Country Aire Retirement Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewistown, Missouri.
- Location
- 18540 State Highway 16, Lewistown, Missouri 63452
- CMS Provider Number
- 265474
- Inspections on file
- 18
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Country Aire Retirement Center during CMS and state inspections, most recent first.
The facility did not have written policies or procedures for visitation rights, resulting in inconsistent and unclear restrictions on visitors for two residents—one with a guardian and severe cognitive impairment, and another who was cognitively intact. Staff were not consistently informed about visitor limitations, and the reasons for restrictions were not clearly communicated or documented, leading to confusion and distress among residents, staff, and family members.
Staff did not follow professional standards during medication administration, including removing medications from original packaging and placing them in unlabeled cups before the medication pass for multiple residents. Additionally, a CMT failed to administer insulin according to policy by not keeping the insulin pen needle in a resident's skin for the required time, potentially resulting in incomplete dosing.
A resident with severe cognitive impairment was started on Rexulti, an antipsychotic medication, without the facility notifying the responsible party, despite facility policy and care plan requirements for such communication. Family members only learned of the medication after observing changes in the resident's condition and questioning staff.
A certified medication technician crushed and administered extended-release glipizide and metoprolol to a resident with diabetes and hypertension, contrary to physician orders and facility policy, resulting in a significant medication error. The CMT was unaware that these medications should not be crushed, and this was confirmed through observation, record review, and staff interviews.
The facility did not maintain adequate licensed nurse staffing, resulting in an LPN working 36 consecutive hours as the only nurse on duty and being unable to fulfill other assigned roles. Residents and staff reported concerns about exhausted staff, missed care tasks, and unaddressed resident needs, while the facility lacked key nursing positions and was unable to secure additional coverage.
The facility did not provide RN coverage for at least eight consecutive hours daily and failed to have a full-time DON, as required by policy. Staffing schedules and staff interviews confirmed gaps in RN coverage and that the DON role was filled only on paper by a corporate RN who was not present onsite full-time.
Facility administration failed to maintain adequate staffing, leadership, and regulatory systems, resulting in shifts without RN coverage, lack of CPR-certified staff, and absence of a DON, ADON, and Infection Preventionist. Residents and families reported ongoing issues with care, food quality, and supplies, while staff described lack of training, excessive workloads, and no administrative support. The facility also failed to pay vendors for essential supplies and services, leading to disruptions in operations and storage of sensitive records inappropriately.
The facility did not respond to repeated Resident Council concerns about care and quality of life, including issues with food temperature, loud televisions, lack of proper incontinence supplies, and missing water for oxygen concentrators. Staff confirmed that concerns were forwarded to administration and department heads, but no actions were taken or documented, and a resident reported ongoing unresolved issues with care and equipment.
Staff did not implement physician-ordered droplet precautions for several residents with respiratory symptoms, and failed to administer medications as ordered for other residents. Despite clear orders and facility policy, precautions were not followed and residents reported missed or incorrect medications, with no documentation of refusals or corrective action taken.
The facility did not ensure that a CPR-certified staff member was scheduled on every shift, leaving multiple night shifts without certified personnel despite having residents with full code status. There was no policy in place for CPR certification requirements, and documentation of staff certifications was incomplete or outdated. Leadership and scheduling staff were aware of the need for CPR-certified coverage but did not maintain compliance.
The facility did not have a functioning antibiotic stewardship program or a designated Infection Preventionist (IP), as required by its own policies. The only full-time RN, who previously served as IP, was unable to continue due to workload, and there was no tracking of infections or antibiotic use. Interviews with corporate and administrative staff confirmed the lack of oversight and documentation for infection control and antibiotic monitoring.
A resident with multiple Stage IV pressure ulcers did not receive consistent weekly wound measurements or skin assessments as required by facility policy. Staff performed wound care but failed to document or measure wounds regularly, and there was no communication of wound status to the physician. The lack of a designated wound nurse and insufficient monitoring by nursing leadership contributed to the deficiency.
The facility failed to maintain RN coverage for at least eight hours a day, seven days a week, and did not have a full-time DON. Staffing schedules showed multiple days without RN presence, with only a corporate RN available by phone. The DON resigned, leaving the facility with one full-time RN and two as-needed RNs, despite efforts to recruit more staff. This compromised the facility's ability to meet resident care needs.
