Estates Of Perryville, Llc, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Perryville, Missouri.
- Location
- 430 North West Street, Perryville, Missouri 63775
- CMS Provider Number
- 265704
- Inspections on file
- 31
- Latest survey
- November 6, 2025
- Citations (last 12 mo.)
- 4 (2 serious)
Citation history
Health deficiencies cited at Estates Of Perryville, Llc, The during CMS and state inspections, most recent first.
A resident, who was their own responsible party and had no cognitive impairment, was restricted from taking an independent LOA for two weeks following concerns about unsafe behaviors and returning intoxicated. The restriction was ordered by a physician, but the care plan did not address the LOA restriction or alcohol use, and facility policies did not clarify procedures for such restrictions. Staff interviews confirmed the restriction was due to safety concerns, and the resident expressed that their rights were being infringed.
A resident with a history of suicidal ideation and behavioral health issues exited a secured unit undetected after staff failed to follow the facility's rounding policy requiring hourly visual checks. The resident was missing for about 12 hours and attempted suicide while away, with staff documentation showing rounds were not properly conducted.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report identifies a lapse in ensuring resident safety and well-being.
A resident with multiple mental health diagnoses became agitated after being denied a cigarette outside of scheduled times. Despite staff awareness of the resident's behavioral triggers, no de-escalation strategies or alternative interventions were used. The situation escalated when the resident grabbed a CNA, leading another CNA to strike the resident in the face, resulting in injury. Staff interviews indicated a lack of formal mental health training and absence of documented interventions for managing such behaviors.
A resident with diagnoses of PTSD, major depressive disorder, TBI, Alzheimer's, and paranoid schizophrenia did not have a Level I or Level II PASRR screening documented in their record. The facility also lacked a policy for PASRR screenings, and although the care plan referenced a completed PASRR, the actual documentation was not available.
A resident with PTSD, major depressive disorder, traumatic brain injury, and Alzheimer's did not receive trauma-informed or culturally competent care, as the facility lacked a policy and failed to document or implement supportive interventions for managing the resident's known behavioral triggers. Staff were aware of the triggers but had not received formal training or guidance on de-escalation strategies.
A resident with multiple mental health diagnoses became agitated after being denied requests to smoke and have a soda, leading to a physical altercation with staff. Facility staff, including agency CNAs and an RN, did not implement de-escalation interventions or offer alternatives, despite being aware of the resident's triggers. Staff interviews confirmed a lack of formal behavioral health or de-escalation training, and there was no documentation of required behavior monitoring or interventions in the care plan.
A resident with severe mental illness, including PTSD and Alzheimer's, became agitated after being denied requests to smoke and have a soda. Staff, including agency personnel, did not attempt de-escalation or offer alternatives, despite being aware of the resident's triggers. The situation escalated to physical aggression, with a CNA striking the resident. The facility lacked documentation of behavior monitoring, a behavioral health management policy, and formal staff training on mental health or de-escalation techniques.
A resident with a history of aggression was inadequately supervised and struck another resident in the head, causing injury, while staff failed to intervene or call for help. Later, the injured resident was physically removed from a hallway against their will by being rolled onto a blanket and dragged by an LPN and CNA, resulting in anxiety that required medication. Staff did not follow facility policies for abuse prevention or intervention during these incidents.
The facility did not ensure that staff, including agency personnel, had the necessary competencies and training to manage residents with behavioral health needs, resulting in one resident being physically assaulted by another and later being inappropriately moved by staff using a blanket. Staff failed to implement care plan interventions, and agency staff reported not receiving training or information about the behavioral unit or residents' needs.
The facility's kitchen operations were found deficient due to unsanitary conditions, including dirt, debris, and cockroach infestations. Staff failed to follow hygiene protocols, such as wearing hairnets and changing gloves between tasks, leading to potential cross-contamination. Expired food items and improper food storage were also observed, contributing to the deficiency.
The facility failed to maintain proper infection control practices during peri and wound care, as staff did not adhere to enhanced barrier precautions (EBP) and neglected hand hygiene protocols. Additionally, the facility did not follow tuberculosis (TB) screening and testing protocols, with lapses in timely test readings and further testing for residents with symptoms. These deficiencies highlight significant gaps in the facility's infection prevention and control program.
