Eastview Manor Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Trenton, Missouri.
- Location
- 1622 East 28th Street, Trenton, Missouri 64683
- CMS Provider Number
- 265730
- Inspections on file
- 34
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Eastview Manor Care Center during CMS and state inspections, most recent first.
A resident who was cognitively intact, wheelchair-dependent, and on anticoagulant and antiplatelet therapy experienced a fall with a head laceration, multiple abrasions, and jaundiced, cold, clammy skin. An RN assessed and treated the wounds but did not call the physician, instead sending a text message to the NP and Administrator and documenting no provider notification. Later, the same resident became briefly unresponsive with seizure-like activity; an LPN notified the DON and ADON and monitored the resident but did not notify the physician or NP at that time. The provider was not contacted until many hours after this acute change in condition, when the NP was informed of the episode and additional swelling, and then ordered hospital evaluation. Facility policies required prompt verbal notification of clinicians for falls, injuries, and changes in condition, and interviews with leadership and medical staff confirmed that staff actions did not meet these expectations.
A resident with depression, bipolar disorder, and schizophrenia became upset at the nurse’s station after being unable to reach a taxi service and began banging a cup on the glass while requesting ice. Another cognitively intact resident with anxiety, depression, psychotic disorder, and schizophrenia approached to return snacks to the snack room and stood behind the agitated resident, leading to a verbal exchange. Despite a CNA positioning themself between the two, the agitated resident reached around the CNA and struck the other resident on the left side of the face near the ear with a closed hand. The struck resident reported no pain, injury, or aftereffects and stated feeling safe, but the incident occurred despite facility policies stating residents must be protected from abuse by anyone, including other residents.
Multiple residents with cognitive and psychiatric conditions reported unsanitary shower and bathing areas, including slimy floors, black mold-like substances, and hair left behind, as well as ongoing rodent activity throughout the unit. Staff interviews revealed confusion about cleaning responsibilities and limited access to cleaning supplies. Observations confirmed unrepaired ceiling damage and poor maintenance of the physical environment, contributing to resident distress and discomfort.
A resident was physically abused by another resident who grabbed their shirt and hair, causing a fall and then struck them in the face, following a dispute over clothing. Both individuals had complex psychiatric and behavioral histories, and the aggressor had a known pattern of escalating behaviors when not on one-to-one supervision. Despite this, supervision was reduced, leading to the incident and resulting in a failure to protect the resident from abuse.
Two residents were involved in separate physical altercations with peers, resulting in one resident being pushed to the floor over a disagreement and another being shoved and deprived of their walker. Both incidents involved residents with behavioral health histories and were witnessed by staff, but the facility failed to prevent the physical abuse as required by policy.
A resident with a history of aggression was inadequately supervised after being removed from one-on-one observation without IDT input, leading to another aggressive incident. The facility failed to update the care plan or document changes in supervision, and no mental health referrals were made despite the resident's ongoing behavioral issues.
The facility failed to notify physicians and document care for pressure ulcers in two residents. One resident developed a large, unstageable ulcer due to lack of physician notification and treatment orders, while another resident's open area on the coccyx was not properly assessed or treated. Staff interviews revealed communication and documentation lapses, leading to significant deficiencies in wound management.
A resident, identified as a high fall risk, was left unsupervised in a transport wheelchair, resulting in a fall and severe injuries. The resident, weakened by COVID-19, was found face down with a head injury and later died in the hospital. Additionally, the Housekeeping Supervisor used a toilet bowl cleaner on a floor stain, causing a chemical reaction and smoke in the facility. Staff interviews revealed a lack of awareness of fall prevention interventions and unsafe chemical use, leading to immediate jeopardy.
The facility failed to notify responsible parties or physicians of changes in condition for four residents. A resident with severe cognitive impairment experienced a fall with injuries, but the PCP was not informed. Additionally, three residents tested positive for COVID-19, but their legal guardians were not notified. The facility's policy requires such notifications, but staff did not adhere to it.
A facility failed to ensure a wound nurse had the necessary competency, resulting in inadequate care for a resident's wound. The nurse, with limited training, did not assess or document the wound, nor inform the DON or physician. The resident, with multiple health issues and cognitive impairment, had no care plan addressing skin integrity. Staff interviews revealed a lack of awareness about the nurse's training, highlighting a gap in competency assurance.
The facility failed to enroll three nurse aides in a state-approved training program within four months of employment. Despite lacking CNA certification, these aides provided direct care to residents. The facility lacked policies on CNA training, and leadership was unaware of the training status of these aides.
A resident with a history of falls and cognitive impairment was found with multiple bruises of unknown origin, which were not reported by the facility staff as required by policy. An LPN noticed the bruises but failed to document or notify the administration due to being busy. The bruises were later observed by hospital staff after the resident was sent to the hospital following a fall. Interviews revealed that other staff members also failed to report the bruises, contrary to the facility's policy.
A resident with a history of falls and cognitive impairment was found with unexplained bruises on their sides and lower breasts. Despite facility policy requiring investigation of such injuries, staff members, including an LPN and a Nursing Assistant, failed to report the bruises to the DON or Administrator. The bruises were noted during a hospital visit following a fall, but no investigation was conducted, highlighting a lapse in adherence to abuse and neglect policies.