A facility failed to protect two residents from the misappropriation of their narcotic medications by an RN who signed for receiving the medications but did not document their administration or destruction. The medications were not found in the facility, and the RN re-ordered them multiple times without justification. The residents did not report receiving or requesting the medications, and the RN was the only staff member with access during the shifts in question.
The facility was found deficient in maintaining kitchen cleanliness and proper food handling practices. Observations showed a buildup of grease on the range hood, debris on the air conditioner and microwave, and improper food storage. The Dietary Manager was unaware of cleaning responsibilities, and food handling practices were inadequate, with staff not washing hands between tasks and improper use of hair restraints. Additionally, the ice machine lacked an air gap, and a light fixture cover was damaged.
The facility failed to maintain the dignity of three residents by not covering their urinary catheter bags, as required by policy. Observations showed that the catheter bags of a cognitively impaired resident, a cognitively intact resident, and another resident requiring substantial assistance were left uncovered in public areas. Staff interviews confirmed the expectation for dignity covers, but the facility lacked sufficient covers for all residents with catheters.
The facility failed to properly manage the resident trust fund account by not maintaining accurate monthly reconciliations. The Business Office Manager only reconciled petty cash, while corporate staff handled bank accounts. Monthly transfers of $1,500 were made to prevent negative balances, but these were not accounted for in reconciliations. The Administrator expected correct reconciliation, but it was not achieved.
The facility failed to accurately complete MDS assessments for three residents, leading to deficiencies in documenting their medical conditions and treatments. A resident's dialysis treatment was omitted, another's intellectual disability was not recorded, and pressure ulcers were inaccurately staged. The MDS coordinator acknowledged these oversights, and the DON expected accurate assessments reflecting current conditions.
The facility exhibited significant deficiencies in infection control practices, including inadequate hand hygiene, improper use of PPE, and poor urinary catheter care. Staff failed to consistently wash hands and use gowns during high-contact activities, and catheter bags were often found touching the floor. Additionally, soiled materials were not handled in a sanitary manner, contributing to the risk of infection.
The facility failed to maintain the three-compartment sink in the kitchen, which had been leaking and lacked hot water for approximately one year. Despite awareness from the maintenance team and the Administrator, the issue remained unresolved, affecting kitchen operations.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential entrapment risks for three residents. Despite the facility's policy requiring regular safety checks, there was no documentation of entrapment zone measurements for these residents, who used bed rails or assist bars. Observations confirmed the presence of raised assist bars or bed rails, but necessary safety checks were not documented. Interviews revealed that maintenance staff did not complete or track required measurements, and compatibility with specialty mattresses was not checked.
The facility did not post the required contact information for the state survey agency and elder abuse hotline. Observations showed the information was not visible, and interviews with residents and staff confirmed they were unaware of its location. The Administrator was unaware of the oversight.
The facility failed to provide timely NOMNCs to three residents, not adhering to the required two-day notice period before Medicare coverage ended. Staff interviews revealed a lack of awareness and training on issuing these notices, and the facility could not provide a policy on the matter.
The facility failed to post required nurse staffing information, including licensed and unlicensed staff hours, as mandated by policy. Observations showed missing or incomplete postings, and interviews confirmed the deficiency. Approximately one-third of the staffing sheets over 18 months were blank, lacking necessary details.
Failure to Establish and Communicate Visitation Rights Policy
Penalty
Summary
The facility failed to have written policies and procedures regarding visitation rights, including the management of restrictions placed on two residents' visitors. The Administrator confirmed that there was no policy in place addressing visitation rights, and staff were not provided with clear guidance or communication about the reasons for visitor limitations. The facility's existing Resident Rights policy required informing residents and their representatives of their rights and responsibilities, but did not address the process for restricting visitors or communicating such restrictions to staff. For one resident with severe cognitive impairment and a legal guardian, the guardian provided a list of individuals who were not allowed to visit. This list was included in the resident's care plan and posted at the nurse's station, instructing staff to deny access to those individuals and contact authorities if necessary. However, staff interviews revealed confusion and lack of awareness about the restrictions, with some staff only discovering the list after incidents occurred. The rationale for the restrictions was not discussed with the guardian, and there was no documentation of official reasons or supporting court documents for the exclusions, despite allegations of past financial exploitation and family discord. Another resident, who was cognitively intact and had no guardian, was also affected when a family member was barred from visiting after an incident involving another resident. The family member was told by law enforcement not to return to the facility, which caused distress for the resident who had previously received frequent visits. Staff interviews indicated uncertainty about the authority and process for restricting visitors, and the chain of command was not consistently followed. The lack of a formal policy and clear communication led to inconsistent application of visitor restrictions and confusion among staff and visitors.