The facility failed to maintain an effective pest control program, with observations of live and dead cockroaches in the kitchen, dining area, and other locations. Staff interviews confirmed ongoing pest issues despite monthly treatments. The facility's policy aimed to ensure cleanliness and pest prevention, but current measures were inadequate.
The facility failed to maintain a safe and homelike environment, with observations of urine odor, stained and missing ceiling tiles, and exposed wires. Residents expressed concerns about these conditions, and the Maintenance Director and Administrator indicated that repairs were delayed pending a new roof installation.
A resident with a history of aggressive behavior struck two other residents, resulting in a deficiency in resident safety. Despite being under supervision, the resident's actions led to physical abuse incidents, highlighting a lapse in protective measures. The facility's response included separating the residents and updating care plans, but the initial failure to prevent the abuse indicates a deficiency.
The facility failed to notify the ombudsman of all hospital transfers and did not provide written notifications to residents or their representatives. Multiple residents were transferred without proper documentation, and interviews confirmed the lack of written notifications. The facility's policy did not address notifying responsible parties or the ombudsman.
The facility failed to provide written notification of the bed hold policy to residents or their representatives during hospital transfers or therapeutic leave. This issue affected multiple residents, with no documentation found in their records. Interviews with staff revealed a lack of adherence to the policy and communication gaps, leading to the deficiency.
The facility failed to complete significant change MDS assessments within 14 days for three residents following their admission to or discharge from hospice services. Despite the policy outlined in the RAI Manual, the assessments were not conducted in the required timeframe. The facility relies on a contracted company for MDS coordination, with the DON and ADON conducting assessments and providing information for completion.
The facility failed to update and revise care plans for six residents, resulting in care plans that did not reflect current medical conditions or orders, such as the presence of an ostomy, use of tobacco pouches, hospice services, dietary changes, and the use of a Foley catheter. Interviews revealed that a contract company, along with Social Services and the DON, is responsible for updates, but the care plans did not accurately reflect the residents' current conditions as expected by the facility's policy.
The facility failed to follow physician's orders for several residents, including missing blood pressure monitoring, lab draws, and weight records. Residents with various diagnoses, such as schizoaffective disorder, diabetes, and Alzheimer's, did not receive prescribed care, including necessary lab tests and catheter changes. The facility's leadership acknowledged the expectation for adherence to physician's orders, indicating a lapse in maintaining care standards.
The facility failed to provide a comprehensive activity program for residents, affecting their physical, mental, and psychosocial well-being. Several residents reported a lack of suitable activities, especially on weekends, and the Activities Director admitted to being behind on updating care plans. The Administrator and DON expected activities to be available for all residents, including those with special needs.
The facility failed to attempt gradual dose reductions (GDR) or document contraindications for two residents on psychotropic medications, potentially preventing them from receiving the lowest effective dosage. Despite recommendations from the pharmacist, there was no physician response or documentation of GDR attempts. Interviews with staff revealed issues in managing medication regimen reviews and GDRs, contributing to the deficiency.
The facility failed to provide palatable, attractive food at safe temperatures, affecting several residents. Observations showed cold food items served above the expected temperature, and there was no food temperature policy or complete logs. Residents expressed dissatisfaction with the food quality, and the Dietary Manager and Administrator acknowledged the expectations for food service standards.
Failure to Honor Resident's Right to Self-Determination During LOA Restriction
Penalty
Summary
The facility failed to honor a resident's right to self-determination and a dignified existence by restricting the resident, who was their own responsible party and had no cognitive impairment, from taking an independent leave of absence (LOA) for a two-week period. This restriction was implemented through a physician's order following concerns about the resident's safety during previous LOAs, including reports of returning to the facility intoxicated and engaging in unsafe behaviors while away. The resident's care plan did not address the restriction or the resident's alcohol use, and there was no documentation of law enforcement involvement or consideration of a change in the resident's decision-making status. The facility's policy and admission documents did not specify procedures for restricting LOA for residents who are their own responsible party, nor did they clarify the process for evaluating or communicating such restrictions. Interviews with staff confirmed that the restriction was based on safety concerns, but the resident was not provided with alternative options or a formal process for contesting the restriction. The resident expressed frustration, stating that the restriction infringed on their rights, and there was no evidence of a care plan update or further assessment regarding the resident's ability to safely exercise their rights.
