Gainesville Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Gainesville, Missouri.
- Location
- 77 Medical Drive, Gainesville, Missouri 65655
- CMS Provider Number
- 265312
- Inspections on file
- 17
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Gainesville Nursing during CMS and state inspections, most recent first.
A nurse with a known history of medication diversion repeatedly accessed the I-STAT automated dispensing cabinet to withdraw oxycodone, hydrocodone-APAP, and tramadol tablets under the names of ten residents with PRN pain orders, including individuals with conditions such as MS, COPD, dementia, Parkinson’s disease, cancer, heart failure, stroke, and recent amputation. These controlled substances were not documented as administered on the MAR or in the EHR, resulting in 19 unaccounted-for narcotic tablets. Staff interviews confirmed that narcotics were supposed to be double-locked, counted each shift, and signed out on both the narcotic log and MAR, and that missing narcotics constituted misappropriation. The DON, who knew of the nurse’s prior diversion history and had instructed the nurse not to administer narcotics, had been relying on I-STAT discrepancy and monthly narcotic counts, which did not reveal the pattern because cabinet counts remained correct. A later comparison of I-STAT withdrawals by nurse name against MAR and narcotic logs exposed the misappropriation of resident medications.
A staff member in environmental services obtained a cognitively intact resident’s debit card and PIN under the pretense of helping with cash withdrawals and shopping, then conducted multiple unauthorized ATM withdrawals and Venmo transfers for personal use. Bank statements showed extra withdrawals and electronic payments beyond the amounts the resident requested, leading to overdraft fees and an insufficient funds notice. The resident reported never authorizing these additional transactions or the use of Venmo. Multiple staff, including CNAs, a CMT, an LPN, SSD, Activity Director, BOM, DON, and the Administrator, stated that only designated administrative and activities staff were allowed to shop for residents, that no staff were permitted to take residents’ debit or credit cards or accept money from residents, and that using a resident’s funds for personal purposes was misappropriation. Despite these policies and staff awareness, the employee used the resident’s card and funds for personal financial gain.
A deficiency was identified due to the failure to timely report suspected abuse, neglect, or theft, and to report the investigation results to the proper authorities. The incident was noted during a survey, but specific details about the individuals involved or the nature of the incident are not provided.
The facility failed to provide palatable meals, with residents reporting cold, flavorless, and tough food. Observations confirmed food temperatures below acceptable levels, and the Dietary Manager acknowledged the issue. Residents expressed dissatisfaction with meal quality and menu inconsistencies.
A facility failed to report an allegation of neglect to the state agency within the required timeframe. A visitor accused the Administrator of neglecting a resident, who had significant weight loss and appeared unkempt. Despite the facility's policy requiring immediate reporting of such allegations, the Administrator did not report the incident, leading to a deficiency.
A facility failed to investigate an allegation of neglect when a visitor accused the Administrator of allowing a resident to lie in bed and die. The resident, who had severe dementia and required assistance with daily activities, was observed by the visitor to have lost significant weight and appeared unkempt. Despite staff acknowledging such claims as potential neglect, the Administrator did not initiate a full investigation or report the incident to the State Survey Agency.
The facility failed to develop complete care plans for two residents, one requiring side rails for mobility assistance and another at risk for elopement due to Alzheimer's. The use of side rails was not included in the care plan despite consent and ongoing use, while the elopement risk was not addressed despite documented wandering behavior. These omissions were confirmed by the MDS Coordinator and DON.
A resident with severe cognitive impairment and dementia repeatedly attempted to elope from the facility, exhibiting combative behavior. Despite being identified as an elopement risk, the facility failed to update the care plan with new interventions or conduct a root cause analysis. Staff interventions were ineffective, and the issue was not addressed in Quality Assurance meetings.
A resident with specific dietary needs was served a whole pork chop instead of having the meat cut up as ordered by the physician. The resident, who was cognitively intact and had gastroesophageal reflux disease, could not eat the meal as served. The deficiency occurred because the dietary change was not communicated to the Dietary Manager, resulting in the Tray Card not being updated.