Failure to Follow Professional Standards in Medication and Insulin Administration
Penalty
Summary
Staff at the facility failed to adhere to professional standards of practice during medication administration for multiple residents. Certified Medication Technicians (CMTs) were observed removing medications from their original packaging and placing them into unlabeled medication cups with only the resident's first name written on the side, prior to the scheduled medication pass. This practice was observed for 13 residents, and the cups were stored in the medication cart drawers until administration. The medications in the cups were not labeled to indicate their contents, and the CMT acknowledged that this was done to expedite the medication pass, despite knowing that medications should not be removed from packaging until the time of administration. The Director of Nursing confirmed that this practice was not in accordance with facility policy and could lead to medication errors. Additionally, staff failed to follow the facility's policy and manufacturer instructions for insulin administration for a resident with diabetes. The CMT administering insulin did not keep the insulin pen needle in the resident's skin for the required 6-10 seconds after pressing the plunger, as specified in both the facility's policy and the medication instructions. Instead, the needle was removed immediately after the dose counter reached zero, potentially resulting in incomplete administration of the prescribed insulin dose. The CMT stated they were unaware of the need to keep the needle in place for the specified duration.
Failure to Notify Representative of New Antipsychotic Medication
Penalty
Summary
The facility failed to notify a resident's representative when a new antipsychotic medication, Rexulti, was initiated. The resident, who had severe cognitive impairment, disorganized thinking, and inattention, was started on Rexulti for anxiety as documented in the physician's orders. Despite the resident's significant cognitive deficits and the presence of a responsible party who had signed the consent to treat form, there was no evidence in the progress notes that the responsible party was informed of the new medication. The facility's own Resident Rights form and care plan required notification and education of the resident or family regarding changes in care and treatment, including new medications. Interviews with family members revealed that they were not notified about the initiation of Rexulti and only became aware of the medication after noticing changes in the resident's behavior, such as increased grogginess and difficulty with speech. The DON stated an expectation that responsible parties should be notified of new medications, while the Administrator expressed uncertainty about the requirement to notify family members in the absence of a legal POA. The facility's failure to notify the resident's representative of the new medication constituted a deficiency in communication and adherence to resident rights.
Crushing and Administering Extended-Release Medications
Penalty
Summary
A certified medication technician (CMT) crushed and administered two extended-release medications, glipizide ER and metoprolol ER, to a resident diagnosed with diabetes and hypertension. The medications were intended to be taken whole, as per physician orders and manufacturer instructions, to ensure gradual release over 24 hours. The CMT was observed removing the tablets from the medication cart, crushing them, mixing them with yogurt, and administering them to the resident. Documentation in the Medication Administration Record confirmed that both medications were given in the morning as prescribed, but in crushed form. During interviews, the CMT stated they were unaware that the medications were extended-release and should not be crushed, acknowledging that crushing such medications would result in the entire dose being absorbed at once rather than over 24 hours. The Director of Nursing and the Administrator both confirmed that extended-release medications should not be crushed, as this practice is inconsistent with facility policy and standard medication administration protocols. The facility's policy and drug information resources also specify that extended-release medications must be swallowed whole and not crushed.
Failure to Maintain Adequate Licensed Nurse Staffing
Penalty
Summary
The facility failed to provide an adequate number of licensed nurses on duty to meet the needs of all residents, as required by policy. The Social Service Director, who was also a Licensed Practical Nurse (LPN), was repeatedly pulled from their primary duties to serve as the only charge nurse on multiple occasions, including working 36 consecutive hours without relief. During this extended shift, the LPN was observed sleeping in a recliner at the nurse's station due to exhaustion. The facility's staffing records confirmed that this LPN was the sole licensed nurse in the building for three consecutive 12-hour shifts. Additionally, the facility lacked an Infection Preventionist, a designated wound nurse, and an Assistant Director of Nursing due to ongoing staffing shortages. Interviews with residents and staff revealed significant concerns about the lack of nursing staff. Multiple residents expressed worry about the safety and adequacy of care, noting that the LPN was visibly exhausted and that other staff, such as a Certified Medication Technician, also worked extended hours to support the LPN. Residents reported issues such as infrequent showers, unchanged bed linens, and improper maintenance of medical equipment like oxygen concentrators. Staff interviews confirmed that the LPN was unable to fulfill their social service duties or follow up on resident concerns due to being consistently assigned to nursing shifts. The only full-time RN was leaving employment, and the facility had been unable to secure additional licensed nurse coverage through staffing agencies. The facility's own assessment indicated a need for more RNs and LPNs than were currently employed, and the census included residents with complex care needs, such as those with contractures, psychiatric diagnoses, pressure ulcers, and specialized treatments. The lack of adequate licensed nursing staff resulted in incomplete wound assessments, missed routine skin checks, and insufficient documentation. Corporate and administrative staff acknowledged the staffing shortages and the inability to cover necessary shifts, confirming that essential care tasks were not being completed as required.