A resident with a history of mental illness and aggressive behavior assaulted two other residents, leading to a deficiency in resident safety. Despite being on one-to-one supervision, the resident managed to physically attack others, leaving them feeling unsafe. The facility's care plan and staff training were inadequate in managing the resident's behavior, resulting in repeated incidents of abuse.
The facility failed to ensure staff were trained to meet the behavioral health needs of residents, leading to incidents of physical altercations and self-harm. Staff lacked training in non-pharmacological interventions and crisis intervention techniques, as evidenced by incidents involving two residents with mental health diagnoses. The facility's policies were not effectively implemented, and staff files showed no documentation of necessary training.
The facility failed to address the behavioral health needs of two residents, resulting in incidents of abuse and self-harm. One resident engaged in physical aggression due to inadequate interventions, while another continued self-harming without necessary support. Additionally, a CMT failed to follow medication administration protocols, compromising a resident's safety.
A staff member misappropriated medications belonging to three residents, which were found at the staff member's home by law enforcement. The facility's policies on medication security and key management were not effectively implemented, leading to unauthorized access. Facility leadership was unaware of the missing keys and medications until informed by law enforcement, indicating a lack of oversight.
Facility staff failed to maintain or improve residents' abilities to perform ADLs, resulting in four residents being observed with poor hygiene and grooming. Despite being assessed as independent, these residents had greasy hair, dirty clothing, and body odor. Staff interviews revealed a focus on assisting those who need help, with less attention to those who are independent but may still require encouragement or reminders.
The facility failed to assist three residents with activities of daily living (ADLs), resulting in poor personal hygiene. The residents, who were dependent on staff for ADLs, were observed with greasy hair, dirty clothing, body odor, and ungroomed facial hair. Despite expectations for cleanliness, staff did not consistently reapproach residents who refused care, leading to deficiencies in resident care.
The facility was found to have strong odors of urine and body odor, sticky floors, and evidence of flies and mice. A resident's air conditioning unit had mold, and the pest control program was ineffective. The Director of Nursing did not conduct formal inspections, and housekeeping staff were unsure about cleaning supplies for mold.
A resident using a manual wheelchair for mobility reported feeling unsafe due to the worn-out back support, which caused back pain and fear of tipping over. Despite multiple requests to staff, including the DON, the resident had not received a new wheelchair. The DON was aware of the request but did not follow up, and the administrator was unaware of the issue. The facility lacked a policy to ensure assistive devices are well-maintained and safe.
The facility failed to maintain professional standards for food safety and sanitation, with issues including unclean kitchen conditions, improper food temperature checks, and inadequate pest control. Staff did not consistently document food temperatures, and some items were not reheated to safe levels. Hand hygiene was compromised by excessively hot water, and equipment sanitation was insufficient, with pitchers stored upright against policy.
The facility failed to protect residents' personal belongings, resulting in the loss or theft of items for several residents. Despite policies ensuring a safe environment and the right to retain personal possessions, residents reported missing clothing and personal items. Interviews revealed systemic issues in the laundry department, including a lack of structured processes for labeling and returning items, contributing to the deficiency.
The facility failed to provide scheduled showers for several residents due to staffing shortages, resulting in missed showers and inadequate personal hygiene. Residents expressed feelings of uncleanliness and low self-esteem. The primary shower aide was often reassigned to other duties, leading to missed shower opportunities.
A resident with a history of mental illness and self-harm was inadequately supervised, allowing them to tie a string around their neck. Despite being on one-on-one supervision due to recent aggressive behavior, the CNA failed to maintain visual contact, leading to the incident. The resident was found with a string around their neck but did not lose consciousness and refused hospital transfer.
Failure to Promptly Notify Physician After Fall With Head Injury and Acute Change in Condition
Penalty
Summary
Facility staff failed to follow multiple facility policies requiring prompt verbal notification of a resident’s physician after significant changes in condition and accidents. The facility’s Notification of Changes policy required prompt consultation with the resident’s physician and notification of the resident and representative when there was a change requiring notification, including accidents resulting in injury or with potential to require physician intervention. The Incidents and Accidents policy required the nurse to contact the resident’s practitioner after an incident/accident to report injuries or findings and obtain orders, and to document the incident, findings, interventions, and notifications. The Notifying Clinicians policy required clinicians to be notified of changes in condition, emergent situations, and incidents such as falls, out-of-range vital signs, altered mental status, and any change from baseline, with an expectation of verbal communication when an immediate change in the plan of care might be needed. Resident #2 was cognitively intact, used a wheelchair, and required supervision or assistance for toileting, bathing, and hygiene. The resident was on anticoagulant and antiplatelet medications, with diagnoses including heart failure, diabetes, and hypertension. The resident’s care plan directed staff to follow the facility fall protocol if a fall occurred. On 01/21/26 at approximately 1:45 A.M., RN A heard the resident calling for help and found the resident on the floor with his/her head against the sink cabinet. RN A observed a four-centimeter laceration to the left side of the head with a moderate amount of bleeding, cleaned the wound, and applied two Steri-Strips, and also noted five other abrasions and a kiwi-sized area on the resident. Later documentation that morning described the resident’s skin as jaundiced, cold, and clammy, and fragile. There was no documentation that the physician was notified of the fall, the head laceration, the abrasions, or the skin findings. RN A later stated he/she did not call the physician, but instead sent a text message to the nurse practitioner and Administrator around 5:23 A.M., and believed non-emergent incidents could be reported by text. On 01/24/26 at about 8:00 P.M., LPN B documented that the resident became unresponsive for about one minute and then had seizure-like activity for about 45 seconds before becoming responsive again. LPN B documented that the DON and ADON were notified and that the resident was monitored and required three staff for transfer, but there was no documentation that the physician or NP was notified of this acute change in condition. LPN B later stated the resident had no prior similar activity, that the resident was responsive to painful stimuli and appeared fine afterward, and that he/she monitored the resident every 30 to 60 minutes; LPN B acknowledged he/she should have notified the physician. The physician/NP was not notified until 01/25/26 at 12:00 P.M., approximately 16 hours after the unresponsiveness and seizure-like activity, when LPN A informed the NP of the episode, the resident’s