Unaccounted Narcotics and Misappropriation of Resident Medications via I-STAT Withdrawals
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of property when staff could not account for 19 missing controlled-substance tablets for 10 residents. Facility policies required controlled substances to be stored under double-lock conditions, counted every shift, and any discrepancies reported immediately to the DON. Policies also required that if a medication with an active order could not be located in the cart, staff should search other areas and, if still not found, obtain it from the I-STAT and document administration on the MAR. The abuse and misappropriation policy required investigation of suspected misappropriation and staff education on prevention and reporting responsibilities. The events leading to the deficiency centered on RN A’s repeated withdrawal of narcotics from the I-STAT automated dispensing cabinet without corresponding documentation of administration on the MAR or in the EHR. On one morning, after receiving shift report, RN B observed RN A in the medication room logging into the I-STAT and withdrawing an oxycodone 10 mg tablet under a resident’s name without a request from the CMT assigned to that hall. RN B then saw RN A coming from the bathroom, and RN A made a comment about feeling alive again. The resident under whose name the oxycodone was withdrawn could not recall exactly when they last received a pain pill and only remembered that a female had given it. Review of I-STAT records showed that on multiple prior occasions over several months, RN A had withdrawn oxycodone, hydrocodone-APAP, and tramadol tablets for various residents without any documentation of administration on the MAR. Ten residents with orders for PRN narcotic analgesics were involved. One resident with multiple sclerosis, COPD, atrial fibrillation, dementia, and frequent, constant pain had an order for oxycodone IR 10 mg every four hours PRN; I-STAT records showed several oxycodone tablets withdrawn by RN A on different dates with no corresponding MAR entries. Another resident with brain cancer, COPD, and diabetes had tramadol 50 mg PRN ordered, and a tramadol tablet was withdrawn by RN A without documentation. Additional residents with diagnoses including rhabdomyolysis, hip pain, Parkinson’s disease, Alzheimer’s disease, dementia, heart failure, atrial fibrillation, obesity, unspecified pain, encopresis, cachexia, stroke, and recent amputation had PRN orders for hydrocodone-APAP or tramadol; for each, I-STAT reports showed narcotic tablets removed by RN A on specific dates and times with no documentation of administration in the EHR or MAR. Staff interviews confirmed that narcotics were supposed to be double-locked, counted each shift, signed out on the narcotic log and MAR, and that missing narcotics were considered misappropriation. The consultant pharmacist explained that the I-STAT system tracks cabinet inventory but does not by itself confirm administration, so withdrawals that are not documented on the MAR would not create an automatic discrepancy in the I-STAT count. The DON stated awareness that RN A had a history of medication diversion and had instructed RN A not to administer narcotics, indicating that CMTs were to administer all medications. Despite this, it was later discovered that RN A had been pulling narcotics from the I-STAT. The DON had been running weekly discrepancy reports on the I-STAT and conducting monthly narcotic counts with the consultant pharmacist, but these processes did not detect RN A’s pattern because the I-STAT counts remained correct. Only when the DON ran a report by nurse name and compared each I-STAT withdrawal to the EHR MAR and narcotic log did it become evident that RN A had repeatedly removed narcotics without documented administration, resulting in 19 missing narcotic tablets for 10 residents and constituting misappropriation of resident medications. Interviews with CMTs and an RN confirmed that they performed narcotic counts with off-going staff each shift, maintained double-lock security, did not give their keys to others, and would notify the DON immediately of any discrepancy. They also stated that they signed out narcotics on both the narcotic log and MAR and that they considered missing narcotics to be misappropriation. The consultant pharmacist confirmed that medications were delivered daily and that the pharmacy ran a daily controlled-medication report, but that the I-STAT system alone would not flag missing doses if the cabinet count remained accurate. The Administrator stated that missing narcotics were considered misappropriation of property and that an investigation was initiated after being notified of potential diversion, ultimately revealing that RN A had been removing narcotics from the I-STAT and not administering them to residents. Overall, the facility failed to prevent misappropriation of resident medications by not detecting that RN A, who had a known history of diversion and had been instructed not to administer narcotics, was repeatedly withdrawing controlled substances from the I-STAT without documentation of administration. This resulted in 19 unaccounted-for narcotic tablets intended for 10 residents with documented pain and PRN orders for oxycodone, hydrocodone-APAP, or tramadol, in violation of the facility’s own policies on controlled substances, medication administration, and prevention of misappropriation of resident property.
