Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Country View Nursing during CMS and state inspections, most recent first.
The facility failed to keep resident bathrooms and a resident room door in good repair. Multiple residents shared a bathroom with a loose, unsecured toilet seat and armrest frame that had been broken for weeks, and residents reported falls and fear of falling. Another shared bathroom was without a functioning toilet for about two months, forcing residents to use a commode in the room, which one resident described as undignified and odorous. A resident’s room door also would not latch properly and squeaked loudly when opened or closed.
A broken toilet seat and loose armrest frame in a shared bathroom remained unrepaired for weeks, and no portable commode was available. Three residents with significant mobility and fall-risk issues used the bathroom during this time; two residents fell while getting on or off the toilet, and one resident reported fear and prolonged waiting to use the toilet because the seat moved and the armrest was loose. Staff and maintenance were aware of the problem, but the toilet was still not secured when observed.
A cognitively intact resident who required one-person assistance with ADLs reported that an agency CNA refused needed help at bedtime, told the resident to perform tasks independently, and then slapped the resident in the face with a soiled brief while providing rough care that caused pain and pinching. The CNA spoke in a harsh, rude tone and falsely gave another staff member’s name when asked to identify themselves. The resident’s cognitively intact roommate corroborated hearing the resident complain of pinching, hearing the CNA deny it, and seeing the CNA repeatedly smack the resident’s face with gloves while speaking in a mean, disrespectful manner, all occurring without the privacy curtain drawn. Another CNA later reported the resident’s allegation to the charge nurse, and facility records linked the conduct to an agency CNA assigned to that hall.
Failure to Provide Ordered Restorative ROM Services: A resident with stroke-related hemiplegia, hemiparesis, and contractures had a physician order for restorative nursing six days a week, but the record showed no documentation that PROM was provided as ordered or as reflected in the care plan. Observations found the resident contracted in bed with no ROM performed during cares, and interviews with the resident, family, CNA, LPN, DON, administrator, and MD confirmed the restorative program was not in place and the resident had become stiffer and more uncomfortable.
Failure to Document and Update Fall Interventions After Repeated Falls A resident with dementia, pain, and high fall risk and another resident with dementia, wandering, and prior fractures both had repeated falls, including unwitnessed events and falls with injuries such as skin tears, hematoma, contusions, and rib and pelvic fractures. The record showed missing or delayed physician and DON notifications, incomplete fall documentation, no timely IDT review after several falls, and no consistent care plan updates or new interventions despite repeated incidents and high fall-risk assessments.
A resident with an indwelling catheter and neurogenic bladder missed multiple urology follow-ups, and the catheter was not documented as changed for months after a hospital discharge order for monthly changes. Staff later found the catheter tubing split and taped together, and at one point the catheter was left open to drain into an incontinent brief instead of being connected to a drainage bag. The resident later had a UTI with Proteus mirabilis and was treated with Augmentin.
Failure to Address Significant Weight Loss: Two residents experienced significant unplanned weight loss, but nursing did not notify the MD or RD, assess causes, update the care plan, or start timely interventions. One resident lost over 6% in a month while the other lost nearly 8% in a week, and records showed delayed recognition and delayed nutrition intervention despite poor intake observed at meals.
A resident environment deficiency was cited after surveyors found widespread disrepair and poor housekeeping throughout the facility, including dirty baseboards, broken and taped-over bathroom tile, worn grip strips, raised thresholds, damaged door frames, loose ceiling material, stained ceilings, and soiled shower rooms. A resident reported repeated concerns about broken tile and a raised strip between the bedroom and bathroom, and said the strip had caused stumbling. Surveyors also observed sewer gas odor in a shower room, damaged toilets and walls, dirty utility and common areas, and exterior rot, cracked gutters, and disconnected downspouts. The Maintenance Director said he had just started and had not completed a full environment assessment, while the Administrator acknowledged ongoing ceiling and repair issues.
The facility failed to employ a qualified dietary manager to direct food and nutrition services. The facility assessment called for a director of food and nutrition services, but the Head Dietary employee stated the facility did not have a dietary manager and had not started training to become a certified dietary manager. The Administrator said the facility had been without a dietary manager for several months.
Food service failed to provide meals at proper temperatures and with acceptable taste and texture. Residents reported cold oatmeal, bland or poorly seasoned food, hard vegetables, dry bread, and meals that seemed undercooked or straight from a can. During meal observations, dietary staff plated and sent trays to resident rooms without checking temperatures, and test tray items were later found well below hot-food standards, including vegetable blend, garlic bread, corn, peach cobbler, tomato soup, and a grilled cheese sandwich.
Food service staff failed to maintain proper hand hygiene, glove use, and hair restraint use while handling resident meals and beverages. A nurse aide and dietary staff member touched dropped items, food, utensils, and beverage surfaces without washing hands or changing gloves, and one staff member handled food with bare hands. Kitchen sanitation was also poor, with grease, debris, rust, dirty equipment, broken or uncovered light fixtures, and no air gap at the ice machine drain.
Infection prevention and control failures included incomplete Legionella water management policies, no documented risk assessment, and no testing of residents with new pneumonia for Legionnaires’ disease. Staff also failed to use required PPE when entering a COVID-positive resident’s room, failed to place a barrier under or properly clean a multi-use blood glucose monitor during resident testing, and did not complete employee TB screening in the required time frames.
Resident trust funds were mismanaged when multiple residents’ accounts went into negative balances, withdrawals lacked resident signatures, and statements were not sent to residents or RP/guardians. Records also showed check printing fees were charged to the trust account and not reimbursed, and one discharged resident’s negative balance remained unresolved. Interviews with the SSD, BOM, and Admin confirmed the account handling and statement process were not being followed.
Resident trust fund balances were not returned for multiple residents after discharge or death. Records showed several residents discharged with money still in their accounts for days to more than 1,000 days past the required timeframe, and deceased residents on Medicaid had no documentation that notice of death was sent to the state or that funds were refunded to the State of MO. Interviews with the SSD, BOM, and Admin confirmed there was no effective tracking or completion of the required refunds.
Failure to provide transfer notices, bed-hold info, and discharge recapitulation: two residents were sent to the hospital by ambulance for acute illness or symptoms, and a third resident was transferred twice for behavioral issues and later discharged. The records showed no written transfer/discharge notice or bed-hold policy was given to the residents or their DPOAs, and for one resident the facility also failed to complete a discharge recapitulation with a stay summary, discharge status, and med reconciliation.
Insufficient Bedtime Snack Availability: Residents reported that bedtime snacks were no longer routinely passed, had to be requested, and often ran out, with only cookies, snack cakes, or graham crackers generally available. Observations showed no snacks at the nursing station and no staff offering snacks during evening hours. The DON/administrator confirmed snacks were limited, no protein-based snacks were offered, and there were no specific snacks for diabetic residents, while the MD expected a protein-based snack to be available at bedtime for diabetic residents.
A resident with moderate cognitive impairment, mobility dependence, multiple falls, and a significant weight loss had incomplete notification documentation after changes in condition. The record showed no documentation that the physician, dietician, or representative were notified of the weight loss, and several falls had missing notification documentation for either the physician or the representative. The resident’s representative said they were not informed every time the resident fell or when the resident lost weight, and the DON, corporate nursing manager, and medical director stated staff were responsible for notifying the physician and representative of falls and significant weight loss.