Failure to Provide Adequate Supervision Resulting in Resident Elopement and Self-Harm
Penalty
Summary
A deficiency occurred when facility staff failed to provide adequate supervision for a resident assessed as needing 24-hour supervision for safety due to a history of suicidal ideation, aggression, and behavioral health diagnoses. The resident, who had diagnoses including schizoaffective disorder, personality disorder, impulse disorder, major depressive disorder, and anxiety, was independently ambulatory and had a care plan indicating a need for close monitoring due to risks of self-harm and aggression. Despite these documented needs, staff did not follow the facility's rounding policy, which required hourly checks and physically seeing each resident in their rooms. On the night of the incident, the resident exited the secured behavioral unit through a window without staff knowledge and was missing for approximately 12 hours. Staff statements indicated that rounds were documented at various times, but none of the staff physically entered the resident's room to visually confirm their presence after the last observed time at the 8:00 P.M. smoke break. The resident was later found by police at a local store, having spent the night outside and attempted suicide using a piece of glass found at the location. Interviews and record reviews confirmed that staff did not adhere to the facility's policy for making rounds and direct observations, resulting in the resident's undetected elopement and subsequent self-harm. The failure to provide the required supervision and to follow established safety protocols directly led to the resident's ability to leave the facility and attempt suicide while unsupervised.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions at the time, are provided in the report.
Physical Abuse of Resident Following Escalation Due to Denied Request
Penalty
Summary
A deficiency occurred when a staff member physically abused a resident by striking them in the face with a closed fist, resulting in an injured eyelid and a broken nose. The incident took place after the resident, who has a history of mental health disorders including major depressive disorder, PTSD, traumatic brain injury, Alzheimer's, and paranoid schizophrenia, became agitated when denied a cigarette outside of scheduled smoking times. The resident's care plan noted a pattern of agitation and aggression when requests were denied, particularly regarding smoking, but did not include documented interventions for managing escalating behaviors. On the day of the incident, the resident requested a cigarette and soda from a nurse, who informed them they would have to wait until the scheduled time. The resident became increasingly agitated, and multiple staff reiterated the denial. The resident then grabbed a CNA by the shirt collar and appeared to push the CNA down the hallway. Another CNA intervened by approaching and striking the resident in the right eye, causing visible injury. The staff did not attempt to de-escalate the situation with alternative options or interventions, despite being aware of the resident's behavioral triggers. Interviews with staff revealed that they had not received formal mental health training prior to working at the facility, and their preparation consisted mainly of reading a training manual. Staff acknowledged the resident's known triggers and aggressive behaviors but did not implement any specific de-escalation techniques or alternative strategies during the incident. The lack of documented behavioral interventions and insufficient staff training contributed to the escalation and subsequent physical abuse of the resident.
Missing PASRR Documentation for Resident with Serious Mental Illness and Intellectual Disability
Penalty
Summary
The facility failed to maintain documentation of a Level I preadmission screening and resident review (PASRR) assessment for a resident with serious mental illness and intellectual disability diagnoses. Record review showed that the resident had diagnoses including post-traumatic stress disorder (PTSD), major depressive disorder, traumatic brain injury (TBI), Alzheimer's disease, and paranoid schizophrenia. Despite these diagnoses, there was no evidence in the resident's medical record of a completed PASRR Level I or Level II screening prior to admission, nor was there a current PASRR assessment available. The care plan referenced a completed PASRR and outlined interventions for managing the resident's mental health needs, but the actual PASRR documentation was not provided by the facility. Additionally, the facility did not have a policy related to PASRR screenings. During an interview, a Central Office Medical Review Unit (COMRU) nurse confirmed that a Level II screening had been completed in the past, but stated that a replacement application would be required since the previous screening was over a year old. The absence of current and accessible PASRR documentation in the resident's record constituted a deficiency in ensuring the resident's behavioral health needs were properly identified and addressed.
