Golden Age Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Braymer, Missouri.
- Location
- 12498 Se Highway 116, Braymer, Missouri 64624
- CMS Provider Number
- 265718
- Inspections on file
- 16
- Latest survey
- September 5, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Golden Age Nursing Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was subjected to verbal and physical abuse by a CNA, who forcibly placed the resident into a wheelchair while using harsh language. The incidents were witnessed by dietary staff but were not reported immediately, contrary to the facility's abuse prevention policy. The CNA was later terminated, but the lack of immediate reporting and proper documentation contributed to the deficiency.
The facility did not employ a full-time LNHA, resulting in inadequate oversight of operations such as the Facility Assessment and Quality Assurance program. The Administrator worked part-time, while the unlicensed Assistant Administrator assumed many duties, causing confusion among residents and staff. The absence of a full-time LNHA led to gaps in administrative functions, including outdated facility assessments and poorly attended QAPI and QAA meetings.
The facility did not conduct or document a facility-wide assessment to determine necessary resources for resident care during routine and emergency situations. The Administrator, who does not work full-time at the facility, was unaware of the requirement and had not completed an assessment. The facility's Matrix for Providers showed a census of 43 residents with various care needs, including dementia, tube feeding, and hospice services.
The facility failed to obtain signatures on the NOMNC and SNF ABN forms for two residents before discharging them from Medicare services. One resident had moderate cognitive impairment and required total assistance, while the other had severe cognitive impairment and also required total assistance. Interviews revealed that the Social Services Director and Administrator were unaware of the unsigned documents, indicating a lapse in the facility's process to ensure compliance with Medicare requirements.
The facility failed to maintain a clean and homelike environment, with numerous deficiencies observed such as damaged walls, rusted vents, water-stained tiles, and debris in light fixtures. Interviews revealed unclear responsibilities between housekeeping and maintenance staff, and the facility lacked a policy for cleaning and maintenance.
The facility failed to conduct necessary background checks on newly hired employees, affecting eight employees. The facility did not verify these employees through the Family Care Safe Registry (FCSR) or the Nurse Aide (NA) Registry. The Personnel Policy lacked information on criminal background checks, and the Abuse and Neglect Policy did not include verification procedures. The Business Office Manager was unaware of these requirements, and the Administrator confirmed that verifications should be completed before employment.
The facility failed to ensure that nursing staff, including nurse aides and a certified medication technician, had the appropriate competencies and skills to provide care. Employee files showed no competency evaluations at hire or within the last 12 months. The DON admitted to not documenting observations of staff performance, contributing to the deficiency.
A facility failed to ensure a nurse aide completed required CNA training within four months of employment. The aide, hired while in high school, was unaware of the certification requirement and was not enrolled in classes. The administration had not discussed the need for certification, and the DON confirmed the aide was uncertified. The facility lacked a policy on nurse aide use.
The facility lacked administrative oversight for its QAPI program, potentially affecting all 43 residents. The Administrator, responsible for the QAPI and QAA programs, did not attend several 2024 meetings. The Administrator works two days a week, while the Assistant Administrator, who is not licensed, is usually present but may not attend every meeting.
The facility did not hold quarterly QAA meetings with the required members. Only the Medical Director and DON attended meetings, and the Administrator, who works part-time, did not participate. The QAA Coordinator compiles information from QAPI meetings for review, but no other staff were involved in discussions with the Medical Director.
The facility failed to implement an effective training program for staff, lacking a comprehensive facility assessment and tracking of required training hours. This affected all 43 residents, with no education on dementia care or care of cognitively impaired residents. Employee files showed no tracking of required training, and the DON admitted to not documenting observations or having a tracking tool for education hours.
The facility failed to conduct competency evaluations for nursing staff, including nurse aides and a certified medication technician, at least yearly. This deficiency affected all residents, with no evaluations documented at the time of hire or within the last 12 months. The DON and Assistant DON observed staff quarterly but did not document these observations, acknowledging that undocumented actions are considered not done.
A facility failed to follow its abuse and neglect policy when staff did not immediately report or intervene in two incidents of abuse involving a resident with severe cognitive impairment. A CNA was observed verbally and physically abusing the resident, causing fear and injury. The incidents were not reported immediately due to staff oversight, leading to a delay in addressing the abuse. The CNA was later terminated after an investigation.
A resident with severe cognitive impairment was subjected to verbal and physical abuse by a CNA, who grabbed and jerked the resident into a wheelchair while yelling. The incidents were witnessed by staff but not reported immediately, violating the facility's abuse policy. The resident suffered bruising, and the CNA was suspended after the investigation.