Failure to complete SCSA MDSs for two residents after multiple status changes. One resident had new weight loss, new pain, a mechanically altered diet, and new meds/interventions, while another had declines in ADLs, new bowel/bladder incontinence, catheter removal, a new skin tear, new pain treatment, and an added antidepressant. The MDS/care plan coordinator, DON, and corporate operations manager were interviewed about SCSA requirements, and the assessments were not completed within the required timeframe.
A resident with a history of depression later developed a new diagnosis of paranoid schizophrenia, and the facility did not promptly submit the required PASRR Level II referral to the state mental health authority after the significant change in mental condition. Records showed schizophrenia on the resident’s hospital and re-entry assessments, while interviews with the SSD, DON, and MDS Coordinator showed confusion about who was responsible for ensuring the Level II PASRR was completed.
PTSD Triggers and Trauma-Informed Interventions Missing From Care Plan: A resident with PTSD, anxiety, nightmares, and insomnia had documented trauma assessments identifying triggers such as loud crowds, arguing, loud sudden noises, and sudden environmental changes, but the care plan only addressed psychotropic use and did not include the resident’s triggers or PTSD-specific interventions. The resident said these issues sometimes caused flashbacks and believed staff knew about them, while a CNA did not know the triggers and an LPN stated all needed care information should be on the care plan; the DON said PTSD and triggers were expected to be included.
Insulin Pen Not Primed Before Administration: A resident with DM and daily insulin administration was prescribed NovoLog 5 units before meals, but an LPN administered the dose without priming the insulin pen. Observation showed the LPN cleaned the site, attached the needle, skipped the air shot/priming step, dialed 5 units, and gave the injection. The LPN stated he/she was not aware priming was required, and the DON confirmed that insulin pen administration required priming with 2 units.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely.
A resident with significant mobility impairments was transported in a facility van using only two functional wheelchair straps, resulting in the wheelchair tipping over and the resident sustaining a head injury. Multiple residents reported feeling unsafe during van transport due to loose or missing straps, and staff lacked training on proper securing procedures. Despite repeated concerns raised in council meetings, maintenance issues with the van's straps and seatbelts were not addressed or documented, and no policy or training was provided for transport staff.
The facility did not have a full-time, licensed administrator physically present as required, with the acting administrator not holding a current license and the displayed license belonging to another administrator who was only present once a week. Staff interviews confirmed gaps in administrator coverage, and the facility lacked a policy outlining administrator duties.
Two residents did not receive wound care as ordered due to failures in transcribing and documenting physician and wound care clinic orders, including missing or incomplete entries for dressing changes and ace wrap applications. Additionally, one resident missed multiple wound care clinic appointments because transportation was not provided. LPNs reported that orders were sometimes missed or not fully entered, and there was no consistent review process for faxed orders. The DON expected staff to follow and document all treatment orders as directed.
The facility failed to provide dignified care when staff did not promptly answer call lights, causing two residents to experience incontinence. Despite being cognitively intact, the residents had to wait 35 minutes for assistance, with one becoming incontinent. Observations showed multiple call lights activated, with staff present but not responding promptly. The facility's policy required all staff, including temporary agency staff, to answer call lights, but this was not adhered to.
A facility failed to provide a resident's POA with medical records within 24 hours of a request. The POA initially asked an LPN for access but was only given physician orders. An email request was sent to the Social Services Director, who forwarded it to medical records staff. However, the staff was unaware of the request, leading to a delay in providing the records.
The facility did not notify the POAs of two residents involved in an altercation, despite its policy requiring such notification. One resident with dementia slapped another with schizoaffective disorder, and although the incident was reported and the residents were separated, the POAs were not informed. Interviews revealed that the POAs were unaware of the incident, highlighting a deficiency in the facility's notification procedures.
A resident with a history of stroke and recent surgery did not receive prescribed anticoagulant medication due to incorrect discontinuation of the order by an LPN. Additionally, the facility failed to coordinate follow-up appointments as per hospital discharge orders. The Medical Records/Transportation Staff were not informed of the need for transportation, and the discharge orders were not scanned into the electronic medical record.
The facility failed to treat residents with dignity and respect, as evidenced by rough handling and dismissive comments from staff, refusal to assist a resident due to their MRSA diagnosis, and repeated turning off of a call light without providing help. These incidents involved residents who were cognitively intact and had specific care needs, highlighting a lack of proper communication and support from staff.
Unsafe Bathroom Fixtures and Poorly Maintained Resident Door
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by leaving multiple resident bathroom toilets unrepaired for extended periods and by not adequately repairing one resident’s room door. The facility policy required environmental issues to be logged and corrected, including structural damage and safety hazards. The administrator acknowledged that the facility had an ongoing problem with toilet seat bolts breaking and that the issue had continued for weeks. In one shared bathroom used by three residents, the toilet seat was missing a bolt, was loose, and was not secured in place; the armrest frame was also loose. The maintenance log documented the missing bolt, but the repair date was left blank. Residents reported that the toilet seat and armrest moved when they sat down or got off the toilet, that the condition had existed for weeks, and that at least two residents had fallen in the bathroom. Maintenance staff and the maintenance supervisor stated they knew the toilet was broken and unsafe, but the plumber did not complete the repair when first seen, and staff did not ensure the repair was finished. In another shared bathroom, the toilet had been documented as swiveling and then fixed, but residents reported they were without a functioning toilet for two to three months and used a commode in the middle of the room. One resident said the commode was undignified and had odors because it was not cleaned well. The administrator stated the toilet was not usable for about two months and that it was not homelike for a resident to use a portable commode in the middle of the room for over two months. The facility also documented a resident’s door that would not latch, was adjusted, and later was observed squeaking loudly when opened or closed; the resident said the door only closed if a towel was placed along the top of it.
Broken toilet seat and loose armrest created bathroom fall hazards
Penalty
Summary
The facility failed to ensure a safe environment free of fall hazards for three residents who shared a bathroom with a broken toilet seat and a loose toilet armrest frame that remained unrepaired for over two weeks. The toilet seat was missing a bolt and was not secured to the toilet, and the armrest frame was loose and not secured in place. The maintenance log documented the missing bolt, but the repair date was left blank. Observation showed there was no portable commode available in the bathroom or in the residents' room, despite staff statements that residents were supposed to use one when the toilet was broken. Resident #2 had diagnoses including legal blindness, muscle weakness, dizziness and giddiness, and repeated falls. The resident's care plan identified impaired visual function, fall risk, limited mobility, and the need for one staff member to assist with ambulation and toileting. The resident fell while trying to get off the toilet, sustained an abrasion to the right knee, and stated the toilet seat was broken and too high. The resident also reported that the toilet seat and armrests were loose and had been broken for a couple of weeks, and that the resident was afraid to use the bathroom because of the condition of the toilet. Resident #1 had diagnoses including hemiplegia, hemiparesis following cerebral infarction, dementia, and muscle weakness. The resident's care plan identified the need for assistance with ADLs and reminders to use the call light. The resident fell in the bathroom while trying to transfer from the toilet to the wheelchair, and the fall report identified gait imbalance and unsafe ambulation factors. The resident stated the toilet seat and armrest support were very loose, had been broken for about a month, and had caused a prior fall. The resident's care plan did not show documentation of that fall or evidence that staff reviewed or revised the plan after the event. Resident #3 was cognitively intact and used a walker and wheelchair, with supervision or touch assistance required for toilet transfers and a history of falls. The resident stated the toilet seat had been broken for a few weeks, moved around, and made the resident nervous to use the bathroom. The resident reported having to sit on the toilet for over 15 minutes because of fear of falling while getting up and waiting for staff assistance. Maintenance staff and the Maintenance Supervisor acknowledged awareness of the broken toilet seat and loose armrest frame, and the Maintenance Supervisor stated the toilet was unstable and spun around, but the toilet remained unrepaired during the period described.