Failure to Maintain Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and did not ensure a full-time RN was designated as the Director of Nursing (DON). Review of staffing schedules showed that there was no RN coverage on two specific days, and interviews with staff confirmed that the facility only had one full-time RN, whose last day was shortly after the deficiency was identified. After this RN's departure, only one as-needed (PRN) RN remained, and attempts to secure routine RN coverage through a staffing agency were unsuccessful. Interviews with various staff and corporate personnel revealed that the facility had been listing a corporate RN as the DON on paper, but this individual was rarely present onsite and was not available on a full-time basis. The facility's own policies required a full-time DON and RN coverage for eight hours daily, but these requirements were not met. The administrator and other staff acknowledged the lack of consistent RN presence and the absence of a full-time DON in the building.
Failure to Maintain Adequate Staffing, Leadership, and Regulatory Systems
Penalty
Summary
Facility administration failed to ensure effective and efficient operations, resulting in multiple regulatory deficiencies. The facility did not have a full-time Director of Nursing (DON), Assistant Director of Nursing (ADON), or an adequate number of licensed nurses to meet resident needs. There was also no Infection Preventionist (IP) or antibiotic stewardship program in place, and the facility was not tracking antibiotic use or infections. Staffing schedules revealed shifts without Registered Nurse (RN) coverage, and several shifts lacked staff with current CPR certification. New nurse assistants reported receiving only onboarding videos with no further training or education, and there was no designated person for staff to approach with questions or concerns. The administrator was seldom present, and staff, including the HR Director and Social Service Director, confirmed ongoing issues with expired or missing CPR certifications and lack of leadership presence. Residents and their families reported ongoing concerns, including insufficient nurse staffing, lack of response to grievances, and persistent issues with food quality, incontinence supplies, and basic care such as showering and linen changes. Resident Council minutes documented repeated complaints about cold food, loud televisions, and inadequate snacks, with no documented staff response. One resident stated that their oxygen concentrator was not properly maintained, and another family member had to purchase incontinence briefs due to facility shortages. Staff interviews corroborated these issues, with reports of exhaustion from working excessive hours due to lack of licensed nurse coverage and no administrative follow-up on resident concerns. The facility also failed to pay vendors for essential supplies and services in a timely manner, resulting in credit holds and inability to reorder necessary items. The maintenance supervisor reported that document shredding services were suspended due to unpaid bills, leading to storage of sensitive records in a shed. The business office manager and corporate staff were unaware of outstanding bills, and the administrator was not informed of these financial issues. The medical director expressed concern about the lack of leadership, absence of required administrative roles, and the facility's inability to meet residents' needs. There was no evidence of infection control tracking or an antibiotic stewardship program, and the facility did not have a designated wound nurse.
Failure to Address Resident Council Grievances and Provide Responses
Penalty
Summary
The facility failed to act promptly on grievances and recommendations made by the Resident Council regarding resident care and quality of life issues. Despite holding monthly Resident Council meetings where residents raised concerns such as loud televisions, inappropriate food options, lack of proper incontinence supplies, absence of water for oxygen concentrators, and dissatisfaction with snacks and meal temperatures, there was no documented response from staff or administration to address these issues. Review of the Administrator's job description indicated a responsibility to review complaints and make written reports of actions taken, but the Administrator was unsure if a written policy on council meetings existed and confirmed only that meetings were held monthly. Interviews with staff and residents revealed ongoing dissatisfaction and a lack of resolution to repeated concerns. A resident reported not having anyone to address their issues, including infrequent showers, unchanged sheets, and an oxygen concentrator without water for humidification, which was confirmed by observation. The Social Service Director/LPN stated that concerns from Resident Council meetings were passed to the previous Administrator and department heads, but no actions were taken. The new Administrator, who had just started, expected policies and regulations to be followed but acknowledged the lack of documented responses to resident concerns.
