed hold policy sent with the resident or to the resident's representative after the resident was transferred to the emergency room for multiple head lacerations. Similarly, for Resident #35, the facility checklist did not indicate that bed hold information was provided when the resident was transferred to the hospital following a fall and other medical issues. The same issue was noted for Resident #261, whose transfer documentation lacked any indication that the bed hold policy was provided. Interviews with facility staff revealed a lack of awareness and inconsistent practices regarding the distribution of the bed hold policy. The Business Office Manager was unaware of the bed hold policies, and the Social Services Director acknowledged that there was no written notification sent to residents or their representatives. Registered nurses and the Assistant Director of Nursing provided conflicting information about the process, indicating a systemic issue in ensuring compliance with the facility's bed hold policy requirements.
Failure to Document Physician Orders for Catheter Care
Penalty
Summary
The facility failed to ensure proper catheter usage and care according to standards of practice, as evidenced by the lack of physician's orders for catheter placement and care for two residents. Resident #29, who was admitted with diagnoses including obstructive and reflux uropathy, retention of urine, and acute kidney failure, had a severe cognitive impairment and an indwelling catheter. Despite the care plan indicating the need for catheter care and assessment, there were no physician's orders documented for the indwelling catheter or its care. Resident #32, admitted with renal failure, returned from a hospital stay with a catheter due to urinary retention. However, the facility staff did not document any orders for the catheter placement or care until several days after the resident's return. Observations showed the resident with a catheter bag attached to the wheelchair, but the necessary orders were only entered into the system after the deficiency was noted. Interviews with facility staff, including RNs, CNAs, and the ADON, revealed a lack of clarity and consistency in the process of obtaining and documenting physician's orders for catheter care. Staff members indicated that orders should be entered by nurses or doctors, and that catheter care tasks appear on work lists, but there was a failure to ensure that all residents with catheters had the appropriate orders documented in their medical records.
Inadequate Documentation and Reconciliation of Controlled Substances
Penalty
Summary
The facility failed to ensure proper pharmacy services for the consistent counting, reconciliation, and destruction of controlled substances. This deficiency was identified through observations, interviews, and record reviews, revealing that staff did not consistently document the number of medication packages and doses of controlled medications at the change of shift on the controlled substance shift change log. Additionally, there was a failure to document the administration of medications on individual resident controlled drug record logs for three residents. The facility's policy required that controlled substances be counted at shift changes and discrepancies be resolved immediately, but these procedures were not consistently followed. Specific instances of non-compliance included single staff members signing the shift count sheet instead of the required two, and missing documentation for several shifts. For example, on multiple occasions, only one staff member signed the shift count sheet, and there were no documented counts for certain days. Furthermore, discrepancies were found in the controlled drug records for three residents, where the actual tablet count did not match the documented count. Interviews with staff revealed that some did not perform counts with another staff member and occasionally passed narcotics without verifying the count. The Director of Nursing (DON) and the Administrator both expressed expectations for narcotic counts to be completed at every shift change and whenever narcotic keys were exchanged. However, these expectations were not met, as evidenced by the lack of documentation and unresolved discrepancies. Staff interviews indicated a lack of adherence to the facility's policy, with some staff members admitting to not counting narcotics with another staff member and failing to document administered doses on the controlled drug record logs.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.14% error rate due to improper administration of levothyroxine for two residents. The errors occurred when the medication was not administered at the specified time of 6:00 A.M., before breakfast, and separate from other medications, as per physician orders. Instead, the medication was given after breakfast and alongside other medications, contrary to the instructions for it to be taken on an empty stomach. Resident #98, diagnosed with Alzheimer's disease and a thyroid disorder, was observed receiving levothyroxine at 9:05 A.M., after breakfast, and with other medications. The Registered Medication Technician (RMT) acknowledged administering the medication at the wrong time and with other medications, despite knowing it should be given at 6:00 A.M. on an empty stomach. Similarly, Resident #101, with a diagnosis of hypothyroidism, received levothyroxine at 8:57 A.M., after breakfast, and with other medications. The RMT admitted to the same error, citing the challenge of administering medications separately due to the number of residents. Interviews with staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed the expectation that levothyroxine should be administered before breakfast and on an empty stomach. The facility's policy allows a liberal three-hour window for medication administration, but specific instructions for certain medications, like levothyroxine, were not being followed. The DON and Administrator were aware of the issue, acknowledging that the medication timing was not in compliance with physician orders.