Failure to Protect Resident From Physical and Verbal Abuse by Agency CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from staff abuse, as required by its Abuse, Prevention and Prohibition Policy. The resident, who was responsible for self and had diagnoses including unspecified dementia, low back pain, neuralgia and neuritis, and osteoarthritis, required assistance with ADLs such as undergarment changes, peri-care, dressing, transfers, and toileting. On the evening in question, the resident requested help from an agency CNA at bedtime to change an incontinent brief and get ready for bed. The CNA told the resident to do it independently and insisted the resident did not need help, despite the resident’s care plan indicating a need for one-person assistance with these tasks. During this interaction, the CNA took the resident’s soiled brief and slapped the resident in the face with it. The resident reported that the CNA was physically rough, jerked the resident around while assisting with clothing and brief changes, and pulled the brief up in a way that pinched and caused shoulder pain. The CNA spoke in a rude, harsh tone, repeatedly telling the resident to perform tasks independently and denying that pinching was occurring when the resident protested. The resident stated this treatment made him or her angry and feel unsafe. The resident also reported hitting a hand on the door when coming out of the bathroom and described the CNA as an agency staff member without a name tag who falsely gave another staff member’s name when asked to identify themselves. The resident’s roommate, who was also cognitively intact, corroborated key aspects of the abusive interaction. The roommate reported hearing the resident tell the CNA to stop pinching and hearing the CNA deny pinching while stating they were just trying to provide care. The roommate observed the CNA smack the resident back and forth in the face several times with gloves in the resident’s room, noted that the privacy curtain was not pulled, and described the CNA’s tone as harsh, rude, disrespectful, and mean. The roommate stated the CNA told the resident they would not help with getting ready for bed and that the resident could do it alone. The roommate felt uncomfortable witnessing the interaction and confirmed that the resident later reported the incident to staff. Facility records showed that the allegation was reported by another CNA after the resident described feeling unwell due to the way the aide had treated them, and the facility’s investigation identified the agency CNA assigned to that hall as the alleged perpetrator of physical abuse.
Failure to Provide Ordered Restorative ROM Services
Penalty
Summary
The facility failed to provide restorative nursing services to a resident with stroke-related hemiplegia, hemiparesis, and contractures who had a physician order to participate in a restorative nursing program six days a week. The resident’s care plan identified bilateral upper and lower extremity contractures, limited mobility, and pain related to multiple disease processes, and included restorative interventions for PROM and active ROM. The resident’s record also showed a muscle relaxant order for contracture-related symptoms. Review of the medical record showed no documentation that staff completed PROM six days a week from 04/04/25 through 08/05/25, from 08/06/25 through 12/19/25, or from 12/19/25 through 01/07/25, despite the order and care plan directions. A quarterly MDS documented functional limitations in ROM, dependence on staff for multiple ADLs and transfers, and restorative nursing program completion only for limited items, while another MDS noted no restorative nursing program documented. The facility’s own policy stated residents would receive restorative nursing care as needed and that restorative goals would be individualized and included in the plan of care. On observation, the resident was found lying on the right side with the left arm drawn up, the left hand contracted and closed, and the legs drawn up in a fetal position. The resident could not straighten the legs, left arm, or hand, and CNAs assisting with care did not perform ROM exercises during the observed cares. During interview, the resident stated there had been no restorative nursing program for the past two months, that stiffness and discomfort had increased, that sleep was affected, and that the resident needed staff help to reposition because of contractures. The responsible party, CNA, LPN, DON, administrator, and Medical Director all confirmed there was no restorative nursing program in place at the facility during the period reviewed, and the Medical Director stated staff had not notified him that the resident was not receiving ROM or that pain, stiffness, or worsening contractures were occurring.
Failure to Document, Notify, Review, and Update Fall Interventions
Penalty
Summary
The facility failed to follow its fall clinical protocol for documentation, notification, review, and monitoring of falls, and failed to implement or update interventions for two residents who experienced multiple falls. The report states that the facility did not consistently document fall details, notify the physician or administration after falls, complete interdisciplinary team (IDT) reviews, or update care plans with new interventions after repeated falls. The deficiencies were identified through observation, interview, and record review in a census of 40 residents. Resident #5 had diagnoses including Alzheimer’s disease, cervical radiculopathy, and chronic pain, and was assessed as high risk for falls. The resident experienced multiple falls, including an unwitnessed fall found in front of the bathroom door with pain to both arms and the head, a large skin tear to the left arm, and later an event in which the resident was found kneeling and holding onto a walker and wheelchair while trying to get to the bathroom. The record showed a fall with subsequent emergency room evaluation that identified a scalp hematoma and chest wall contusion, and later x-ray findings of fractures of the seventh, eighth, and ninth ribs. The record also showed additional falls on the floor in the bathroom, in the fetal position beside the bed, and while attempting to toilet or move from the dining room to the room. The report states there was no evidence of timely physician or administration notification for some falls, no IDT review after several falls, and no documentation that the care plan was reviewed or updated with new interventions after the falls. Resident #6 had diagnoses including anemia, dementia, depression, and multiple traumatic fractures including a pelvic fracture, and was also identified as high risk for falls. The resident had a history of falls with fractures and was documented as wandering, confused, and requiring extensive assistance with transfers and toileting. The resident was found on the floor in another resident’s room with head contact to a bedside table and pain to the lower back and forehead, and the hospital later reported displaced fractures of the right and left iliac crest and sacrum. The resident also had additional falls in another resident’s room, in front of a bathroom toilet, while reaching for a wheelchair, and while rolling off the bed during sleep. The report states there was no evidence of IDT review after several of these falls, no care plan reevaluation or new fall-prevention interventions after some events, and that ordered fall-prevention items such as gripper strips, motion sensor, and call-don’t-fall signage were not present in the room as documented in the care plan.