jaundiced color, and swollen areas to the right hip and abdomen, at which time an order was given to send the resident to the emergency room. Interviews with facility leadership and providers confirmed that the facility’s expectations were not met. The Administrator stated that when a resident is injured or has a change in condition, staff are to call the resident’s physician. The DON stated nurses should have notified the resident’s provider as quickly as possible and should also notify the ADON, Administrator, guardians, and regional administration, and document physician notification in the medical record. LPN A described that when a resident falls or has an incident, the nurse should assess, obtain vital signs, complete risk management documentation, update the care plan, initiate interventions, and notify the primary care provider and leadership. The NP stated she expected to be notified of injuries, acute occurrences, or urgent issues right away and that, in this resident’s case, she would have expected a call rather than a message. The Medical Director stated the nurse should have called the physician about the fall with injury and that the resident should have been sent to the hospital. The resident’s primary physician stated that he/she or the NP should have been called when the resident fell. These statements, combined with the documentation, show that staff did not promptly notify the physician of the resident’s fall with head injury and subsequent episode of unresponsiveness with seizure-like activity, contrary to facility policy and provider expectations.
Resident-on-resident physical abuse at nurse’s station
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from abuse when one resident struck another resident near the left ear with a closed hand. According to interviews and record review, the incident occurred in the early morning hours when one resident, who was upset about being unable to reach a taxi service, was at the nurse’s station banging a cup on the glass and requesting ice. Another resident approached the area to return snacks to the snack room and stood behind the agitated resident. When the agitated resident turned and asked if the other resident was enjoying the “show,” the second resident replied that they did not care about the “pathetic ass show,” which preceded the physical contact. The striking resident, who had diagnoses including depression, bipolar disorder, and schizophrenia, then attempted to punch the other resident. CNA A was positioned between the two residents, and the striking resident had to reach around the CNA, resulting in a closed-hand hit to the left side of the other resident’s face near the ear rather than a full punch. Staff accounts, including those of CNA A and RN A, consistently described the sequence of events as beginning with the striking resident’s agitation over the taxi call, followed by the verbal exchange at the nurse’s station, and culminating in the physical contact. The facility’s abuse and neglect policy states that the facility is committed to protecting residents from abuse by anyone, including other residents, and that residents who allegedly mistreat another resident will be removed from contact with the resident during the course of an investigation. The resident who was struck had intact cognitive skills, no documented behaviors, and required supervision or touch assistance with eating and transfers, with diagnoses including anxiety, depression, psychotic disorder, and schizophrenia. After the incident, this resident reported having no pain, no red marks or injuries, and no aftereffects, and stated feeling safe in the facility, though feeling better after a room change. The facility’s policy also indicates that the environment and resident characteristics should be assessed to identify situations in which abuse is more likely to occur and that residents with behaviors that might lead to conflict should be identified, but the report documents that both residents’ most recent MDS assessments showed cognitive skills intact and no behaviors prior to the incident. Despite the presence of staff at the nurse’s station and CNA A’s attempt to intervene, the physical contact occurred, constituting the failure to protect the resident from abuse by another resident.
Failure to Maintain Sanitary and Comfortable Environment in Secured Unit
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment in the secured unit, as evidenced by multiple observations, interviews, and record reviews. Staff did not ensure that showers and tubs were cleaned between residents, resulting in the presence of slimy, black mold-like substances, dirty floors, and hair left in bathing areas. Residents reported that showers were not cleaned after each use, with some stating they had to place towels on the floor due to the slimy conditions and that they often encountered other residents' hair and soap scum. Housekeeping and nursing staff interviews confirmed uncertainty about cleaning responsibilities and schedules, and cleaning supplies were not readily accessible to all staff responsible for cleaning between residents. The physical environment was further compromised by unrepaired ceiling damage in the shower area, including peeling sheetrock, missing plaster, water stains, and rusted fixtures. The damage was attributed to a roofing incident, and the ceiling remained in disrepair due to unresolved disputes between the facility and the roofing company. Observations documented large, dark water spots, missing ceiling tape, and exposed foam in furniture, all of which contributed to an environment that was not clean or well-maintained. Additionally, the facility did not maintain an effective pest control system, as evidenced by ongoing rodent activity reported by multiple residents and staff. Residents described seeing mice in their rooms and throughout the secured unit, with mouse droppings found in sinks and on floors. Pest control records indicated an escalation in rodent activity, with increased bait stations and glue traps, but the problem persisted. These deficiencies affected at least three residents with cognitive and psychiatric diagnoses, who expressed feelings of unsafety and distress related to the unsanitary and uncomfortable environment.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident. The incident involved one resident grabbing another by the back of the shirt and hair, causing the victim to lose balance and fall to the ground. The aggressor then made closed hand contact with the victim's face. Both residents were in a common area at the time, and the altercation was triggered by a dispute over a shirt that one resident believed belonged to them. The facility's policy defines abuse as the willful infliction of injury or mistreatment, and requires identification of residents at risk for abuse or with behaviors that might lead to conflict. The resident who was attacked had a history of multiple mental health diagnoses, including schizophrenia, adjustment disorder with anxiety, and major depressive disorder, but was assessed as having no cognitive impairment and was able to communicate effectively. The aggressor had a history of schizophrenia, bipolar disorder, traumatic brain injury, and impulse disorder, and was assessed as having moderate cognitive impairment with a pattern of delusions and aggressive behaviors. The care plans for both residents included interventions for behavioral issues and altercations, but the aggressor had a documented pattern of escalating behaviors when not on one-to-one supervision. Interviews with staff and consultants revealed that the aggressor frequently escalated to altercations when supervision was reduced, and that there was a history of such incidents. Despite this, there was a directive from corporate leadership to reduce one-to-one supervision for the aggressor, which corresponded with repeated resident-to-resident altercations. The facility's failure to maintain adequate supervision and prevent the altercation resulted in a resident being subjected to physical abuse.