Failure to Provide Trauma-Informed and Culturally Competent Care for Resident with PTSD
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for a resident diagnosed with PTSD, major depressive disorder, traumatic brain injury, and Alzheimer's disease. The resident's care plan noted triggers such as not receiving medications on time and being denied smoking, which led to physical and verbal aggression. However, the care plan lacked specific interventions for de-escalation or alternatives to manage these behaviors, and there was no documentation of supportive strategies to help the resident cope with escalating behaviors. Additionally, the facility did not have a policy on trauma-informed care or behavioral health management. Interviews with staff revealed that they were aware of the resident's triggers but had not received formal training on trauma-informed care or specific interventions for managing the resident's behaviors. The DON confirmed knowledge of the resident's triggers but was unaware of any interventions in place on the care plan to address them. The absence of a trauma-informed care policy and lack of documented interventions contributed to the facility's failure to provide care that was trauma-informed and culturally competent for the resident.
Failure to Provide Behavioral Health Training and De-escalation Interventions
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to meet the behavioral health needs of a resident with complex mental health diagnoses, including PTSD, major depressive disorder, traumatic brain injury, and Alzheimer's disease. The resident had active orders for behavior monitoring and multiple psychotropic medications, but there was no documentation of behavior monitoring being completed. The care plan identified the resident's triggers, such as requests to smoke, and noted a history of physical and verbal aggression when these requests were denied. However, there were no documented interventions in place to prevent escalation, and staff were only instructed to attempt to accommodate the resident's requests. On the day of the incident, the resident became agitated after being denied a request to smoke and have a soda outside of scheduled times. Multiple staff, including agency CNAs and an RN, told the resident to wait, which further increased the resident's agitation. The situation escalated when the resident grabbed a CNA, and another CNA responded by striking the resident in the eye. Staff did not attempt any de-escalation interventions or offer alternative options to address the resident's agitation, despite being aware of the resident's triggers and behavioral history. Interviews with staff revealed that there was no formal behavioral health or de-escalation training provided, especially for agency staff, who were only required to read a manual and sign a sheet without any monitoring or verification. The DON and staff confirmed the lack of mental health training and guidance for managing residents with behavioral health needs. Law enforcement also noted repeated issues at the facility related to staff decisions that aggravated residents with mental health conditions.
Failure to Provide Behavioral Health Services and De-escalation for Resident with Severe Mental Illness
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with severe mental illness, including PTSD, major depressive disorder, traumatic brain injury, and Alzheimer's disease. The resident, who is their own responsible party, exhibited agitated and aggressive behaviors when denied requests to smoke and have a soda outside of scheduled times. Staff, including agency personnel, did not attempt to de-escalate the situation or offer alternative options, despite being aware of the resident's triggers. Instead, staff repeatedly told the resident to wait, which further increased agitation, ultimately resulting in the resident physically grabbing a CNA, and the CNA responding by striking the resident in the eye. The facility did not provide documentation of required behavior monitoring, despite physician orders for such monitoring every shift. There were also no documented interventions in the care plan to prevent escalation of behaviors, and the facility lacked a policy on behavioral health management. Staff interviews revealed that there was no formal training on mental health disorders or de-escalation techniques, and agency staff were only required to read a manual without any verification or monitoring of their understanding. The DON and RN involved acknowledged the lack of formal training and the absence of alternative interventions offered during the incident. Law enforcement and the medical director confirmed the incident, with law enforcement noting that staff actions often instigated residents with mental health issues by denying requests, leading to aggressive reactions. The medical director stated that staff should never hit a resident, regardless of the situation. The facility did not provide a PASRR for the resident, and there was no evidence of a behavioral health management policy or adequate staff training to address the needs of residents with mental health disorders.
Failure to Prevent Resident-to-Resident and Staff-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by both another resident and staff. One resident, who had a history of aggression and required one-on-one supervision, became agitated after being denied medication and was inadequately monitored by staff. Despite being assigned a one-on-one aide, staff did not intervene or call for assistance when the resident became agitated and began walking down the hallway. Staff observed from a distance as the agitated resident entered another resident's room and struck the resident in the head, causing a hematoma. Staff admitted to not attempting to de-escalate or physically intervene before the assault occurred, and no Code Gray was called as required by facility policy. Following this incident, the assaulted resident, who had diagnoses including schizoaffective disorder and heart failure, was relocated to another hall. The resident attempted to return to their previous room and, when refusing to leave, sat on the floor. Staff, including an LPN and a CNA, attempted to physically move the resident by rolling them onto a blanket and dragging them through the facility to the new room, despite the resident's resistance. This action caused the resident to become anxious, requiring administration of lorazepam for anxiety shortly after the incident. One staff member expressed concern about the appropriateness of this action but was instructed not to document the event. Interviews with staff and the administrator confirmed that staff were aware of the aggressive resident's history and the need for close supervision, yet failed to take appropriate preventive measures. The administrator acknowledged that staff should have intervened to protect residents and that the physical handling of the resident by staff was inappropriate. The facility's own policies on abuse prevention and resident-to-resident altercations were not followed, as staff did not call for assistance or remain in the area to ensure safety during the incidents.