Failure to Maintain Catheter Care and Prevent UTI
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent and treat UTIs for a resident with an indwelling urinary catheter and neuromuscular dysfunction of the bladder. The resident was ordered to have the catheter changed monthly and as needed, but the record showed the catheter was changed on 10/31/25 and then not documented as changed again before the February 2026 urology visit. After the resident returned from the hospital in November 2025 with a catheter placed following urethral dilation for urinary retention, the discharge instructions said to return to urology in about one month for catheter change unless facility staff changed it. The resident missed multiple scheduled urology appointments, and the record did not show documentation that the appointments were rescheduled or that the catheter was changed by facility staff. The resident later developed a UTI, with urine culture results showing greater than 100,000 CFU/mL Proteus mirabilis, and was treated with Augmentin. The chart contained no documentation explaining why the urine culture was obtained. Nursing documentation also showed that on 02/14/26 the resident’s urinary catheter was split at the attachment to the drainage site, had been taped together, and urine was leaking from the end of the catheter. Staff cleaned the tubing and reconnected the drainage bag with tape, but there was no documentation that the urologist or physician was notified at that time. Earlier that same day, staff had documented the catheter as patent and draining, but later found the split tubing and taped connection. At the February urology clinic visit, the resident reported the facility had been unable to complete prior follow-up because of transportation problems, and clinic staff documented that the catheter was still the same one placed in November. The clinic note stated the catheter was not attached to a drainage bag and was open to air in an incontinent brief, with tape wrapped around the split tubing. The resident said the catheter had not been changed since the November hospitalization. Interviews with facility staff and the medical director confirmed the catheter should have been changed regularly, that the taped split catheter was not professional practice, and that the lack of catheter changes could increase the resident’s risk of infection or UTI.
Failure to Address Significant Resident Weight Loss
Penalty
Summary
The facility failed to follow its weight assessment and nutrition protocols for two residents with significant unplanned weight loss. The report states that staff did not notify the physician of the weight loss, did not assess for root causes, did not evaluate or update the care plan, and did not initiate interventions based on the weight changes. The deficiency was identified during review of 17 sampled residents. One resident had diagnoses including anemia, dementia, depression, and multiple traumatic fractures. The resident was ordered a regular/mechanical soft diet and a 60 ml med pass supplement twice daily. Weight records showed the resident weighed 117 lbs. on 10/01/25 and 109.6 lbs. on 11/01/25, a 6.32% loss in one month. The record showed no documentation that nursing notified the physician or dietitian about the significant weight loss, and there were no updates, reviews, or new interventions in the care plan or physician orders after the loss was documented. The dietitian later documented the resident’s weight as slight loss and continued the same plan. The record also showed the resident had a new mechanically altered diet on a later MDS, but the care plan still had no nutrition-risk updates after the weight loss. The second resident had diagnoses including Alzheimer’s disease, anemia, thyroid disorder, and depression, and was initially on a regular diet. Weight records showed 115.2 lbs. on 10/31/25 and 106.0 lbs. on 11/07/25, a 9.2 lb loss in one week, and later weights showed continued loss, including 107.8 lbs. on 11/14/25 and 108.2 lbs. on 12/01/25. The record showed no identification of the weight loss, no notification to the physician, dietitian, or resident representative, no evaluation, no interventions, and no care plan updates. A later dietary note documented weight loss and recommended Med Pass 60 ml twice daily, with a physician order entered on 12/23/25; the report states the first significant weight loss was identified on 11/07/25 and the first intervention was not added until 12/23/25. Observations also showed the resident eating poorly at meals without staff cueing or encouragement, and interviews with nursing, the DON, the RD, and the Medical Director confirmed expectations that weight loss should be identified, communicated, assessed, and addressed, but those actions were not done for these residents.
Facility Failed to Maintain Safe and Clean Resident Rooms, Bathrooms, and Common Areas
Penalty
Summary
The facility failed to provide a clean, comfortable, safe, and homelike environment by allowing multiple areas of the building to remain in disrepair. In an occupied resident room, surveyors observed dirt buildup around the baseboards, duct tape covering cracks or broken tile in the bathroom floor, a missing section of bathroom tile, worn anti-skid tape, a raised tack strip between the bedroom and bathroom, and a bathroom door frame with exposed metal from scrapes. The resident stated the room needed a deep cleaning, especially around the baseboards, said the duct tape had been there for a long time, and reported the broken bathroom tiles and raised tack strip had been brought to staff attention several times. The resident also said the raised metal strip into the bathroom had caused stumbling about three times and that the resident was afraid of falling. Surveyors also observed extensive damage and poor condition in shared bathing areas and resident rooms. In the women’s shower room, the door would not close fully, the frame was chipped and missing paint, the toilet was scratched with discolored and missing caulk, wall tiles were duct taped, missing, cracked, and bulging, grip strips were worn and disintegrating, the shower head had scaling and low pressure with leaking, drywall tape was loose near the ceiling, and the floor tile by the tub was soiled. Resident #20 stated the shower rooms needed repair and that they were dirty and smelled bad. In the men’s shower room, the room smelled like sewer gas, the toilet lid exposed the bowl, the toilet bowl had silver streaks and gouges, the floor grip strips were worn, and trim was missing between the wall and ceiling with brown discoloration visible. Additional observations included damaged door frames, marred walls, missing or loose cove base, loose boards with exposed screws, missing floor tile, dirty buildup under wardrobes, a loose ceiling patch, holes in walls, a cracked toilet base, and a soiled utility room floor with missing tile exposing concrete. The survey also identified common area and exterior maintenance issues. The dining room ceiling had drywall tape hanging and mud that had not been sanded or painted. The sitting area by the nurses’ station had a brown-stained ceiling, and the drinking water fountain had dried drips, stains, and debris. Outside, several corner wood sections showed heavy rot and missing paint, trim boards near the roof line and gutters were missing paint, a gutter outside a resident room was not securely connected with a disconnected downspout, and another gutter section was cracked with dried leaves accumulated in it. The Maintenance Director said he had started only a few days earlier, had not completed a full environment assessment, and did not know where the maintenance documentation was other than what administration had in his office. The Administrator stated the metal plate between the room and bathroom should be flush, that environment issues were handled through housekeeping and maintenance staff, that quotes were being sought for the broken tiles in the women’s shower room, that the dining room ceiling kept coming down, and that staff were to place identified needs in the maintenance book.
Lack of Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a qualified dietary manager with the appropriate competencies and skill set to carry out the food and nutrition services program. The facility assessment dated 02/11/25 identified food and nutrition services resources as including a director, support staff, and a registered dietitian, and listed the staffing plan as three full-time day staff, three part-time evening staff, and one dietitian or other clinically qualified nutrition professional to serve as the director of food and nutrition services. However, the current employee list showed the Head Dietary employee started on 9/22/25, and during interview on 01/09/26, the Head Dietary employee stated he/she had been at the facility for four months, that the facility did not have a dietary manager, and that he/she was unsure how long the facility had been without one. The Head Dietary employee said he/she was working to become a certified dietary manager but had not started any training. The Administrator stated during interview that the facility had been without a dietary manager since June 2025.