Resident Abuse by CNA and Delayed Reporting
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a Certified Nursing Assistant (CNA). The incident involved a resident with severe cognitive impairment due to dementia, who requires substantial assistance with daily activities. On two separate occasions, the CNA was observed grabbing the resident's arm and forcing them into a wheelchair while using harsh language. The resident was visibly shaken and fearful during these interactions, and on one occasion, sustained bruising to the right forearm. The facility's Abuse and Neglect Policy mandates that all staff be trained to prevent and report abuse. However, the incidents were not reported immediately by the witnesses, which included dietary staff. The Kitchen Supervisor and Dietary Aide A both witnessed the CNA's rough handling of the resident but failed to report the incidents to a supervisor or administrator as required by the policy. This lack of immediate reporting delayed the facility's response to the abuse. The facility's investigation into the incidents revealed that the CNA admitted to using force because the resident did not listen. The CNA was subsequently suspended and later terminated. The Assistant Administrator confirmed that there was no documentation in the employee's file regarding the reason for termination, highlighting a gap in the facility's documentation practices. The facility's failure to ensure immediate reporting and documentation of the abuse incidents contributed to the deficiency.
Lack of Full-Time LNHA Leads to Administrative Deficiencies
Penalty
Summary
The facility failed to employ a full-time Licensed Nursing Home Administrator (LNHA) responsible for the operation of the facility, which led to a lack of oversight in critical areas such as the development of a Facility Assessment and the Quality Assurance program. The Administrator worked only part-time, two days a week, while the Assistant Administrator, who was not a licensed LNHA, assumed many of the administrative duties. This arrangement resulted in confusion among residents and staff, who often perceived the Assistant Administrator as the primary authority figure. The absence of a full-time LNHA contributed to significant gaps in the facility's operations. The Administrator was unaware of the requirement for a current facility assessment, with the most recent one dated 2022. Additionally, the Quality Assurance and Performance Improvement (QAPI) meetings were inadequately attended, with the Administrator missing several meetings throughout the year. The QAA Committee meetings were also poorly attended, with only the Medical Director and Director of Nursing present, indicating a lack of comprehensive oversight and participation from key administrative personnel. The facility's failure to maintain a full-time LNHA and the resulting administrative deficiencies were evident in the interviews conducted with residents, family members, and staff. Residents and family members were under the impression that the Assistant Administrator was the Administrator due to her constant presence, while the Director of Nursing confirmed that the Assistant Administrator made decisions in the absence of the Administrator. This situation highlights the facility's inability to ensure proper administrative oversight and compliance with federal and state regulations, ultimately affecting the quality of care provided to the residents.
Failure to Conduct Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. This deficiency was identified through interviews and record reviews, revealing that the facility did not have a current assessment in place. The facility's Matrix for Providers indicated a census of 43 residents, with specific characteristics including 26 residents diagnosed with dementia, one resident fed via tube, three residents with indwelling catheters, 11 residents with a history of falls, and six residents receiving hospice services. During an interview, the Administrator admitted to not working full-time at the facility and being unaware of the requirement for a facility assessment, stating that she had found information online but had not yet completed an assessment.
Failure to Obtain Required Signatures on Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to obtain necessary signatures on the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms for two residents prior to their discharge from Medicare services. Resident #4, who had moderate cognitive impairment and required total assistance with activities of daily living, was admitted to skilled Medicare Part A services on March 1, 2024, with the last covered day being April 26, 2024. Similarly, Resident #11, who had severe cognitive impairment and also required total assistance, was admitted on February 22, 2024, with the last covered day being March 31, 2024. In both cases, the facility did not secure signatures from the residents, their representatives, or facility staff on the required forms. Interviews with facility staff revealed a lack of awareness regarding the unsigned documents. The Social Services Director was unaware that the forms lacked signatures, although she acknowledged that they should be signed to confirm receipt. The Administrator indicated that the social service designee was responsible for managing these forms and was also unaware of the oversight. This deficiency highlights a failure in the facility's process to ensure compliance with Medicare requirements for notifying residents or their representatives about coverage and potential liability for services not covered.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by numerous deficiencies observed in the physical condition of the facility. Observations revealed significant issues such as a gash in the sheet-rock, multiple nicks and scratches on hallway walls, rusted ceiling vents, water-stained ceiling tiles, and carpets with water stains. Additionally, there were multiple light fixtures with dead bugs and debris, cobwebs in various corners, and dust, dirt, and debris behind fire doors. The nurse's station area had peeling non-skid matting, cracked and peeling vinyl chairs, a water fountain with crusty debris, and loose or missing handrail components. Similar issues were noted in other areas, including the 400 and 200 halls, the conference room, and the north dining room area, which also had cobwebs, dust, debris, and rusted fixtures. Interviews with facility staff indicated a lack of clarity and responsibility regarding cleaning and maintenance duties. The Housekeeping supervisor stated that maintenance personnel were responsible for cleaning hallways, dusting, and cleaning light fixtures, while the Administrator confirmed that maintenance was responsible for cleaning hallways and lights and completing repairs, with housekeeping handling daily room cleanings. The facility did not provide a policy for cleaning, maintenance, and care of furnishings, contributing to the observed deficiencies in maintaining a homelike environment.