Failure to Follow Physician Orders for Droplet Precautions and Medication Administration
Penalty
Summary
The facility failed to follow professional standards of practice by not implementing physician-ordered droplet precautions for four residents who exhibited respiratory symptoms such as cough, congestion, and fever. Despite clear orders from the Medical Director to place symptomatic residents on droplet precautions to prevent the spread of infection, staff did not follow these orders. Observations confirmed the absence of required signage and precautions, and interviews with staff revealed that the previous administrator instructed staff to disregard the droplet precaution orders due to the lack of a definitive diagnosis, even though the orders remained in the residents' charts. Additionally, the facility did not ensure that physician orders for medications were followed for three residents. In several instances, an agency RN was documented as having administered medications, including insulin and other routine morning medications, but residents reported that they either did not receive their medications or were given incorrect medications. These residents, who were cognitively intact and familiar with their medication regimens, reported the discrepancies to facility leadership. There was no documentation of medication refusals, and the agency RN did not provide the correct medications as ordered. Multiple staff interviews corroborated that there were widespread complaints from residents about missed or incorrect medication administration by the agency RN. The facility's own policies required prompt and accurate implementation of physician orders, regular audits, and corrective actions for discrepancies, but these were not followed. The administrator was unable to provide evidence of any education or corrective action taken with the agency RN after the incidents were reported.
Failure to Ensure CPR-Certified Staff Coverage and Maintain Certification Records
Penalty
Summary
The facility failed to ensure that CPR-certified staff were scheduled on all shifts, as required for residents with full code status. A review of staffing records and CPR certification documentation revealed that on multiple night shifts, there was no staff member present with a valid CPR certification. The facility had 13 residents designated as full code, meaning they required full resuscitation efforts in the event of cardiac arrest. Additionally, the facility did not have a policy addressing CPR requirements for staff, nor did it maintain up-to-date documentation of staff CPR certifications. Interviews with facility staff indicated a lack of clarity and oversight regarding CPR certification status. The HR Director reported that many staff had expired certifications or lacked documentation, and that the responsibility for arranging CPR classes had not been fulfilled. The staff member responsible for scheduling was unaware of which employees held current certifications, and both the Administrator and other leadership acknowledged that a CPR-certified staff member should be present on each shift. Despite this, the facility did not ensure compliance, resulting in shifts without appropriately certified personnel.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an infection prevention and control program (IPCP) that included an antibiotic stewardship program and a system to monitor antibiotic use. Review of the facility's Infection Control Policy and Procedure indicated requirements for evidence-based infection prevention practices, oversight by a designated Infection Preventionist (IP), surveillance of infections, prevention strategies, education, and regular review of antibiotic use. However, interviews and record reviews revealed that the facility did not have a functioning antibiotic stewardship program or a designated IP. The only full-time day shift RN, who previously served as the IP, reported being unable to fulfill IP duties due to workload and overtime, and confirmed that the facility was not tracking infections or antibiotic use. Further interviews with a corporate RN and the facility administrator confirmed the absence of an IP and lack of documentation regarding infection or antibiotic use tracking. The administrator, who had recently started, acknowledged the expectation for a designated IP or for the DON to fulfill that role, and that the facility should follow its infection control policies and CDC guidelines. The facility census at the time was 37, and there was no evidence of an active system to monitor or review antibiotic use as required by policy.
Failure to Provide Consistent Pressure Ulcer Assessment and Documentation
Penalty
Summary
Facility staff failed to provide necessary treatment and services consistent with standards of practice to promote healing of existing pressure ulcers and prevent new ulcers from developing for a resident with multiple Stage IV pressure ulcers. The resident was identified as at risk for pressure ulcers, with a Braden Scale score indicating risk, and had a history of multiple pressure ulcers present upon admission, including Stage III, Stage IV, and unstageable ulcers. The care plan included interventions such as frequent repositioning, use of pressure-reducing devices, dietary consults, and wound care treatments, as well as regular wound assessments and documentation. Despite these interventions being outlined in the care plan and facility policy, staff did not consistently perform or document weekly wound measurements or skin assessments as required. Nursing notes and skin assessments over several months showed no evidence of weekly wound measurements or completed skin assessments. During observation, a registered nurse performed wound care but did not measure the wounds, and staff interviews confirmed that wound measurements and assessments were not being completed as per policy. Staff cited short staffing and workload as reasons for not completing required documentation and assessments. Additionally, there was a lack of communication with the physician regarding the status of the wounds, as the physician reported not receiving any wound documentation or weekly reports. The facility did not have a designated wound nurse, and the Director of Nursing or designee was not monitoring wounds as required. The failure to follow facility policy and standard wound care practices resulted in inadequate monitoring and documentation of the resident's pressure ulcers.