Food Served at Improper Temperatures and Poor Quality
Penalty
Summary
Food and drink were not consistently served at a safe and appetizing temperature, and multiple residents reported that meals were warm instead of hot, cold, bland, dry, or poorly cooked. Residents described oatmeal that was cold, vegetables that were hard, bread that was hard and dry, food that tasted like it came straight out of a can, and meals that were not well seasoned. The facility policy required hot food to be above 165 degrees and cold food below 40 degrees, with temperatures checked during meal preparation and again on the steamtable before meal service. During observations on two separate meal services, dietary staff served food from the steamtable, plated hall trays, and sent a test tray with the resident meal carts to the halls without checking temperatures during service. After residents had been served, the test tray items were measured and found to be below acceptable hot-food temperatures, including Italian vegetable blend at 104.9 degrees, garlic bread at 98.8 degrees, corn at 111 degrees, peach cobbler at 66.9 degrees, tomato soup at 117.7 degrees, and a grilled cheese sandwich at 102.9 degrees. Surveyors also noted bland taste, firm vegetables, stale chips, dry and pasty casserole, and a sponge-like sandwich. The Head Dietary staff member stated food should be heated to 150-160 degrees before going to the steamtable and was not sure what temperature food should be when served to residents; the Administrator stated the facility had been without a dietary manager since June 2025 and that food should taste good, with hot foods hot and cold foods cold.
Food Service Sanitation and Hygiene Failures
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards. During kitchen and dining room observations, staff handled food and food service items with poor hand and glove hygiene. A nurse aide used an ice scoop to portion ice into resident cups, dropped a lid onto the floor, picked it up, placed it on the beverage preparation counter, and then returned to scooping ice without washing hands. A head dietary staff member sorted meal cards with gloved hands, dropped a card on the floor, picked it up, and continued serving food without washing hands or changing gloves. The same staff member touched glasses, serving utensil handles, resident meal cards, chips, and a grilled cheese sandwich while using the same gloves or bare hands, and a nurse assistant touched the drinking surfaces of resident beverage cups while serving trays in the dining room. Staff also did not follow the facility's hair restraint requirements. A nurse aide entered the kitchen without a hair restraint and had an approximately 8-inch ponytail that was not contained. A dietary aide wore a hair restraint, but several six-inch sections of hair along the front and sides of the head were not contained within it. That dietary aide also removed uncovered bowls of pudding from the refrigerator and placed them on resident meal trays along with beverages and silverware. The kitchen environment was observed to have multiple sanitation problems. In the walk-in cooler, trash, food debris, dried black residue, rust, and pitted flooring were present. The rangehood filters, backsplash, stove burners, fryer surfaces, and surrounding areas had grease, debris, and encrusted buildup. The ice machine had black moist specks on the underside of the lid, and the ice scoop holder contained moist brown residue. The bread storage rack was heavily corroded, and multiple light fixtures in food preparation, dishwashing, clean dish storage, and serving areas were dusty, broken, uncovered, cracked, or not illuminated. The facility also did not maintain an air gap at the ice machine drain; the drain hose was inserted directly into the floor drainpipe. The head dietary staff member, maintenance director, and administrator each acknowledged aspects of these conditions during interviews.
Infection Prevention and Control Failures
Penalty
Summary
The facility failed to develop complete policies and procedures to monitor its water system and implement its Legionella monitoring policy. The facility’s Legionella Water Management Program referenced CDC and ASHRAE guidance, but the water management team listed in the binder consisted of former employees who no longer worked at the facility. The Water Safety Management Assessment and Plan was dated 01/14/23 and had not been reviewed yearly as the policy directed. When asked, the facility could not provide a facility risk assessment identifying where Legionella and other opportunistic waterborne pathogens could grow and spread in the water system. The facility also failed to monitor residents with pneumonia for possible Legionnaires’ disease. The Antibiotic Stewardship Log showed residents diagnosed with pneumonia on 09/25/25, 10/6/25, and 11/6/25, with no documentation that they were tested for Legionnaires’ disease. During interview, the Infection Preventionist stated the facility did not do screening or testing for residents with new pneumonia cases for possible Legionella. The Maintenance Director, DON, and Administrator each stated they did not know key elements of the water management program, including Legionella, ASHRAE guidance, water temperature documentation, or whether the CDC toolkit had been implemented. Observation of water temperatures showed hot water readings of 105 degrees F, 104.3 degrees F, and 107.2 degrees F in occupied resident room sinks, and 104.5 degrees F at shower heads in both the women’s and men’s shower rooms. The shower heads also had very low water pressure and scaling. The facility’s COVID-19 Action Plan required staff entering a COVID-positive resident’s room to use a respirator, gown, gloves, and eye protection, but CNA I entered the room of a resident with COVID without PPE and then assisted another resident without changing PPE. The facility also failed to use a barrier under a multi-use blood glucose monitor and failed to clean the monitor correctly after use for residents with diabetes. In addition, new employee TB screening was not completed in the required time frames for two employees, one employee’s second-step TST was not documented, and one employee received compensation before the first-step TST was administered and read.
Resident Trust Accounts Mismanaged With Negative Balances and Missing Documentation
Penalty
Summary
The facility failed to properly hold, secure, and manage resident personal money deposited with the nursing home because resident trust accounts were allowed to go into negative balances for multiple residents, including four sampled residents and one additional resident. Review of the facility’s resident trust records showed negative balances tied to beauty shop charges, including accounts that remained negative across multiple monthly statements. In several cases, the statements were addressed to old or out-of-facility addresses, and residents or responsible parties reported they had not been told the accounts were negative or that they owed money. The facility also failed to obtain resident signatures for withdrawals from the Resident Trust Fund account. For the residents reviewed, the facility did not provide ledgers or receipts with resident signatures for the transactions. The facility policy required all Resident Trust Fund withdrawals to have the resident signature on a receipt and ledger page, but the records reviewed did not show that requirement was followed. One resident who was his or her own responsible party stated he or she had no money in the trust account and had not been told about any debt, while another resident’s power of attorney and another resident’s guardian both stated they had not received trust statements and were unaware of negative balances. The facility further failed to send quarterly statements to residents or their representatives for those with trust account transactions, and failed to reimburse the Resident Trust Fund account for check printing fees charged to the account. The accounting records showed two deluxe check charges that were not refunded back to the trust account over multiple months, despite the facility policy stating bank charges or fees were the responsibility of the facility and had to be reimbursed. One discharged resident also had a negative trust balance that remained unresolved in the records reviewed, and no documentation showed the balance was refunded after discharge. Interviews with facility leadership confirmed that negative balances were not supposed to occur, that residents should have signed for withdrawals, that statements were supposed to be sent to residents or responsible parties, and that check fees were not supposed to be charged to the Resident Trust Fund account.