Failure to Conduct Background Checks on New Employees
Penalty
Summary
The facility failed to conduct necessary background checks on newly hired employees, affecting eight out of eight sampled employees hired since August 2024. The facility did not verify these employees through the Family Care Safe Registry (FCSR) or the Nurse Aide (NA) Registry to ensure they did not have a history of abuse, neglect, exploitation, or theft. The facility's Personnel Policy, dated January 2020, lacked information regarding the requirement for criminal background checks prior to employment. Additionally, the facility's undated Abuse and Neglect Policy did not include procedures for verifying staff through the FCSR or the NA Registry. During interviews, the Business Office Manager and the Administrator acknowledged the oversight, with the Business Office Manager unaware of the verification requirements and the Administrator confirming that such verifications should be completed before new employees start work.
Deficiency in Staff Competency Evaluations
Penalty
Summary
The facility failed to ensure that five randomly sampled nursing staff, including Nurse Aide A, Certified Nurse Aides A, B, and C, and a Certified Medication Technician, had the appropriate competencies and skill sets to provide nursing and related services. This deficiency was identified through observation, interview, and record review, and it potentially affected all residents in the facility, which had a census of 43. The facility did not have a policy on competencies, and the employee files reviewed showed that none of the sampled staff had undergone a competency evaluation at the time of hire or within the last 12 months. During interviews, the Administrator stated that the Director of Nursing (DON) was responsible for training and competency. The DON mentioned that in-services were planned a year in advance and as needed, and that she and the Assistant DON observed aides performing care quarterly. However, the DON admitted that these observations were not documented, acknowledging that if something is not documented, it is considered not done. This lack of documentation and formal competency evaluations contributed to the deficiency in ensuring staff competencies.
Failure to Enroll Nurse Aide in Required Training
Penalty
Summary
The facility failed to ensure that a nurse aide completed a nurse aide training program within four months of employment, as required. The nurse aide, who was hired on September 13, 2023, completed an orientation module but was not enrolled in any Certified Nurse Aide (CNA) training classes. During an interview, the nurse aide stated that they began employment while still in high school and were not aware of the requirement to be certified within four months of hire. The administration had not discussed CNA classes with the nurse aide, and the Director of Nursing confirmed that the nurse aide was not certified and was unsure why they had not been enrolled in classes. The facility did not provide a policy on the use of nurse aides.
Lack of Administrative Oversight in QAPI Program
Penalty
Summary
The facility failed to maintain administrative oversight for its Quality Assurance and Performance Improvement (QAPI) program, which had the potential to affect all 43 residents. The facility's policy, dated February 13, 2023, states that the Board of Directors and Administration are responsible for the ongoing QAPI program. However, the review of QAPI meeting minutes for 2024 revealed that the Administrator did not attend meetings on February 2nd, May 30th, June 21st, and August 1st. Interviews with the Human Resources/QAPI Coordinator and the Assistant Administrator indicated that the Administrator works only two days a week, and the Assistant Administrator, who is not licensed, is typically present Monday through Friday but may not attend every meeting. Despite the Assistant Administrator's presence, the Administrator is designated as the head of the QAPI and Quality Assessment and Assurance (QAA) program.
Inadequate QAA Meeting Attendance
Penalty
Summary
The facility failed to ensure that quarterly Quality Assessment and Assurance (QAA) meetings were held with the required members. The facility's policy, dated March 3, 2023, mandates that the QAA Committee should include the Administrator, Medical Director, Director of Nursing (DON), Infection Preventionist, and clerical staff, with additional staff as needed. However, the review of meeting notes revealed that only the Medical Director and DON were present for the meetings held on January 31, 2024, April 22, 2024, and August 24, 2024, with no meeting conducted in July 2024. During an interview, the DON stated that she typically meets with the Medical Director on weekends, and the QAA Coordinator compiles information from monthly Quality Assurance and Performance Improvement (QAPI) meetings for review. The Administrator, who works only two days a week, does not attend these meetings, and no other staff members participate in the discussions with the Medical Director.