Failure to Protect Residents from Physical Abuse During Peer Altercations
Penalty
Summary
The facility failed to protect residents from physical abuse when four residents were involved in two separate physical altercations. In the first incident, one resident, who was cognitively intact and had a history of behavioral challenges and mental health diagnoses, was at the nurses' station with another resident. After a disagreement over sharing pizza, the second resident, who was mildly cognitively impaired and also had a history of behavioral challenges and mental health conditions, open-handedly applied force to the first resident's shoulders, causing the resident to lose balance and fall to the floor. Staff were present and witnessed the altercation, and the incident was not accidental. In the second incident, another resident with intact cognition and multiple mental health diagnoses was ambulating past a peer's doorway and asked to play cards. The peer, who had a history of behavioral challenges, became agitated, stepped out of the room, and open-handedly applied force to the resident's chest, causing the resident to lose balance and stumble into a wall. The aggressor then took the resident's walker and threw it away, further impeding the resident's mobility. The aggressor also became physically aggressive with a staff member. Staff responded by calling a code green and separating the residents. Both incidents were observed by staff, and the altercations were not accidental. In both cases, the facility's failure to prevent these altercations resulted in residents being subjected to physical abuse by peers. The involved residents had documented histories of behavioral issues and triggers, and the facility's policies required assessment, care planning, and monitoring to prevent such incidents. Despite these requirements, the altercations occurred, and residents were not protected from physical abuse.
Failure to Provide Appropriate Behavioral Health Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with behavioral health needs, resulting in a deficiency. The resident, who had a history of verbal aggression, physical altercations, and other behavioral issues, was initially placed on one-on-one supervision following an aggressive incident. However, the resident was removed from this supervision without the input of the Interdisciplinary Team (IDT) and placed on 15-minute checks. This change in supervision was not documented, and no additional interventions were implemented to address the resident's behavioral health needs. The resident's care plan was not updated between the removal of one-on-one supervision and a subsequent aggressive outburst, during which the resident struck another resident. The facility's policies on behavioral emergencies and abuse and neglect were not adequately followed, as there was no IDT review of the decision to change the resident's supervision level, and the care plan was not adjusted to reflect the resident's ongoing behavioral issues. Additionally, there was a lack of communication and documentation regarding the resident's increased agitation and reports of hearing voices, which contributed to the failure to provide appropriate care. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's behavioral changes and the decision to alter the supervision level. The facility's Administrator and Director of Nursing (DON) did not document the change from one-on-one supervision to 15-minute checks, and there was no referral made to mental health resources for the resident. The resident's aggressive behavior continued, resulting in harm to another resident, highlighting the deficiency in the facility's management of the resident's behavioral health needs.
Failure to Notify Physician and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to adhere to its policies regarding pressure ulcer care and physician notification, resulting in significant deficiencies in the care of two residents. For one resident, the facility did not notify the physician or obtain treatment orders when two small blisters were discovered on the resident's buttocks. Despite the blisters being noted during a shower, there was no documentation of physician notification or wound assessments from 10/2/24 to 10/10/24. The resident's condition deteriorated, and upon admission to a hospital on 10/15/24, a large, unstageable pressure ulcer with foul-smelling drainage was discovered on the resident's coccyx. The facility also failed to provide appropriate care for another resident who had an open area on the coccyx. Although the resident was at high risk for skin breakdown, the facility did not notify the physician or obtain treatment orders for the open area. Staff members were aware of the resident's condition but did not take appropriate action to ensure the wound was assessed and treated according to facility policy. The resident reported having the sore area for a few weeks, and staff applied cream without proper assessment or documentation. Interviews with staff revealed a lack of communication and documentation regarding the residents' wounds. The Wound Nurse and other staff members did not follow through with necessary assessments, documentation, or physician notifications. The facility's failure to adhere to its wound care policies and procedures resulted in the development and deterioration of pressure ulcers in both residents, highlighting significant deficiencies in the facility's wound management practices.