Failure to Ensure Staff Competency in Behavioral Health Management
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to meet the behavioral health needs of residents, resulting in two significant incidents involving residents with complex mental health histories. One resident with schizoaffective disorder and a history of aggression, including throwing urine and elopement attempts, was residing on a secured behavioral unit and required close supervision and specific behavioral interventions. Another resident, diagnosed with autistic disorder and schizophrenia, had a documented history of physical and verbal aggression, including striking other residents and staff, and was on one-on-one monitoring due to previous altercations. On one occasion, the resident with a history of aggression became agitated after being denied early medication administration. The assigned staff, including agency and facility employees, failed to implement care plan interventions such as redirection or de-escalation techniques. Instead, one staff member hid in a closet, and others observed from a distance as the agitated resident entered another resident's room and struck them, causing a hematoma. Interviews revealed that staff were either unaware of the care plan interventions or did not attempt to use them, and agency staff reported not receiving training or information about the behavioral unit or residents' needs. In a separate incident, after being relocated for safety, the same resident who had been struck attempted to return to their previous room and refused to leave the hallway, sitting on the floor. Agency staff, lacking training and familiarity with the unit or the resident's history, physically moved the resident by rolling them onto a blanket and dragging them through the facility to another hall. The staff involved did not attempt further redirection or allow the resident time to calm down, and facility leadership acknowledged that agency staff had not received required training or policies for the behavioral unit.
Sanitation and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, leading to potential cross-contamination and food-borne illness risks for all residents. Observations revealed significant cleanliness issues, including dirt, debris, and trash on the kitchen floor, black carbon buildup on cooking equipment, and the presence of live cockroaches. Additionally, there were missing knobs on the stove, dented cans in storage, and expired food items, such as an opened container of peanut butter past its expiration date. The facility also lacked a policy regarding food storage. During meal service, staff did not adhere to proper hygiene practices. Dietary aides were observed not wearing hairnets, failing to sanitize hands, and not changing gloves between tasks. They touched dirty surfaces and then handled clean plates and residents' food without proper sanitation. The ice scoop and drink pitchers were improperly handled, touching residents' personal cups, which were used throughout the day. These actions were contrary to the facility's handwashing policy, which emphasized the importance of hand hygiene and glove use. Interviews with staff, including the Dietary Manager and Dietary Aides, confirmed ongoing issues with cockroaches and inadequate pest control measures. Staff acknowledged the need for better hygiene practices, such as changing gloves and sanitizing hands between tasks. The Maintenance Director mentioned a pest control book for tracking issues, but it was not available as the pest control company had taken it. The Administrator and DON expressed expectations for a pest-free environment and adherence to hygiene protocols, but these were not met, contributing to the deficiency.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices during perineal and wound care for several residents. Observations revealed that staff did not adhere to enhanced barrier precautions (EBP) as required. For Resident #6, CNAs and an LPN performed peri and wound care without wearing gowns, which are part of the EBP for residents with wounds. Additionally, there was no EBP signage or supplies available near the resident's room, indicating a lack of implementation of these precautions. In another instance, during peri care for Resident #4, CNAs failed to perform hand hygiene before donning gloves and did not change gloves between tasks, leading to potential cross-contamination. The CNAs handled various items in the room with soiled gloves, including the resident's nightstand and personal items, without performing hand hygiene. Similar issues were observed with Resident #66, where CNAs did not change gloves or perform hand hygiene between handling soiled and clean items, further compromising infection control practices. The facility also failed in tuberculosis (TB) screening and testing protocols. Resident #8's first-step TB test was read a day late, and Resident #23, who had a prolonged cough, did not receive further testing or instructions as required. The Director of Nursing acknowledged these lapses, indicating a failure to adhere to the facility's TB testing policy. These deficiencies highlight significant gaps in the facility's infection prevention and control program, particularly in the areas of hand hygiene, use of personal protective equipment, and communicable disease screening.