Failure to Maintain RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and did not ensure a full-time Director of Nursing (DON) was designated. The facility's assessment indicated the need for a DON and two full-time RNs, but staffing schedules revealed significant gaps in RN coverage. On multiple occasions in December 2024 and January 2025, there was no RN coverage in the facility, with a corporate RN only available by phone. The facility's policies required adequate staffing to meet resident needs, but these were not adhered to, resulting in insufficient RN presence. Interviews with the Administrator in Training (AIT) and the Administrator highlighted the challenges faced by the facility in maintaining adequate RN staffing. The DON had resigned on December 29, 2024, leaving the facility with only one full-time RN and two RNs working as needed. Despite efforts to recruit through staffing agencies and corporate support, the facility struggled to fill the RN and DON positions. The lack of a full-time DON and consistent RN coverage compromised the facility's ability to meet the nursing care needs of its residents, as outlined in their policies and the Centers for Medicare and Medicaid Services guidelines.
Misappropriation of Narcotic Medications by RN
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their narcotic medications by a Registered Nurse (RN) who was also the Former Assistant Director of Nursing (ADON). The RN signed for receiving narcotic medications from the pharmacy for two residents but did not document their administration or destruction. The medications were not found in the facility after being received by the RN, indicating a misappropriation of property. Resident #1, who had a diagnosis of complete traumatic amputation at the level between the knee and ankle, was prescribed oxycodone-acetaminophen for pain management. Despite receiving multiple deliveries of this medication, there was no documentation of its administration, and the resident reported not requesting or receiving pain medication. The RN re-ordered the medication multiple times without justification, and the medication was not logged into the narcotic count/lock box. Resident #2 had an order for hydrocodone-acetaminophen for hand pain but similarly showed no documentation of administration. The RN discontinued the order in the computer system and signed for a delivery of the medication, which was not logged into the narcotic count/lock box. The facility's investigation revealed that the RN was the only staff member with access to the medications during the shifts in question, and the narcotics were ordered and received by the RN without being accounted for in the facility.
Deficiencies in Kitchen Cleanliness and Food Handling Practices
Penalty
Summary
The facility failed to maintain cleanliness and proper food handling practices in the kitchen, leading to multiple deficiencies. Observations revealed a significant buildup of grease and debris on the range hood and filters, which had not been cleaned as per the facility's policy. The Dietary Manager was unaware that the responsibility for cleaning the hood filters fell on the dietary staff, and the Maintenance Supervisor was unsure of the last cleaning date. Additionally, the air conditioner and microwave in the kitchen were found with a heavy buildup of debris, and the microwave showed signs of rust and damage. Food storage practices were also found to be inadequate. Several food items in the refrigerator and freezer were uncovered, unlabeled, or not dated, contrary to the facility's policy. This included ice cream, burritos, hamburger patties, and various other food items. The Dietary Manager reheated and served chicken noodle soup that was improperly dated, and several spice containers were left open and unsealed. The water dispenser and its filter were not maintained properly, with a buildup of debris observed on the dispensing spout. The facility also failed to ensure safe food handling practices. The Dietary Manager was observed handling food with gloves without washing hands between tasks, and staff did not wear hair restraints properly, leaving hair exposed while handling food. Furthermore, the ice machine lacked an appropriate air gap to prevent back siphonage, and a light fixture cover in the kitchen was damaged, posing potential contamination risks. Interviews with the Dietary Manager and Maintenance Supervisor revealed a lack of awareness and adherence to the facility's policies regarding these issues.