Inadequate Supervision and Unsafe Chemical Use Lead to Resident Injury and Facility Hazard
Penalty
Summary
The facility failed to provide adequate supervision to prevent an accident involving a resident who was a high fall risk. The resident, who had a history of falls and was recently weakened due to COVID-19, was left unsupervised in a transport wheelchair by two staff members after being transferred from bed. Approximately ten minutes later, the resident was found face down on the floor with significant injuries, including a laceration to the forehead and skin tears on the arms. The resident was subsequently sent to the hospital, where they were placed on end-of-life care and later passed away due to a traumatic subarachnoid hemorrhage resulting from the fall. Additionally, the facility failed to ensure the safe use of chemicals, leading to a hazardous incident. The Housekeeping Supervisor used a toilet bowl cleaner to clean a floor stain in the beauty shop, which caused a chemical reaction and resulted in a smoky haze throughout the facility, triggering the fire alarm. The Housekeeping Supervisor had not received proper training on the safe use of chemicals and was unaware of the potential hazards associated with using the cleaner on surfaces other than toilets. Interviews with staff revealed a lack of awareness and understanding of the fall prevention interventions required for the resident, as well as a failure to adhere to the facility's policies and procedures. The staff members involved in the incident were unsure of the specific interventions needed for the resident and did not remain with the resident while they were in the wheelchair, despite the resident's weakened condition. The facility's failure to provide adequate supervision and ensure the safe use of chemicals resulted in immediate jeopardy to resident safety.
Failure to Notify Responsible Parties of Changes in Condition
Penalty
Summary
The facility failed to notify the responsible party or physician of a change in condition for four residents. Resident #1, who had a history of bradycardia, osteoarthritis, repeated falls, and severe cognitive impairment, experienced a fall resulting in injuries. Although the fall was documented, the resident's primary care physician was not notified, contrary to the facility's policy. The wound nurse, who was responsible for notifying the physician, admitted to forgetting to do so due to the urgency of sending the resident to the hospital. For Residents #3, #4, and #5, all of whom had legal guardians and varying levels of cognitive impairment, the facility failed to notify their guardians when the residents tested positive for COVID-19. There was no documentation in the residents' medical records indicating that the legal guardians were informed of the positive test results. Interviews with the legal guardians confirmed that they were not notified of the COVID-19 diagnoses. The Interim Director of Nursing and the Administrator both stated that it was their expectation for staff to notify the resident's family and physician of any change in condition. However, the facility's failure to adhere to its own Notification of Changes policy resulted in a deficiency in communication regarding significant changes in the residents' conditions.
Inadequate Wound Care Competency Leads to Deficiency
Penalty
Summary
The facility failed to ensure that the wound nurse had the appropriate competency and skill set, resulting in a deficiency related to the care of a resident's wound. The wound nurse, who had limited training in wound care, did not assess, document, or take pictures of the resident's wound when it was discovered. Instead, the nurse instructed staff to apply a patch and lay the resident back down without further assessment or notification to the Director of Nursing or physician. The facility did not provide a job description or requirements for the wound nurse, and the wound nurse's training consisted only of an online course and basic nursing school education. The resident involved had a history of bradycardia, osteoarthritis, repeated falls, weakness, and anemia, with severely impaired cognitive abilities. The resident required assistance with activities of daily living and was occasionally incontinent. Despite these conditions, the resident's comprehensive care plan did not address skin integrity issues, and the wound nurse did not follow the facility's policies for wound treatment management and documentation. Interviews with facility staff revealed a lack of awareness regarding the wound nurse's education and training, highlighting a gap in ensuring that staff had the necessary competencies to provide appropriate care.
Failure to Enroll Nurse Aides in Required Training
Penalty
Summary
The facility failed to ensure that three sampled nurse aides (NAs) were enrolled in a state-approved training and competency evaluation program and completed a nurse aide training program within four months of employment. NA A, initially hired as a floor tech, was observed assisting residents with eating and drinking, and later with changing a resident's clothing, despite not being enrolled in or having completed a CNA course. NA B, employed for about three years as a Hall Monitor, also had no record of CNA course enrollment or completion, yet provided direct care to residents, including bathing and dressing. NA C, recently hired, similarly lacked training or enrollment in a CNA course but was involved in resident care activities. The facility did not provide policies on education and CNA training or for the Hall Monitor position. Interviews with the Assistant Director of Nursing/Interim Director of Nursing and the Administrator revealed a lack of awareness and responsibility regarding the enrollment of NAs in CNA courses. The Assistant Director was unsure of the number of NAs or Hall Monitors working and did not know who was responsible for enrolling them in training. The Administrator was unaware of the uncertified NAs working on the floor and expected all NAs to complete a CNA course within four months of employment.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility staff failed to report an injury of unknown origin for a resident who was discovered with multiple bruises on their sides and lower breasts. The incident occurred when an LPN noticed the bruises during an overnight shift but did not document or report them to the Director of Nursing (DON) or the Administrator. The LPN admitted to forgetting to report the bruises due to being busy with other residents. This oversight was contrary to the facility's policy, which mandates reporting all injuries of unknown origin to the Administrator and appropriate agencies. The resident involved had a history of bradycardia, osteoarthritis, repeated falls, weakness, and anemia, with severely impaired cognitive abilities. The resident required assistance with daily activities and had experienced falls since admission. Despite these conditions, the resident's care plan did not address skin integrity issues. The facility's skin checks prior to the incident did not note any skin issues, but a subsequent fall led to the discovery of a new laceration on the resident's forehead and the bruises noted by hospital staff. Interviews with various staff members, including CNAs, a Wound Nurse, and the Assistant Director of Nursing (ADON), revealed that none of them reported the bruises to the administration. The ADON and Wound Nurse noticed the bruises after a fall but did not report them, as they were focused on transferring the resident to the hospital. The facility's policy requires immediate reporting of such injuries, but this was not followed, resulting in a failure to notify the state agency or the resident's Primary Care Physician about the bruises until after the hospital admission.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who was discovered with multiple bruises on their sides and lower breasts. The facility's policy requires that any injuries of unknown source be investigated, but this was not done in this case. The resident, who had a history of bradycardia, osteoarthritis, repeated falls, weakness, and anemia, was found with bruises that were not observed by any staff member or explained by the resident. The bruises were noted by various staff members, including an LPN, a Nursing Assistant, and the Wound Nurse, but none of them reported the injuries to the Director of Nursing (DON) or the Administrator as required by the facility's policy. The resident's medical records indicated that they had been sent to the hospital following a fall, where emergency room staff noted the bruises. Despite the facility's policy on abuse and neglect, which mandates the investigation of such injuries, no investigation was conducted. The LPN who first observed the bruises did not document them or notify the appropriate authorities, citing being busy with other residents as the reason for the oversight. Similarly, other staff members who noticed the bruises also failed to report them, despite having received training on the importance of reporting injuries of unknown origin. Interviews with the facility's staff, including the Assistant Director of Nursing and the Administrator, revealed that there was an expectation for staff to report any injuries of unknown origin. However, this expectation was not met, as the bruises were not reported or investigated. The Administrator was unaware of the bruises until the survey, indicating a breakdown in communication and adherence to the facility's policies on reporting and investigating potential abuse or neglect.