Ineffective Pest Control Program in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of live and dead cockroaches in various areas, including the kitchen, dry goods storage room, main dining room serving area, and nursing office. The facility's policy, dated 08/24/24, outlined measures to ensure cleanliness and pest prevention, including daily cleaning, monthly pest control treatments, and maintaining entry points in good repair. However, observations revealed significant pest presence, such as live cockroaches in the oven and on walls, dead cockroaches in the dining area, and mouse droppings in serving counter cabinets. Interviews with staff, including the Dietary Manager, Dietary Aides, and the Maintenance Director, confirmed that cockroaches have been an ongoing issue despite monthly pest control treatments. The Maintenance Director mentioned a pest control book for employees to note pest issues, but it was not available as the pest control company had taken it. The Administrator expressed an expectation for the facility to be free from pests, but the current pest control measures were insufficient to address the ongoing infestation.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment, as evidenced by several observations and resident interviews. Observations revealed an overwhelming urine odor in the main entrance common area and numerous brown stains on ceiling tiles near the nurses' station and fire doors on C hall. In the D hall common area, there were missing ceiling tiles with exposed wires, large brown stains on remaining ceiling tiles, and dirt and debris in vented tiles. These conditions were confirmed by resident interviews, with one resident expressing concern about the leaking roof and the use of buckets to catch water, and another resident expressing discomfort with the missing ceiling tiles and exposed wires. The facility's Maintenance Repair Policy outlines procedures for addressing maintenance issues, including a work order log and timelines for addressing routine and emergency work orders. However, the Maintenance Director indicated that ceiling tiles had not been replaced due to an anticipated new roof installation. The Administrator confirmed that a new roof was in process, and ceiling tiles would be replaced afterward. This delay in addressing the maintenance issues contributed to the deficiency, impacting the overall environment for the residents.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, leading to a deficiency in ensuring resident safety. Resident #27, who has a history of schizoaffective disorder and impulse control issues, struck Resident #12 and Resident #96 on separate occasions. Resident #12 was sitting in a hallway when Resident #27, perceiving that Resident #12 was yelling at him, struck him on the right side of the face. This resulted in a scratch mark and significant pain for Resident #12, who was subsequently sent to the hospital for evaluation. Later that day, Resident #27 struck Resident #96 in the face after becoming agitated by Resident #96's behavior, although no injuries were noted for Resident #96. Resident #27's care plan indicated a need for supervision due to behaviors of physical aggression and poor impulse control, yet the incidents occurred despite these precautions. The facility's policy mandates that any suspicion or report of abuse must be communicated to the administration and an investigation initiated. However, the incidents suggest a lapse in effectively managing Resident #27's aggressive behaviors and ensuring the safety of other residents. The facility's response included separating the residents and sending them for medical evaluation, but the initial failure to prevent the abuse indicates a deficiency in the facility's protective measures. The facility's investigation revealed that Resident #27 was placed under 1:1 supervision after the incidents, and care plans were updated. However, the deficiency lies in the fact that the abuse occurred in the first place, highlighting a gap in the facility's ability to prevent such incidents. The report does not mention any corrective actions taken prior to the incidents to address Resident #27's known aggressive behaviors, which could have potentially prevented the abuse of Residents #12 and #96.