Failure to Cover Urinary Catheter Bags
Penalty
Summary
The facility failed to ensure the dignity and respect of three residents by not covering their urinary catheter bags, as required by the facility's policy. The policy, dated August 2009, mandates that each resident should be cared for in a manner that promotes dignity and prohibits demeaning practices. Specifically, the policy requires staff to assist residents in keeping urinary catheter bags covered. However, observations revealed that the urinary catheter bags of Residents #40, #293, and #35 were consistently left uncovered in public areas, compromising their dignity. Resident #40, who was cognitively impaired and dependent on assistance for toileting, was observed multiple times in the common area and dining room with an uncovered urinary catheter bag. Despite the care plan indicating the need for a dignity cover, the bag remained exposed on several occasions, including during meals and in the presence of other residents. Similarly, Resident #293, who was cognitively intact and independent for toileting, was observed with an uncovered catheter bag while dining and moving around the facility. The lack of a dignity cover was noted during interactions with staff and other residents. Resident #35, who was cognitively impaired and required substantial assistance for toileting, also had an uncovered urinary catheter bag during meals and while being transferred by staff. Interviews with facility staff, including CNAs and the Infection Preventionist/RN, confirmed that catheter bags should always have dignity covers. The Director of Nursing acknowledged the issue and admitted that the facility did not have enough dignity covers for all residents with urinary catheters.
Deficiency in Resident Trust Fund Account Management
Penalty
Summary
The facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles. Specifically, the facility did not maintain an accurate accounting of all monies held in the resident trust fund account by failing to reconcile each month. The facility managed funds for 25 residents, and the census was 43. A request for a facility policy regarding the reconciliation of the resident funds account was made, but none was provided. Record reviews showed no reconciliation for the full resident trust account, and the Corporate Accountant's attempted reconciliation for specific accounts showed no reconciliations for the period from June 2023 through June 2024. Interviews revealed that the Business Office Manager (BOM) only reconciled the petty cash accounts, while corporate staff reconciled the bank accounts. The BOM and Corporate Accountant confirmed that only petty cash was reconciled, and the facility management company staff indicated that $1,500 was transferred monthly to the resident trust account to prevent negative balances. However, the reconciliation did not account for these transfers, and there was no documentation to verify the source of the petty cash funds. The Administrator expected the resident funds account to be reconciled correctly, but this was not the case.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately complete comprehensive assessments for three residents, leading to deficiencies in the documentation of their medical conditions and treatments. Resident #25's quarterly Minimum Data Set (MDS) did not document the resident's ongoing dialysis treatment, despite the resident's care plan and physician orders indicating regular dialysis sessions. The MDS coordinator admitted to an oversight in failing to include this critical information. Similarly, Resident #2's MDS lacked documentation of a severe intellectual disability, a condition confirmed in the resident's physician progress notes. The MDS coordinator was unaware of this diagnosis, resulting in an inaccurate assessment. Resident #18's MDS inaccurately documented the presence of three stage III pressure ulcers upon readmission, while the nursing admission screening indicated the presence of stage II pressure ulcers. The MDS coordinator acknowledged the error after reviewing the resident's medical records, which showed no evidence of the ulcers worsening. The Director of Nursing (DON) expected the MDS to be accurate and reflective of current resident conditions, but the inaccuracies in these assessments indicate a failure to meet these expectations.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control procedures, particularly in hand hygiene and the use of personal protective equipment (PPE). Observations revealed that staff did not consistently wash their hands before and after resident contact, nor did they use gowns when required for Enhanced Barrier Precautions (EBP). For instance, the Assistant Director of Nursing (ADON) and other staff members were observed performing wound care and other high-contact activities without wearing gowns, despite the presence of wounds and indwelling medical devices that necessitated such precautions. Additionally, signage indicating EBP was often missing from resident rooms, and PPE was not readily available, further contributing to the lapses in infection control. The facility also failed to maintain proper urinary catheter care, as drainage bags were frequently observed touching the floor, which poses a risk for contamination and infection. This was noted for several residents, including those with urinary catheters for retention or other medical conditions. Despite facility policies requiring that catheter bags be kept off the floor, observations showed that bags were often found dragging on the ground or resting directly on the floor, both in resident rooms and common areas. Furthermore, the handling of soiled materials and the execution of perineal care were not conducted in a sanitary manner. Staff were seen placing soiled washcloths on surfaces without barriers and failing to perform hand hygiene after removing gloves or handling contaminated items. These actions were contrary to the facility's policies and expectations for infection prevention, as stated by the Director of Nursing and the Infection Preventionist. The lack of adherence to these protocols highlights significant deficiencies in the facility's infection control practices.
Deficiency in Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential kitchen equipment in good working order, specifically the three-compartment sink used for sanitizer solution. Observations revealed that the drain pipe for the third sink well was leaking, causing water to overflow from a plastic tub onto the floor. The Dietary Manager confirmed that the pipes under the sink leaked due to broken seals and that the sink lacked hot water. Despite being aware of these issues, the maintenance team and the Administrator had not resolved the problem, which had persisted for approximately one year. Interviews with the Maintenance Supervisor and the Administrator indicated that the sink had not functioned properly for at least six months, and previous repair attempts were unsuccessful. The facility was in the process of finding a custom-built replacement due to size constraints in the kitchen. The kitchen staff had stopped using the sink for washing large items or dishware when the dish machine was broken, highlighting the ongoing impact of the deficiency on kitchen operations.