Failure to Protect Residents from Abuse by Another Resident
Penalty
Summary
The facility failed to protect two residents from abuse by another resident, leading to a deficiency in resident safety. Resident #1, who has a history of mental illness and aggressive behaviors, physically assaulted Residents #3 and #5 on multiple occasions. Despite being on one-to-one supervision, Resident #1 managed to hit Resident #3 in the head and later assaulted Resident #5 in the dining room and during an altercation in the hallway. These incidents left the affected residents feeling unsafe and fearful of further attacks. Resident #1's medical history includes chronic PTSD, Borderline Intellect, Bipolar Disorder, and other mental health conditions, which contribute to their aggressive behavior. The facility's care plan for Resident #1 included behavior modification and calming techniques, but these interventions were not effectively implemented. Staff members, including the CNA assigned to supervise Resident #1, were not adequately trained or informed about the specific interventions needed to manage Resident #1's behavior, leading to repeated incidents of abuse. Interviews with residents and staff revealed a pervasive sense of insecurity within the secure unit, with multiple residents expressing fear of Resident #1's unpredictable outbursts. The Director of Nursing and the Administrator acknowledged the expectation that aggressive residents should be separated and assessed, but these measures were not effectively executed. The facility's failure to adequately protect residents from abuse and to implement appropriate interventions for Resident #1's behavior resulted in a serious deficiency in resident safety.
Inadequate Staff Training for Behavioral Health Needs
Penalty
Summary
The facility failed to provide adequate education and ensure staff competency in caring for residents with mental and behavioral health diagnoses. This deficiency was highlighted by incidents involving two residents. One resident, residing in a secured special care unit, was involved in multiple physical altercations with other residents, causing physical injury and emotional distress. The staff were not equipped with the necessary skills or knowledge to implement non-pharmacological interventions or individual care plan interventions, as they had not received appropriate training prior to their assignment in the special care unit. Another resident engaged in self-harming behaviors, resulting in lacerations to their forearms and upper legs. The staff were unaware of how to provide appropriate protection or interventions, as they had not been educated on non-pharmacological interventions or individual care plan interventions. The resident expressed a need for help to stop these behaviors and reported that facility staff were not providing the necessary assistance. The facility's policies on abuse and neglect, as well as behavioral emergencies, were not effectively implemented. Staff files showed no documentation of training in providing care for residents with mental and behavioral health diagnoses. Interviews with various staff members, including a Certified Nurse Aide, Laundry Aide, Housekeeper, and the Director of Nursing, revealed a lack of training in de-escalation techniques and crisis intervention. The facility had previously used CALM training for de-escalation but had not maintained certification, and the new training program had not yet been implemented.
Failure to Address Behavioral Health Needs and Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and services to address the behavioral health needs of two residents, leading to incidents of abuse and self-harm. One resident, with a history of mental illness and physically abusive behaviors, was involved in multiple altercations with other residents. Despite being on one-to-one supervision, this resident engaged in physical aggression, hitting other residents on several occasions. The facility did not implement the necessary interventions from the resident's Level II evaluation, such as counseling and behavior modification programs, to support the resident and minimize these behaviors. Another resident, also with a history of mental illness and self-harming behaviors, was not provided with the necessary interventions outlined in their Level II evaluation. This resident engaged in self-harm by scratching and cutting themselves with pen caps, and despite expressing a need for help to stop these behaviors, the facility did not implement appropriate interventions. The resident's care plan lacked specific interventions for addressing self-harming behaviors, and the facility failed to provide the required counseling and support services. Additionally, the facility did not adhere to medication administration protocols for one of the residents. A Certified Medication Technician failed to crush medications as ordered and did not check to ensure the resident swallowed the medication, leading to the resident saving the medication instead of consuming it. This negligence in medication administration further compromised the resident's care and safety.