Inconsistent Tube Feeding Administration Due to Unclear Orders
Penalty
Summary
The facility failed to provide enteral nutrition per standards of practice for Resident #102, who was on a tube feeding regimen. The resident had a history of nontraumatic subarachnoid hemorrhage, type 2 diabetes mellitus, and a personal history of aneurysm rupture, which necessitated the use of a feeding tube due to poor oral intake and frequent changes in condition. The physician had ordered continuous feeding of Jevity 1.5 calorie at 30 ml per hour for 18 hours, with a 6-hour break to promote eating during the day. However, the orders were not clear, and staff did not consistently administer the tube feeding as prescribed. Observations revealed inconsistencies in the administration of the tube feeding. On several occasions, the tube feeding was either not attached or not running when it should have been, and the resident was observed not eating during meal times. Interviews with nursing staff, including RNs and LPNs, indicated confusion regarding the tube feeding schedule. Some staff believed the feeding was continuous, while others mentioned a rotating schedule without a set time for turning the feeding on and off. This inconsistency led to the tube feeding being turned off and on at varying times, not aligning with the physician's orders. The facility's policy required tube feeding to be administered by licensed nursing personnel according to physician orders, with documentation of feeding, water flush, intake, and output. However, interviews with the ADON, DON, and the facility's pharmacist highlighted a lack of familiarity with the resident's specific orders and a failure to ensure clarity in the orders. The administrator acknowledged the issue of unclear tube feeding orders, emphasizing the need for staff to seek clarification when necessary.
Failure to Complete Timely MDS Assessments for Two Residents
Penalty
Summary
The facility staff failed to complete quarterly Minimum Data Set (MDS) assessments for two residents within the required 92-day timeframe. Resident #18's last MDS assessment was recorded on 07/24/24, and no subsequent assessment was documented for over 129 days. Similarly, Resident #77's last assessment was on 07/29/24, with no follow-up assessment documented for over 124 days. The facility's census was 109, and the absence of timely assessments was attributed to a glitch in the tracking system, which led to the omission of the next assessment dates for these residents. Interviews with the MDS Coordinator and Assistant MDS Coordinator revealed that until recently, the MDS Coordinator was solely responsible for conducting these assessments. The Assistant MDS Coordinator, who had recently begun assisting, confirmed the oversight in the tracking system that resulted in the missed assessments. The Administrator was unaware of the tracking system used by the MDS Coordinator and was not informed of any untimely assessments, although they expected assessments to be completed within the designated timeframe.
Failure to Provide SNFABN for Medicare Part A Discharge
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for a resident who remained in the facility upon discharge from Medicare Part A services. The resident, identified as Resident #49, was admitted to the facility and had a Medicare Part A skilled services episode starting on October 14, 2024, with the last covered day being December 6, 2024. The facility initiated the discharge from Medicare Part A services before benefit days were exhausted but did not provide the required SNFABN or an alternative denial letter to the resident or their legal representative. During interviews, the resident stated that they signed the Notice of Medicare Non-Coverage (CMS-10123-NOMNC) but did not receive any documentation showing the estimated cost of services that would not be covered after the last covered day. The resident had to conduct their own research to determine the daily cost of room/board and therapy, as they needed to stay in the facility until they could bear weight on their affected leg and transfer independently. The Social Services Director (SSD) and the Administrator acknowledged the oversight, with the SSD indicating that they were instructed to issue the SNFABN only if a resident was staying for long-term care, which led to the failure to provide the necessary notice to the resident.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its abuse/neglect policy by not reporting an allegation of inappropriate touching between two residents to the State Survey Agency within the required two-hour timeframe. The incident involved Resident #1, who was cognitively intact and had a history of bipolar disorder, Parkinson's disease, and dementia, and Resident #2, who had moderate cognitive impairment and a history of major depressive disorder and stroke. The incident was documented in nursing notes, but there was no record of the facility reporting the allegation to the Department of Health and Senior Services (DHSS). Interviews with staff revealed a lack of clarity and consistency in understanding the reporting requirements for such incidents. Certified Nurse Assistants (CNAs) and Licensed Practical Nurses (LPNs) expressed differing views on whether the incident constituted abuse and whether it needed to be reported to the state agency. Some staff believed that the guardian's or Durable Power of Attorney's (DPOA) decisions regarding residents' sexual activity should guide their actions, while others recognized the need to report the incident as potential abuse. The Director of Nursing (DON) and the Administrator also provided conflicting statements regarding the necessity of reporting the incident to the state agency. The DON did not consider the incident as needing to be reported, citing the absence of an abuse allegation, while the Administrator acknowledged the need to separate the residents and notify the guardians but did not ensure the incident was reported to the state agency. This inconsistency in policy implementation and understanding among staff and management contributed to the facility's failure to report the incident as required.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its abuse/neglect policy effectively, as evidenced by the lack of a documented investigation into an incident involving inappropriate touching between two residents. The incident occurred when one resident was found touching another resident's genitalia in the courtyard. Despite the facility's policy requiring immediate investigation and documentation of such allegations, no written investigation was completed, and the Department of Health and Senior Services (DHSS) did not receive any report of the incident. Resident #1, who was cognitively intact and had a guardian, was involved in the incident. The resident had a history of bipolar disorder, Parkinson's disease, and dementia. The nursing notes indicated that the resident was educated about the inappropriateness of their actions, and both residents were placed on 15-minute checks. However, the facility did not conduct a formal investigation or document the incident as required by their policy. Resident #2, who had a Durable Power of Attorney (DPOA) and a history of major depressive disorder and stroke, was the other party involved. The resident expressed that such an incident would be considered traumatic. Despite this, the facility did not verify consent from Resident #2 or conduct a thorough investigation. Interviews with staff revealed a lack of clarity on handling such situations, and the facility's management did not follow through with the necessary steps to ensure compliance with their abuse/neglect policy.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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