Failure to Conduct Regular Bed Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential entrapment risks for three residents. The facility's policy, dated December 2007, required maintenance staff to inspect all beds and related equipment as part of a regular bed safety program. However, there was no documentation of entrapment zone measurements for Residents #24, #25, and #40, despite their use of bed rails or assist bars. Observations confirmed that these residents had assist bars or bed rails in the raised position, but the necessary safety checks were not documented. Resident #40, who was cognitively intact but had upper and lower extremity impairments, was observed with assist bars on both sides of the bed. The resident's Bed Rail Assessment indicated a need for these bars to promote independence, yet there was no documentation of entrapment zone measurements. Similarly, Resident #24, who required substantial assistance with bed mobility, had mobility bars as per physician orders, but again, no entrapment zone measurements were documented. Resident #25, also non-ambulatory and requiring assistance, had quarter bed rails, but the necessary safety checks were not recorded. Interviews with facility staff revealed gaps in the implementation of the bed safety policy. The Maintenance Supervisor admitted to installing bed rails without completing or tracking the required measurements and did not check compatibility with specialty mattresses. The DON stated that maintenance staff were responsible for measuring entrapment zones and ensuring compatibility, but these tasks were not completed as expected. The Administrator acknowledged that maintenance and nursing staff should collaborate to ensure these measurements are completed and tracked, as per facility policy.
Failure to Post State Agency and Elder Abuse Hotline Information
Penalty
Summary
The facility failed to ensure that the telephone number and contact information for the state survey agency and the elder abuse hotline were posted in the facility, as required by federal and state laws. Observations conducted over several days revealed that there was no visible posting of this information throughout the facility. Although the elder abuse hotline number was found in the front foyer area, it was not readily visible to those entering the facility, and the state survey agency contact information was not posted at all. Interviews with residents and staff further confirmed the deficiency. During a group resident council interview, residents expressed that they were unaware of where the contact information for the state survey agency or elder abuse hotline was posted. A resident also stated that they had not seen the numbers posted anywhere in the facility, only the Resident's Rights posters in the hallways. The Human Resources staff member corroborated this by stating that she could not find the contact information posted anywhere in the facility. The Administrator acknowledged that social services were responsible for posting the information and admitted that he was unaware it was not posted throughout the facility.
Failure to Timely Issue NOMNCs
Penalty
Summary
The facility failed to provide timely Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Notice of Medicare Non-Coverage (NOMNC) to three residents, as required by regulations. The NOMNC should be delivered at least two calendar days before Medicare coverage services end. However, the facility did not meet this requirement for three residents. Resident #343 received the NOMNC one day before the last skilled day, Resident #34's representative received it on the same day as the last skilled day, and Resident #344's representative received it one day before the last skilled day. This indicates a failure to comply with the required notice period. Interviews with facility staff revealed a lack of awareness and training regarding the issuance of NOMNCs. The Social Services Director (SSD) admitted to being unaware of the two-day notice requirement and stated that they had never been trained in issuing Advance Beneficiary Notices (ABNs) or NOMNCs. The Administrator expected the Business Office Manager or SSD, in collaboration with Therapy, to issue the notices according to regulations, but this expectation was not met. The facility also failed to provide a policy regarding the issuing of NOMNCs when requested.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which includes the facility name, resident census, and total actual hours worked by both licensed and unlicensed nursing staff per shift. Observations on multiple occasions revealed that the required staffing information was not posted in a prominent location as mandated by the facility's policy. On one occasion, the Administrator in Training admitted to removing the postings because a resident was tearing them off the bulletin board. Further observations showed that the posted nurse staffing sheet only contained census information without the necessary details of licensed or unlicensed staffing numbers or hours for each shift. A review of the facility's records over an 18-month period revealed that approximately one-third of the nurse staffing sheets were blank and lacked the required information. Interviews with the Director of Nursing and the Administrator confirmed the deficiency, with both expressing expectations that the staffing sheets should be completed accurately and posted conspicuously as per regulations. The failure to maintain and display accurate staffing information as required by policy and regulations was evident, leading to the deficiency noted in the report.
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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