Misappropriation of Resident Medications by Staff Member
Penalty
Summary
The facility failed to protect three residents from misappropriation of their medications by a staff member, identified as Hall Monitor A. Law enforcement discovered medications labeled with the residents' names at Hall Monitor A's home during a search warrant execution. The medications were found in both bubble packs and bottles, and a set of keys labeled for different stations and an office were also recovered. This incident indicates a breach in the facility's security and medication management protocols. The facility's policies on abuse and neglect, as well as medication storage, were not effectively implemented. The policies require that all medications be stored securely and only accessed by authorized personnel. However, the facility did not have a specific policy regarding the safeguarding of keys, which contributed to the unauthorized access and removal of medications. The Executive Director of Development and Education and the Director of Nursing were unaware of the missing keys and medications until informed by law enforcement, highlighting a lack of oversight and accountability. Interviews with facility staff, including the Administrator, revealed that there was an expectation for all medications and keys to be kept secure and only accessible to authorized staff. Despite these expectations, the facility failed to ensure the security of medications and keys, leading to the misappropriation incident. The facility's failure to account for keys and monitor medication access allowed Hall Monitor A to exploit these vulnerabilities, resulting in the misappropriation of resident medications.
Failure to Maintain Resident Hygiene and ADLs
Penalty
Summary
The facility staff failed to provide appropriate treatment and services to maintain or improve the abilities of residents to carry out activities of daily living (ADLs) for four of the thirteen sampled residents. These residents were assessed and care planned as independent with ADLs, yet they were observed with greasy hair, dirty clothing, body odor, and long, dirty nails. The facility's policy mandates that residents' abilities in ADLs should not deteriorate unless unavoidable, and necessary services should be provided to maintain good grooming and hygiene. Resident #7, who has diagnoses including schizophrenia and anxiety disorder, was observed with greasy hair, a quarter-inch beard, long nails with a dark substance underneath, and a stained shirt. Resident #10, diagnosed with schizophrenia and psychotic disorder, was seen with bare feet, long toenails with a substance on them, disheveled hair, and significant body odor. Resident #11, with diagnoses including anxiety disorder and Parkinson's, had greasy hair, a half-inch beard, long nails with a dark substance, and noticeable body odor. Resident #13, diagnosed with dementia and schizophrenia, was observed with disheveled hair, a stained shirt, a quarter-inch beard, and noticeable body odor. Interviews with staff revealed that many residents who are independent with ADLs choose not to perform them or need reminders. Staff focus on assisting residents who need help with ADLs, and if time permits, they ask independent residents if they need assistance. The Director of Nursing and the Administrator both expressed expectations that all residents should be clean and well-groomed, and staff should offer assistance or encouragement to residents who appear dirty or have an odor. However, the observations and resident interviews indicate that these expectations were not consistently met, leading to the deficiency.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for three residents who were unable to perform these tasks independently. These residents were observed with poor personal hygiene, including greasy hair, dirty clothing, body odor, long and dirty nails, and ungroomed facial hair. Despite being assessed and care planned as dependent on staff for ADLs, the residents were not receiving the necessary care to maintain good personal hygiene. Resident #8, diagnosed with aphasia, cerebralvascular accident, malnutrition, and muscle weakness, was observed with disheveled and greasy hair, a quarter inch of beard growth, long nails with a dark substance underneath, and food particles on their shirt. Resident #9, with diagnoses including aphasia, CVA, seizures, and COPD, was seen with disheveled hair, a quarter inch of beard growth, long nails with a dark substance, and significant body odor. Resident #12, diagnosed with dementia, depression, and respiratory failure, was observed wearing a dirty sweater with brown stains and food particles, disheveled hair, and a small bandage with a dark red substance stuck in their hair. Interviews with staff revealed that while the expectation was for all residents to be clean and well-groomed, there were instances where residents refused care, and staff did not have time to reapproach. The Director of Nursing and the Administrator both expressed expectations that residents should be clean and odor-free, and that staff should reapproach residents who decline ADLs or have another staff member offer assistance. However, these expectations were not consistently met, leading to the observed deficiencies in resident care.
Facility Fails to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a clean, odor-free, and comfortable environment for its residents, staff, and visitors. Observations revealed strong odors of urine and body odor throughout the facility, sticky floors in the entryway and dining rooms, and evidence of flies and mice. Additionally, a resident's air conditioning unit was found to have a dark-colored mold-like substance on it. The facility's pest control program was not effectively managing the presence of flies and rodents, as evidenced by rodent droppings and noises in the administrator's office. Interviews with staff highlighted a lack of formal environmental inspections and documentation by the Director of Nursing, who relied on informal notifications to housekeeping or other staff when issues were identified. Housekeeping staff expressed uncertainty about having the correct cleaning supplies to address mold in air conditioning units. The facility's policies for environmental inspections and pest control were not being effectively implemented, contributing to the unsanitary conditions observed during the survey.