Failure to Notify Ombudsman and Provide Written Transfer Notices
Penalty
Summary
The facility failed to notify the ombudsman of all transfers to the hospital and did not provide written notification to residents or their representatives regarding transfers or discharges to a hospital. This deficiency affected ten residents within the sample and two residents outside the sample. The facility's policy on Admission, Transfer, and Discharge did not address the process of notifying responsible parties or the ombudsman about transfer notices. The review of medical records for several residents revealed multiple instances where residents were transferred to the hospital without written notification being provided to their representatives. For example, one resident was transferred to the hospital numerous times throughout the year, yet there was no documentation that their representative was informed in writing at the time of transfer. Additionally, many of these hospital transfers were not included in the monthly list sent to the ombudsman. Interviews with residents' guardians and facility staff confirmed the lack of written notifications. Guardians reported receiving verbal notifications but not written ones. The facility administrator admitted there was no proof of written notifications being sent to responsible parties or the ombudsman. The admissions director mentioned that only residents who were discharged completely or stayed overnight were included in the list sent to the ombudsman, excluding emergency room visits, based on previous guidance from the ombudsman's office.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written information to residents and/or their representatives regarding the bed hold policy at the time of transfer to a hospital or during therapeutic leave. This deficiency was identified for nine residents within the sample and three residents outside the sample, indicating a systemic issue. The facility's policy requires that residents or their representatives be notified of the bed hold policy upon admission, at the time of transfer, and during non-covered therapeutic leave. However, documentation was lacking in the medical records of the affected residents, showing no evidence that the required notifications were made. Interviews with facility staff, including the Administrator, Director of Nursing (DON), and Admissions Director, revealed a lack of adherence to the policy. The Administrator admitted to having no proof that bed hold policies were sent to responsible parties. The DON and Administrator expected that all residents discharged, including those for emergency room visits, would have a bed hold/transfer form completed and sent to the responsible party and Ombudsman. However, this expectation was not met, as evidenced by the absence of documentation in the residents' records. Further interviews highlighted communication gaps within the facility. The Admissions Director mentioned that she relies on nurses to notify families, guardians, or public administrators about transfers. Despite having master copies of the Notice of Transfer with the bed hold policy at the nurses' stations, the process of ensuring these forms were filled out and communicated was not effectively managed. This lack of coordination and documentation led to the deficiency identified by the surveyors.
Failure to Complete Timely MDS Assessments for Hospice Admissions and Discharges
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for three residents following their admission to or discharge from hospice services. Resident #33 was admitted to hospice services, but the facility did not complete the required MDS assessment within 14 days of this admission. Similarly, Resident #57 was admitted to and later discharged from hospice services, yet the facility did not complete the necessary MDS assessments within the 14-day timeframe for either event. Resident #113 experienced multiple admissions to and discharges from hospice services, and in each instance, the facility failed to complete the significant change MDS assessments within the required 14 days. The facility's policy, as outlined in the Resident Assessment Instrument (RAI) Manual, mandates that a significant change in status assessment (SCSA) must be performed within 14 days of a resident's admission to or discharge from hospice services. However, the facility did not adhere to this policy for the residents in question. During interviews, the Administrator and Director of Nursing (DON) acknowledged the expectation for MDS assessments to be completed per the RAI Manual. The facility relies on a contracted company for MDS coordination, with the Director of Nursing and Assistant Director of Nursing conducting assessments and providing information to the contracted company for completion.
Failure to Update and Revise Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans with specific interventions to meet the individual needs of six residents out of a sample of 23. The care plans did not reflect current medical conditions or orders, such as the presence of an ostomy for one resident, the use of tobacco pouches and hospice services for another, and the need for hospice services for several others. Additionally, dietary changes and the use of a Foley catheter were not addressed in the care plans of two residents. These omissions indicate a lack of timely updates and revisions to the care plans, which are essential for providing accurate and person-centered care. Interviews with the Corporate Nurse/Infection Preventionist and the facility's Administrator and Director of Nursing revealed that a contract company, along with Social Services and the Director of Nursing, is responsible for updating care plans. However, the care plans were not accurately reflecting the residents' current conditions, as expected by the facility's policy. The facility's policy requires care plans to be reviewed quarterly and updated as needed, but this was not adhered to, leading to deficiencies in the care provided to the residents.