Resident Trust Fund Balances Not Returned After Discharge or Death
Penalty
Summary
The facility failed to ensure that resident trust fund balances were returned to discharged residents, their responsible parties, or the appropriate state entity within the required timeframe. Review of the facility policy showed that refund checks for discharged or expired residents were to be completed within five business days, and that funds for deceased residents on Medicaid were to be sent to the State of Missouri by the end of the month following death. The facility census was 40, and review of the resident trust fund account records showed funds still being held for 31 residents, including Residents #106 through #115. Resident records showed multiple examples of delayed or missing refunds after discharge or death. Resident #108, who was his/her own responsible party, discharged with a trust fund balance of $2,162.73, and the facility held the money 1,007 days past the date it should have been returned. Resident #109, who had a responsible party, discharged with a balance of $105.11, and the facility held the money 302 days past the required timeframe. Resident #110 discharged with a balance of $2.19, and the facility held the money 219 days past the date it should have been returned. Resident #112 discharged with a balance of $40.02, and the facility held the money 210 days past the required timeframe. Resident #106, who had a responsible party, discharged with a balance of $14.00, and the facility held the money 200 days past the required timeframe. Resident #107 discharged with a balance of $139.81, and the facility held the money 52 days past the required timeframe. Resident #111 discharged with a balance of $280.51, and the facility held the money 40 days past the required timeframe. The same issue occurred for deceased residents whose records showed Medicaid coverage. Resident #114 expired with a trust fund balance of $45.36, and the facility had no documentation that it sent notice of death to the state or refunded the money to the State of Missouri by the end of the month following death; the money was held 342 days past the required timeframe. Resident #113 expired with a balance of $462.80, and the facility had no documentation that it sent notice of death to the state or refunded the money to the State of Missouri by the end of the month following death; the money was held 283 days past the required timeframe. Resident #115 expired with a balance of $846.14, and the facility had no documentation that it sent notice of death to the state or refunded the money to the State of Missouri by the end of the month following death; the money was held 283 days past the required timeframe. During interviews, the Social Service Director stated that discharged residents should receive their money immediately or by check sent to the resident, responsible party, or next of kin, and that Medicaid residents who expired should have their funds returned to the State of Missouri. The Regional BOM stated that discharged or expired residents should not still have money in the resident trust fund account, that she did not have a tracking system to ensure refunds were completed, and that none of the monies had been refunded for the listed discharged or expired residents. The Administrator stated that discharged or expired residents should not have money remaining in the resident trust fund account and acknowledged that Residents #106 through #115 still had funds held in the account, with no refunds made that he was aware of.
Failure to Provide Transfer Notices, Bed-Hold Information, and Discharge Recapitulation
Penalty
Summary
The facility failed to provide written transfer/discharge notices and bed-hold policy information to residents or their representatives when residents were transferred to the hospital. Resident #1 had a DPOA and was sent to the hospital by ambulance on 08/19/25 with a temperature of 104.9 degrees Fahrenheit and vomiting, then returned to the facility on 08/28/25. The record showed no documentation that a transfer/discharge notice or bed-hold policy was provided. The resident was again transferred to the hospital on 09/18/25 after complaints of nausea and shakiness, with the local hospital later reporting admission for acute respiratory distress, sepsis, and a urinary tract infection; the record again showed no documentation of the required notice or bed-hold policy. The resident's DPOA stated no paperwork related to transfer/discharge or bed-hold policy had been received with either hospitalization. Resident #37 also had a DPOA/responsible party and was transferred to the hospital by ambulance on 07/29/25 after aggressive projectile vomiting and a fever of 102.1 degrees Fahrenheit. The resident was admitted to the hospital for treatment of a urinary tract infection with sepsis and returned to the facility on 08/02/25 with a discharge diagnosis of bacteremia. The medical record showed no documentation that the facility provided a transfer/discharge notice or bed-hold policy to the resident or representative. The resident's DPOA stated in an email that no paperwork related to transfer/discharge or bed-hold policy had been received with any of the resident's hospitalizations. Resident #42 had a DPOA and was transferred to the hospital twice for behavioral concerns, including hitting, kicking, and yelling at staff. On 12/03/25, the resident was sent out by ambulance and returned the same evening after receiving PRN medication with no new orders and no specific diagnosis documented. On 12/06/25, the resident was again transferred to the hospital and returned the next morning after receiving PRN medication with no new diagnosis. The record showed no documentation that a transfer/discharge notice or bed-hold policy was provided for either transfer. The resident's record also showed discharge from the facility on 12/09/25, but there was no documentation of a recapitulation of the resident's stay, including a summary of the stay, the resident's status at discharge, or reconciliation of pre-discharge and post-discharge medications. The DPOA stated no paperwork related to transfer/discharge or bed-hold policy was received, and that the facility did not provide a summary of the resident's stay or a medication list at discharge.
Insufficient Bedtime Snack Availability
Penalty
Summary
The facility failed to ensure residents received sufficient nourishing bedtime snacks. The mealtime service schedule showed supper at 5:30 P.M. and breakfast at 7:45 A.M., leaving 14.25 hours between meals. The facility did not provide a policy for bedtime snacks when requested. During a group interview, residents reported that snacks were no longer routinely passed at night, that snacks had to be requested, and that the available items were generally cookies, snack cakes, or graham crackers. One resident said snacks frequently ran out, and another said staff sometimes delayed providing a snack until after 9:00 P.M. and that the snack was often high in sugar despite the resident having diabetes and wanting a snack with protein instead. Observations on multiple evenings showed no snacks at the nursing station, no staff passing or offering snacks to residents, and no cooler at the nursing station. The Head of [NAME] A stated that evening snacks were prepared in a cooler and delivered to nursing staff, but only 12 to 15 snacks were prepared because not everyone takes one or wants one; the bedtime snacks included graham crackers, oatmeal cream pies, and cookies, and no protein-type snack was offered. The administrator stated bedtime snacks were to be passed at 8:00 P.M., that there were enough snacks for each resident to have one if desired, but also confirmed there were no specific snacks for diabetic residents and no specific protein-based snacks given nightly. The Medical Director stated he would expect a protein-based snack to be available at bedtime for diabetic residents and expected the facility to offer all residents a bedtime snack.
Failure to Notify Physician and Representative of Significant Weight Loss and Falls
Penalty
Summary
The facility failed to maintain documentation showing that staff notified the resident’s physician and the resident’s representative after significant changes in condition for one resident. The resident had moderate cognitive impairment, required substantial assistance with mobility, had experienced multiple falls since admission, and had a recorded weight of 115.2 pounds on 10/31/25 followed by 106.0 pounds on 11/07/25, a 9.2-pound loss in one week. The medical record contained no documentation that staff notified the physician, dietician, or representative of the significant weight loss. The record also showed several falls and inconsistent notification documentation. After a fall on 11/10/25, staff documented that the resident’s representative was notified, but there was no documentation that the physician was notified. After a fall on 12/15/25, staff documented that the DON, hospice, and physician were notified, but there was no documentation that the representative was notified. After a fall on 12/17/25, staff documented that hospice and the representative were notified, but there was no documentation that the physician was notified. After a fall on 1/5/26, there was no documentation that the physician or representative was notified. The resident’s representative stated staff did not call every time the resident fell and was not informed about the weight loss, and the DON, corporate nursing manager, and medical director stated staff were responsible for notifying the physician and representative of falls and significant weight loss.