Misappropriation of Resident Funds via Unauthorized Debit Card Use by Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when an environmental services employee used the resident’s debit card without consent for personal financial gain. The resident, who had diagnoses including COPD, chronic respiratory failure, myocardial infarction, and atrial fibrillation, was documented as cognitively intact on a recent MDS, independent in most ADLs, and requesting supervision only with showers. The care plan also noted impaired cognitive or thought processes and impaired visual function requiring use of glasses and supports. Facility policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent and prohibited such conduct. The sequence of events began when the environmental services employee offered to assist the resident with obtaining items and cash from the community. On one occasion, the employee initially brought back food and a receipt with no discrepancies. Subsequently, the employee asked the resident if he needed anything and suggested using the resident’s debit card to withdraw cash from an ATM when the resident did not have cash. The resident provided the employee with the debit card and PIN and requested a $500 withdrawal, but bank records showed an additional unauthorized ATM withdrawal of $103.25 on the same date. On a later date, the employee again took the resident’s debit card to withdraw money; the resident requested $503, but the bank statement showed additional ATM withdrawals of $123.25 and $306.00 that the resident stated were not authorized. Further review of the resident’s bank statements revealed multiple Venmo transactions to the employee over several days totaling $610.00, along with overdraft fees of $150.00, which the resident reported he did not authorize and did not understand, stating he did not know what Venmo was. The resident reported receiving an insufficient funds notice from the bank, which led to discovery of the unauthorized withdrawals and transfers. Law enforcement investigation documented that the employee admitted adding the resident’s card to a Venmo account and acknowledged transactions linked to the resident’s card, and officers photographed the card showing the resident’s name. Interviews with multiple staff, including CNAs, CMT, LPN, SSD, Activity Director, BOM, DON, and the Administrator, confirmed that only designated staff (BOM, Administrator, Activity Director/front office) were permitted to shop for residents, that staff were not allowed to take residents’ debit or credit cards, withdraw money from ATMs, or accept money or gifts from residents, and that using a resident’s debit card for personal use constituted misappropriation of resident funds. Despite these policies and staff knowledge, the environmental services employee obtained the resident’s debit card and PIN, conducted unauthorized ATM withdrawals and electronic transfers, and used the resident’s funds for personal purposes, resulting in misappropriation of the resident’s money.
Failure to Timely Report Suspected Abuse or Neglect
Penalty
Summary
The report identifies a deficiency related to the failure to timely report suspected abuse, neglect, or theft, and to report the results of the investigation to the proper authorities. This deficiency was found during a survey with the Event ID B3N912, which concluded on 11/14/24. The specific details of the incident, including the individuals involved or the nature of the suspected abuse, neglect, or theft, are not provided in the report. However, the deficiency highlights a lapse in the facility's protocol for handling and reporting such critical incidents.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to ensure that food prepared and served to residents was palatable, as evidenced by multiple complaints from residents about the temperature, flavor, and texture of the meals. Observations and interviews revealed that the food was often served cold, lacked seasoning, and was difficult to chew. Specifically, the temperature of the food was found to be below acceptable levels, with the cheesy rice casserole at 110 degrees Fahrenheit, the pork chop at 95 degrees Fahrenheit, and the broccoli at 90 degrees Fahrenheit when served. The Dietary Manager acknowledged that the food was cooler than it should have been to be considered palatable. Residents expressed dissatisfaction with the meals during interviews, noting that the food was cold, overcooked, and lacked flavor. One resident mentioned that the breakfast pancakes were cold, and another reported that the pork chops were tough and hard to chew. Additionally, there were complaints about the inconsistency of the menu, such as being served tortilla chips with meat instead of the expected burrito with beans and rice. These issues indicate a failure in the facility's food preparation and service processes, impacting the residents' dining experience and satisfaction.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of possible neglect involving a resident to the State Survey Agency within the required two-hour timeframe. The incident involved a visitor who accused the facility's Administrator of neglecting a resident by allowing them to lie in bed and die, noting the resident's significant weight loss and unkempt appearance. Despite the visitor's accusations, the Administrator did not consider the comments to be an allegation of neglect and did not report the incident to the Department of Health and Senior Services (DHSS). The facility's policy mandates that any allegations of abuse or neglect must be reported immediately to the Administrator and subsequently to the state agency within two hours. Interviews with facility staff, including a Certified Nurse Aide, the Activity Director, and the Director of Nursing, confirmed their understanding of this requirement. They all indicated that the visitor's comments should have been treated as an allegation of neglect and reported accordingly. The resident in question was admitted with diagnoses including acute kidney failure, severe dementia with agitation, and required substantial assistance with daily activities. The Administrator documented the visitor's accusations but failed to recognize them as a reportable event. This oversight resulted in a failure to comply with the facility's policy and state regulations regarding the timely reporting of potential neglect.