Failure to Follow Physician's Orders for Multiple Residents
Penalty
Summary
The facility failed to adhere to physician's orders for several residents, leading to deficiencies in care. Resident #5, diagnosed with schizoaffective and anxiety disorders, had an order for daily blood pressure monitoring starting in August 2024, but there were no documented blood pressures for 102 out of 124 days. Resident #8, with diagnoses including type 2 diabetes and major depressive disorder, was on lithium treatment for ten months without any lab draws for lithium levels, and there were missing monthly weight records for September and October. Resident #15, diagnosed with bipolar disorder and hyperlipidemia, had orders for routine blood tests and monthly vital signs and weights, but the tests were not conducted as scheduled, and there was no weight recorded for October. Resident #20, with type II diabetes and schizophrenia, had orders for Hemoglobin A1C tests every three months, but there were gaps in testing, and no weights were recorded for October. Additionally, there were no orders for necessary lab evaluations despite the resident being on multiple medications. Resident #57, diagnosed with muscle wasting, Alzheimer's disease, and urinary retention, was admitted to hospice without an order, and there was no order to change the Foley catheter, which was observed in use over multiple days. The facility's Administrator and DON acknowledged the expectation for residents to have appropriate orders for treatments and special programs, and for these orders to be followed, highlighting a failure in maintaining professional standards of care.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and physical, mental, and psychosocial well-being of each resident. This deficiency affected several residents, both within and outside the sample, and had the potential to impact all residents in the facility. The facility's activities policy outlined the need for a comprehensive, person-centered activity program, but the implementation was lacking. The activities calendar showed a lack of scheduled activities on weekends, and residents reported that activities were sometimes canceled without replacements. Resident #5, who has schizoaffective disorder and anxiety disorder, reported not attending activities due to blindness and a lack of suitable activities. The resident's care plan did not address activities, and there was a delay in providing books on tape. Resident #8, diagnosed with schizophrenia and borderline personality disorder, mentioned that activities were not provided for an entire week in November due to staff absence, and activities on the locked unit were often inaccessible. Resident #15, with schizoaffective disorder and mild intellectual abilities, expressed that there were no activities for younger residents and nothing to do on weekends. Other residents, such as Resident #67, who is legally blind, and Resident #82, with schizoaffective disorder and borderline personality disorder, also reported a lack of age-appropriate activities and insufficient weekend activities. Resident #102, with schizoaffective disorder and bipolar disorder, and Resident #111, with similar diagnoses, both indicated a lack of engaging activities, leading to isolation and inactivity. The Activities Director acknowledged the absence of activities for residents with special needs and sensory issues and admitted to being behind on updating care plans. The Administrator and DON expected activities to be available for all residents, including those with special needs and on weekends.
Failure to Attempt Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) or document contraindications for GDRs for two residents, which could prevent residents from receiving the lowest effective dosage of psychotropic medications. Resident #15, diagnosed with multiple psychiatric disorders, was on several psychotropic medications, including perphenazine, risperidone, sertraline, clonazepam, carbamazepine, and hydroxyzine. Despite the absence of documented behaviors since September 2024, there was no evidence of GDR attempts or contraindications. The pharmacist's recommendations for GDRs were not addressed by the physician, and the facility did not provide a policy regarding GDRs. Resident #20, also diagnosed with psychiatric disorders, was prescribed medications such as paliperidone, lithium, venlafaxine, oxcarbazepine, and trazodone. Similar to Resident #15, there were no documented behaviors since March 2024, and no GDR attempts or contraindications were recorded for venlafaxine and trazodone. The pharmacist's recommendations for GDRs were not responded to by the physician, and the facility failed to provide documentation of the physician's response to the medication regimen review. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and Director of Nursing (DON), revealed that the process for handling medication regimen reviews and GDRs was not effectively managed. The consultant pharmacist noted a delay in receiving timely physician responses to GDR recommendations, indicating a systemic issue in the facility's medication management process. The lack of timely responses and documentation of GDRs or contraindications contributed to the deficiency identified by the surveyors.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to provide palatable, attractive food at safe and appetizing temperatures, affecting both sampled and non-sampled residents. Observations during a lunch meal revealed that cold food items, such as macaroni salad, pears, deviled eggs, and tomatoes, were served at temperatures ranging from 51 to 60 degrees Fahrenheit, which is above the expected 41 degrees Fahrenheit or below for cold foods. The facility did not have a food temperature policy in place, and there were no temperature logs provided for October, while the logs for November were incomplete, lacking specific dates. Interviews with residents indicated dissatisfaction with the food quality, with complaints about the food being unappealing, not hot enough, and generally not good. One resident even resorted to ordering meals from outside the facility. The Dietary Manager and the Administrator both acknowledged the expectation for cold foods to be served at 41 degrees or below and for temperature logs to be completed as per regulations, highlighting a failure in maintaining proper food service standards.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