Failure to Complete Significant Change in Status Assessments
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) for two residents within 14 days after changes occurred that met the criteria for a significant change. The report states that a significant change is a decline or improvement in a resident’s status that affects more than one area of health status and requires interdisciplinary review or care plan revision, and that the facility’s policy required SCSAs to be completed accurately and within the required timeframe. For one resident, the annual MDS showed severe cognitive impairment, no pain, a weight of 117 pounds, oxygen therapy, and diagnoses including cognitive loss/dementia, ADL dependence, urinary incontinence, falls, nutrition issues, pressure ulcer, and psychotropic drug use. The quarterly MDS later showed moderate cognitive impairment, new PRN pain medications and non-medication pain interventions, weight loss to 110 pounds, a new mechanically altered diet, and a new opioid. The facility did not complete a SCSA despite the new weight loss, new pain, new diet, new medications, and new interventions. For the second resident, the annual MDS showed cognitive intactness, independence with eating, partial/moderate assistance for toileting hygiene, lower body dressing, and personal hygiene, an indwelling urinary catheter, bowel continence, multiple diagnoses including stroke, heart failure, diabetes, hemiplegia, anxiety, respiratory failure, insomnia, irregular heartbeat, tremor, and PTSD, plus PRN pain medication and occasional pain. The quarterly MDS later showed set-up or clean-up assistance for eating, dependence for toileting hygiene, lower body dressing, and personal hygiene, removal of the urinary catheter, occasional bowel and bladder incontinence, new scheduled pain medication and non-medication pain intervention, a new skin tear and dressing with nutrition and hydration intervention, antidepressant medication added, and radiation therapy discontinued. The MDS/care plan coordinator, DON, and corporate operations manager were interviewed regarding SCSA requirements, and the report states the SCSA was not completed for this resident either.
Failure to Promptly Notify State Authority After Significant Mental Status Change
Penalty
Summary
The facility failed to notify the state mental health authority promptly after a significant change in the mental condition of a resident with mental illness. Resident #4 had a prior Level I PASRR screening that did not identify serious mental illness or related conditions, but the resident’s record later showed a diagnosis of major depressive disorder with psychotic symptoms and a new diagnosis of paranoid schizophrenia with an onset date of 09/26/22. The resident’s re-entry MDS completed on 12/05/22 also listed schizophrenia as an acute hospital diagnosis. Review of the RAI Manual showed that when a significant change in status occurs for a person known or suspected to have mental illness, a referral to the State Mental Health or Intellectual Disability/Developmental Disabilities Administration authority for a possible Level II PASRR evaluation must promptly occur, and the referral should be made as soon as the criteria are evident. During interviews, the SSD stated that a resident would need a Level II PASRR if there was a change in condition, a new diagnosis, or a return from a psychiatric hospital, but she had started in the role after the resident’s diagnosis and said the diagnosis would not have appeared on her list to follow up. The DON stated that a new diagnosis of schizophrenia or a major psychological change would be handled between social services and MDS staff, and the MDS Coordinator stated that Social Services was responsible for ensuring the Level II PASRR was completed and that a resident reentering with a new schizophrenia diagnosis should have had the Level II PASRR completed by the hospital prior to discharge.
PTSD Triggers and Trauma-Informed Interventions Missing From Care Plan
Penalty
Summary
The facility failed to ensure that Resident #2’s comprehensive care plan included direction to staff for the resident’s PTSD and trauma-informed care needs. The resident’s face sheet listed PTSD and anxiety disorder, and prior Trauma Informed Care Assessments documented that the resident had combat or war zone exposure and identified triggers including loud crowds, people arguing, loud sudden noises, loud noises, and sudden changes in environment. Despite this information, the resident’s care plan last updated 08/24/23 addressed psychotropic drug use related to PTSD, nightmares, and insomnia, but did not identify the resident’s triggers or provide interventions specific to PTSD. The resident’s annual MDS dated 07/23/25 identified the resident as a veteran with diagnoses including stroke, PTSD, anxiety, and insomnia, and noted antipsychotic medication with a GDR attempt and physician-documented clinical contraindication. A quarterly MDS also showed no depression diagnosis or symptoms and that the resident had been started on a new antidepressant medication, but the care plan did not include the new antidepressant, the reason for it, or the resident’s PTSD triggers and interventions to minimize possible triggers that could cause re-traumatization. During interview, the resident stated that loud crowds, people arguing, and loud sudden noises sometimes caused flashbacks and that he/she had told staff about this and thought it was on the care plan. A CNA stated he/she knew the resident had PTSD but did not know the triggers and was not sure they were listed on the care plan. An LPN stated all information needed to care for a resident was expected to be on the care plan, and the DON stated trauma and PTSD were expected to be on the care plan with triggers and interventions to minimize retraumatization, noting the facility did not have an in-house MDS/care plan coordinator at the time.
Insulin Pen Not Primed Before Administration
Penalty
Summary
The facility failed to ensure that a resident with diabetes mellitus and daily insulin administration received the prescribed insulin dosage when staff did not prime an insulin pen before giving NovoLog. Resident #29’s MDS showed a diagnosis of diabetes mellitus and daily insulin administration. The MAR for January 2026 documented NovoLog injection solution 100 units/mL, 5 units subcutaneously before meals for blood sugar control, and staff recorded that 5 units were administered on 01/07/26 at 5:30 P.M. During observation on 01/07/26 at 5:56 P.M., LPN B cleaned the resident’s left arm, cleaned the end of the NovoLog pen, applied a needle, did not prime the needle, dialed up 5 units, showed the dose to the resident, and administered the insulin subcutaneously into the resident’s left arm. The LPN held the needle on the resident’s arm for 17 seconds. In interview, LPN B stated the needle had not been primed and said he/she was not aware priming was needed before administering insulin pens. The DON stated that insulin pen administration required priming with 2 units and holding the pen on the resident’s skin for 10 seconds.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that residents did not consistently receive treatment and supports for daily living in a manner that ensured their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Secure Wheelchair Residents During Van Transport Due to Faulty Straps and Lack of Staff Training
Penalty
Summary
The facility failed to ensure that residents who required wheelchair transport were safely and properly secured during van transportation. On multiple occasions, staff transported residents using a facility van with malfunctioning wheelchair straps, with only two out of four straps functional. During one incident, a resident with end stage renal disease, hemiplegia, and impaired mobility was transported to and from dialysis with only two straps securing the wheelchair. On the return trip, one strap came loose while navigating a roundabout, causing the resident's wheelchair to tip backward, resulting in the resident hitting their head and sliding to the floor of the van. The resident sustained a bump and scratch to the head and later experienced a sudden loss of vision, prompting a hospital evaluation. Prior to this incident, residents had repeatedly voiced concerns about the condition of the van seatbelts and the lack of proper securing during transport in Resident Council meetings. Documentation showed that these concerns were either not addressed, inadequately documented, or not communicated back to residents. Maintenance logs did not reflect any work orders or repairs for the van straps or seatbelts, and there was no evidence of routine checks or a manufacturer's manual for the equipment. Staff interviews revealed a lack of training on how to properly secure wheelchairs in the van, and some staff believed that certain types of wheelchairs did not require strapping. Additionally, unlicensed staff were involved in transporting and assisting residents after accidents occurred. Multiple residents reported feeling unsafe during van transport, with some stating they had to hold onto bars or seats to prevent movement due to loose or missing straps. Staff acknowledged ongoing issues with the straps, but no formal maintenance requests were made, as it was assumed that everyone was aware of the problem. The facility did not provide a policy or training for staff responsible for transporting residents, and there was confusion among staff regarding responsibility for assessing and maintaining the safety of the van's securing mechanisms.