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to investigate an allegation of possible neglect involving a resident, as required by their policy and state regulations. A visitor accused the facility's Administrator of allowing a resident to lie in bed and die, citing the resident's significant weight loss and unkempt appearance. Despite this serious allegation, the Administrator did not consider it as potential neglect and did not initiate a full investigation or report the incident to the State Survey Agency within the mandated five-day period. The resident in question was admitted with diagnoses including acute kidney failure, severe dementia with agitation, repeated falls, and required assistance with personal care. The Minimum Data Set indicated the resident was severely cognitively impaired and dependent on staff for various activities of daily living. The visitor's observations of the resident's condition were not documented as part of a formal investigation, and no interviews were conducted with other staff or residents who might have had relevant information. Interviews with facility staff, including a CNA, the Activity Director, and the Director of Nursing, revealed that they would have considered the visitor's statements as allegations of neglect and would have reported them to their supervisors. However, the Administrator, who was responsible for overseeing abuse and neglect investigations, did not perceive the visitor's comments as an allegation of neglect and failed to follow the facility's policy for conducting a thorough investigation and reporting the findings to the appropriate authorities.
Deficiencies in Care Planning for Side Rails and Elopement Risks
Penalty
Summary
The facility failed to develop a complete person-centered care plan for two residents, leading to deficiencies in addressing their specific needs. For one resident, who had a history of frequent falls and unsteadiness, the facility did not include the use of side rails in the care plan, despite the resident's consent and ongoing use of bilateral half side rails for mobility and repositioning assistance. This oversight was confirmed by both the MDS Coordinator and the Director of Nursing, who acknowledged that the use of side rails should have been care planned. Another resident, diagnosed with Alzheimer's disease and identified as at risk for elopement, did not have a care plan addressing their wandering and elopement risk. The resident exhibited daily wandering behavior and had attempted to exit the facility multiple times, requiring redirection from staff. Despite these behaviors being documented in the resident's assessments and progress notes, the care plan did not reflect the necessary interventions. This omission was confirmed by the MDS Coordinator and the Director of Nursing, who expected the wandering behavior to be addressed in the care plan.
Failure to Address Elopement Risks for a Resident with Dementia
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and provide adequate supervision to prevent accidents, specifically for a resident with severe cognitive impairment and a history of wandering. The resident, diagnosed with dementia, had multiple elopement attempts and exhibited combative behavior. Despite these incidents, the facility did not update the resident's care plan with new interventions or conduct a root cause analysis to address the elopement behavior. The resident's care plan identified them as an elopement risk and wanderer, with interventions such as offering pleasant diversions and identifying a pattern of wandering. However, the resident repeatedly exited the facility unsupervised, and staff interventions, including redirection and therapeutic communication, were ineffective. The resident's behavior escalated to hitting staff and attempting to evade them during elopement attempts. Interviews with facility staff, including the Director of Nursing (DON) and Registered Nurses (RNs), revealed that the facility did not complete a root cause analysis for the resident's exit-seeking behavior. The DON confirmed that the resident had not had an elopement assessment since June 2024 until September 2024, and the issue had not been discussed in Quality Assurance meetings. The facility's failure to evaluate the effectiveness of interventions and update the care plan contributed to the ongoing elopement attempts and associated risks.
Failure to Prepare Food According to Resident's Dietary Needs
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet the individual needs of a resident, specifically Resident #17. The resident had a physician's order for a regular texture, regular consistency diet with no gravy and meats to be cut small. However, the resident's Tray Card, which is printed daily by the kitchen, was not updated to reflect these dietary instructions. As a result, during an observation of the lunch tray line, the resident was served a whole pork chop, contrary to the order for the meat to be cut up. The resident, who was cognitively intact and had a diagnosis of gastroesophageal reflux disease, reported being unable to cut the meat and therefore did not eat it. The Director of Nursing (DON) indicated that when a change to a diet is made by the physician, a copy of the change is supposed to be given to the Dietary Manager (DM) for implementation. However, the paperwork for the change in diet for the resident was not communicated to the DM, leading to the deficiency in food preparation for the resident.
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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