Deficiency in Staff Training and Facility Assessment
Penalty
Summary
The facility failed to implement an effective training program for both new and existing staff members, as evidenced by the absence of a comprehensive facility assessment that should include staff competencies and skill sets necessary for the care of the resident population. The facility also did not track attendance and hours of training for staff members, who are required to complete at least 12 hours of education annually. This oversight had the potential to affect all 43 residents in the facility. The facility did not provide a facility assessment or a policy on staff education and competencies. A review of education records showed various training sessions were completed, but there were no time frames for the length of training to ensure the required 12 hours. Additionally, there was no education provided on dementia care, care of cognitively impaired residents, or restorative nursing. Employee files revealed that several staff members, including nurse aides and certified medication technicians, had no tracking of required training. During interviews, the Director of Nursing (DON) stated that she and the Administrator create the yearly education calendar and observe staff performing care quarterly, but she has not documented these observations. The DON also mentioned that there is no tracking tool for hours of education and attendance at required training. The Administrator confirmed that the DON is responsible for education, tracking, and the education calendar, and acknowledged that the facility did not have a facility assessment.
Failure to Conduct Competency Evaluations for Nursing Staff
Penalty
Summary
The facility failed to ensure the continued competence of nurse aides by not performing competency evaluations at least yearly for five randomly sampled nursing staff, including Nurse Aide A, Certified Nurse Aides A, B, and C, and a Certified Medication Technician. This deficiency had the potential to affect all residents, with the facility census being 43. The facility did not provide a facility assessment or a policy on competency. Employee files revealed that none of the sampled staff had competency evaluations at the time of hire or within the last 12 months. During interviews, the Administrator stated that the Director of Nursing (DON) was responsible for staff training and competency. The DON mentioned that in-services were planned a year in advance and as needed, and that she and the Assistant DON observed aides quarterly but did not document these observations. The DON acknowledged that if something is not documented, it is considered not done.
Failure to Report and Address Resident Abuse
Penalty
Summary
The facility failed to adhere to its abuse and neglect policy when staff did not immediately intervene or report two separate incidents of staff-to-resident abuse. The incidents involved a resident with severe cognitive impairment, who required substantial assistance with daily activities. On one occasion, a Certified Nurses Assistant (CNA) was observed by the Kitchen Supervisor to have verbally and physically abused the resident by jerking them into a wheelchair, causing the resident to cry out in pain and appear fearful. The Kitchen Supervisor, although trained in abuse and neglect reporting, did not report the incident immediately due to being busy and subsequently forgetting. In a second incident, the same CNA was observed by a Dietary Aide to have aggressively handled the resident, insisting they sit in a wheelchair despite the resident's protests. The Dietary Aide assisted the CNA but did not report the incident immediately. The Kitchen Supervisor later noticed a bruise on the resident's forearm, which prompted them to recall the previous incident and report it to the Assistant Administrator two days later. The Assistant Administrator, upon receiving the report, interviewed the CNA, who admitted to using force with the resident. The CNA was subsequently suspended pending investigation and later terminated. The facility's policy requires immediate reporting of abuse or neglect to supervisory staff, but this protocol was not followed, leading to a delay in addressing the abuse incidents.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired resident from verbal and physical abuse by a Certified Nursing Assistant (CNA A). The incident involved CNA A grabbing the resident's arm and jerking them back into a wheelchair while yelling and cursing. This occurred in the dining room, where the resident was observed standing and leaning against a chair. The Kitchen Supervisor witnessed the incident and noted the resident appeared scared and shaken. Despite the resident's cognitive impairment, which included severe difficulty in understanding and communication, the CNA's actions were aggressive and inappropriate. The facility's Abuse and Neglect Policy mandates immediate reporting of any suspected abuse, but this protocol was not followed. The Kitchen Supervisor and Dietary Aide A, who both witnessed the incidents, failed to report them immediately to a supervisor or the administration. The policy clearly states that all employees must report any signs of abuse or neglect immediately, yet the delay in reporting allowed the abusive behavior to continue unchecked for several days. The resident involved had a history of severe cognitive impairment, requiring substantial assistance with daily activities. Despite this, the CNA's handling of the resident was rough and verbally abusive, leading to physical harm, as evidenced by bruising on the resident's forearm. The facility's investigation confirmed these events, and the CNA was eventually suspended pending further investigation. However, the failure to report the incidents promptly contributed to the deficiency in ensuring the resident's safety and well-being.
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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