Failure to Maintain Full-Time Licensed Administrator
Penalty
Summary
The facility failed to comply with state laws by not designating a full-time, licensed administrator who was employed in the facility and serving in that capacity. Multiple interviews revealed that there was a period when the facility was without an administrator for at least one week, and the individual acting as administrator had not applied for a temporary emergency license. The license displayed in the facility belonged to another administrator who was only present in the building once a week, rather than serving full-time as required. Staff interviews confirmed uncertainty about when the licensed administrator was last physically present in the facility. Additionally, the facility did not have a policy regarding the administrator or their duties. The Regional Director of Clinical Operations acknowledged that the acting administrator was hired for the role, but the license displayed was not current for the acting administrator. The census at the time was 42 residents, and the lack of a full-time, licensed administrator had the potential to affect all residents in the facility.
Failure to Complete and Document Physician Wound Care Orders and Ensure Clinic Access
Penalty
Summary
The facility failed to follow professional standards of practice by not completing physician orders for wound care as prescribed for two residents. For one resident with a Stage III pressure ulcer on the left heel, multiple orders from the contracted wound care company, including the application of ace wraps from toes to knee and specific dressing changes, were not transcribed onto the physician order sheet (POS) or the Treatment Administration Record (TAR). As a result, these treatments were not documented as completed, and previous orders were not discontinued when new orders were received, leading to overlapping and potentially conflicting wound care treatments. Another resident with multiple pressure ulcers, including a Stage III sacral ulcer, did not have updated wound care clinic orders entered into the POS or documented on the TAR. Orders for wound cleansing, dressing applications, and wound vac management were either missing or incomplete in the records. On several occasions, staff failed to document that wound care treatments were performed as ordered, and there were discrepancies between the wound care clinic's recommendations and what was recorded in the facility's records. Additionally, the facility failed to ensure that this resident had transportation to scheduled wound care clinic appointments, resulting in missed visits. Interviews with nursing staff revealed that orders from the wound care clinic were sometimes missed or not fully transcribed into the POS, and there was no clear process to ensure that all faxed orders were reviewed and entered correctly. The Director of Nursing confirmed that documentation was expected to match the wound care company's orders and that staff were expected to follow treatment orders as directed.
Delayed Response to Call Lights Leads to Resident Incontinence
Penalty
Summary
The facility failed to provide care in a dignified and respectful manner for two residents when staff did not answer call lights promptly, resulting in incontinence and residents waiting in soiled briefs. Resident #3, who was cognitively intact and required maximal assistance with toileting hygiene, reported having to wait a long time for staff to respond to his/her call light, which led to incontinence. Similarly, Resident #4, also cognitively intact and requiring supervision with toileting hygiene, experienced delays in staff response, resulting in wetting his/her pants before reaching the restroom. Observations on the day of the incident showed multiple call lights activated across different halls, with staff members, including an LPN and a CMT, present but not responding promptly. Both residents had to wait 35 minutes for assistance, during which Resident #3 became incontinent. Interviews with the ADON and the Administrator revealed that all staff, including temporary agency staff, were expected to answer call lights promptly, but this expectation was not met, leading to the deficiency.
Failure to Provide Medical Records to Resident's POA
Penalty
Summary
The facility failed to provide a resident's power of attorney (POA) with a copy of the resident's medical records within 24 hours of a written request. The resident, who was admitted to the facility from the hospital and later discharged, had their POA request access to the medical records. The POA initially asked an LPN to view the records but was informed that they were on the computer and was only provided with a copy of the physician orders. Subsequently, the POA emailed the Social Services Director requesting the records, who then forwarded the request to the medical records staff. However, the Medical Records/Transportation Staff stated that she was unaware of the request and had not received any paperwork regarding it. She mentioned that if she had received the request, she would have provided the records within 24 hours. The Administrator later noted that the Social Services Director should have followed up to ensure the medical records staff received the request. This lack of communication and follow-up resulted in the failure to provide the requested medical records in a timely manner.
Failure to Notify POAs After Resident Altercation
Penalty
Summary
The facility failed to adhere to its policy of notifying the power of attorney (POA) for two residents involved in a resident-to-resident altercation. The incident involved a resident with dementia and anxiety disorder, who slapped another resident with schizoaffective disorder and bipolar depression. The altercation was reported to the Social Services Director three days after it occurred, and both residents were separated immediately. However, the POAs for both residents were not informed about the incident, contrary to the facility's policy that mandates notification of significant changes in a resident's status, including altercations. Interviews with the residents' POAs revealed that neither was contacted by the facility regarding the altercation. One POA learned about the incident through a text from the resident, while the other was unaware until the interview. The facility's administrator was under the impression that the POAs had been contacted, as per the staff's report, but this was not the case. The failure to notify the POAs represents a deficiency in following the facility's policy for significant condition change and notification.
Failure to Follow Hospital Discharge Orders and Medication Administration
Penalty
Summary
The facility failed to adhere to hospital discharge orders for a resident who had undergone surgery on the digestive system and had a history of stroke-related hemiplegia and hemiparesis. The resident was prescribed Eliquis, an anticoagulant, to be taken twice daily. However, the medication was only administered once on the day of admission, and the order was incorrectly discontinued the following day without any documented physician directive to do so. The resident did not receive the prescribed Eliquis from July 31 to August 11, when it was resumed at the resident's request. Additionally, the facility did not coordinate the resident's follow-up appointments with the primary care physician, gastroenterologist, and surgeon as outlined in the hospital discharge orders. The Licensed Practical Nurse (LPN) responsible for transcribing the orders claimed to have seen instructions to hold the Eliquis indefinitely, although no such documentation was found in the medical records. The LPN also failed to ensure that the discharge orders were properly communicated to the Medical Records/Transportation Staff for scheduling necessary follow-up appointments. The Medical Records/Transportation Staff did not schedule transportation for the resident's follow-up appointments, as they were not informed of the need for such arrangements. The hospital discharge orders were not scanned into the electronic medical record, and the resident's Power of Attorney was not informed of the required follow-up appointments while the resident was in the facility. The facility's administrator expected staff to accurately transcribe and communicate admission orders, but these expectations were not met, leading to the deficiencies noted.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that three residents were treated with dignity and respect, as evidenced by multiple incidents involving staff interactions. One resident, who was cognitively intact and had communication difficulties, reported that a nursing assistant was rough during care, causing shoulder pain, and made dismissive comments about the resident's reaction. Additionally, a certified nurse assistant repeatedly turned off the resident's call light without providing assistance, as the resident was unable to communicate effectively while lying down. Another resident, also cognitively intact, experienced distress due to comments made by agency staff regarding their smoking habits and medical diagnosis of MRSA. The resident reported overhearing staff discussing their reluctance to assist due to the MRSA diagnosis, which led to a refusal to help with necessary transfers. This lack of support and the inappropriate comments made the resident upset and frustrated. A third resident reported that a nursing assistant was very rude during interactions. Interviews with staff and residents confirmed that the nursing assistant had a loud tone and was perceived as rude by multiple residents. The facility's lack of orientation for agency staff and failure to ensure respectful communication contributed to these deficiencies in resident care.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 2 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bowling Green
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avenir At Maple Grove | 10.5 mi | ★★★★★ | 2 | 0 |
| Baptist Homes, Tri-county | 15.4 mi | ★★★★★ | 0 | 0 |
| Silex Community Care | 17 mi | — | 0 | 0 |
| Westview Nursing Home | 20.5 mi | ★★★★★ | 0 | 0 |
| Elsberry Missouri Health Care Center | 24.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.