Failure to Provide Safe Assistive Devices for Resident
Penalty
Summary
The facility failed to ensure that a resident had safe and well-maintained assistive devices, specifically a manual wheelchair, to prevent accidents. The resident, who was independent with activities of daily living and used a manual wheelchair for mobility, reported feeling unsafe due to the worn-out back support of the wheelchair. This condition caused the resident to lean forward to avoid tipping over, resulting in back pain. Despite multiple requests to the staff, including the Director of Nursing (DON), the resident had not received a new wheelchair. The DON acknowledged awareness of the resident's request for a new wheelchair but was unsure why it had not been provided. The DON is responsible for ensuring residents have safe equipment, yet failed to follow up on the request. The facility administrator was unaware of the resident's need for a new wheelchair but stated that it is expected that all equipment be in good condition and safe for resident use. The facility also lacked a policy to ensure that residents' assistive devices are well-maintained and safe.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, resulting in multiple deficiencies. Observations revealed that staff did not maintain a clean kitchen environment, as evidenced by food particles and grime on preparation surfaces, greasy stove handles, and food caked to the bottom of the oven. Additionally, dead roaches were found in the dish sanitizer area, and dish racks were improperly stored on the floor. The facility's pest control measures were inadequate, as the dietary manager acknowledged ongoing issues with roaches despite regular treatments. Food safety protocols were not followed, as staff failed to consistently check and document food temperatures. During meal preparation, temperatures were not recorded, and some food items were not reheated to the required temperature of 135 degrees Fahrenheit before serving. For instance, pureed pulled pork was found at 126.1 degrees Fahrenheit and was placed back in the oven, but subsequent temperature checks were not documented. The dietary manager and administrator both expressed expectations for proper temperature checks and documentation, which were not met. The facility also failed to ensure proper hand hygiene and equipment sanitation. Staff did not wash their hands after entering the kitchen, and the handwashing sink's water temperature was excessively hot, causing discomfort to staff. Additionally, pitchers were stored upright instead of inverted, contrary to facility policy, increasing the risk of contamination. These lapses in sanitation and hygiene practices contributed to the overall deficiency in maintaining a safe and sanitary food service environment.
Failure to Protect Residents' Personal Belongings
Penalty
Summary
The facility failed to exercise reasonable care for the protection of residents' property, leading to the loss or theft of personal items for six surveyed residents. The facility's policies, which emphasize the importance of a safe and homelike environment and the right of residents to retain personal possessions, were not adhered to. Residents reported missing clothing items, such as shirts, pants, and socks, as well as personal belongings like a razor charger and cologne. These items were not properly inventoried or labeled, resulting in their loss. Interviews with residents revealed that they had communicated their concerns about missing items to multiple administrators, but the issues persisted. Residents reported seeing their missing items on other residents and receiving damaged clothing that did not belong to them. The facility's lack of a structured process for handling personal items contributed to these issues, as evidenced by the absence of a dedicated laundry staff for a significant period and the improper handling of laundry items. Staff interviews highlighted systemic issues within the facility's laundry department. The laundry aide noted the absence of a formal process for labeling and returning personal items, leading to a backlog of unlabeled clothing in the basement. The administrator acknowledged the problem and mentioned efforts to address it, such as obtaining a labeler for personal items. However, the deficiency persisted due to the lack of immediate and effective measures to ensure residents' belongings were protected and returned to them.
Failure to Provide Scheduled Showers Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that residents received the necessary services to maintain good grooming and personal hygiene, as showers were not provided twice a week for four out of six sampled residents. The facility's policy stated that residents should receive assistance with activities of daily living, including bathing, based on their comprehensive assessment and needs. However, the facility did not adhere to this policy, resulting in residents not receiving the scheduled showers. Resident #1, who had impairments due to a stroke and was dependent on a wheelchair, did not receive showers as scheduled. The resident was supposed to receive showers on Mondays and Thursdays but only received eight out of eighteen scheduled showers from June to August 2024. The resident expressed feeling dirty and having lowered self-esteem due to the lack of regular showers. Similarly, Resident #2, who had impairments in both lower extremities and was dependent on a wheelchair, received only eight out of eighteen scheduled showers during the same period. The resident reported that the shower aide was often pulled to cover staffing shortages, resulting in missed showers. Resident #5, who required supervision with baths and personal hygiene, received only six out of eighteen scheduled showers. The resident reported feeling unclean and going without showers for extended periods. Resident #6, who had severe cognitive impairment and required assistance for all activities of daily living, also experienced missed showers due to staffing issues. The facility's staff, including the primary shower aide and the administrator, acknowledged that residents were not receiving showers as scheduled due to staffing shortages, with the shower aide frequently being reassigned to other duties.
Inadequate Supervision Leads to Resident Self-Harm Incident
Penalty
Summary
The staff at the facility failed to ensure a resident remained free from accident hazards and did not provide adequate supervision to prevent accidents. A resident, who was cognitively intact but had a history of mental illness and self-harm behaviors, was placed on one-on-one supervision for protective oversight following an altercation with a peer. Despite the requirement for the staff member to maintain visual contact and be within arm's length of the resident, the assigned Certified Nurse Aide (CNA) looked away, allowing the resident to tie a string around their neck while in the bathroom. The resident's care plan indicated a long history of mental illness, including post-traumatic stress disorder, bipolar disorder, and borderline personality disorder, with frequent psychiatric hospitalizations and self-injurious behaviors. The resident was assessed as low risk for suicide but had been placed on one-on-one supervision due to recent aggressive behavior. On the day of the incident, the CNA failed to maintain the required level of supervision, resulting in the resident's ability to engage in self-harm by tying a string around their neck. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, revealed that the expectation was for staff to be within arm's length of residents on protective oversight at all times. The incident occurred when the CNA turned away to speak with the resident's roommate, allowing the resident to act unobserved. The resident was found with a string around their neck, but did not lose consciousness and refused hospital transfer after the incident.
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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