Golden Years Center For Rehab And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Harrisonville, Missouri.
- Location
- 2001 Jefferson Parkway, Harrisonville, Missouri 64701
- CMS Provider Number
- 265349
- Inspections on file
- 23
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 11 (3 serious)
Citation history
Health deficiencies cited at Golden Years Center For Rehab And Healthcare during CMS and state inspections, most recent first.
The facility used its van with an expired vehicle registration to transport residents to physician appointments several times a week, despite having a policy requiring safe, compliant transportation and the availability of other transportation services. Emails between facility administration and the parent company showed ongoing awareness that the van’s registration had expired and that the title was needed to renew it. Observation confirmed the expired plate sticker, and review of transportation logs showed repeated use of the van for resident appointments while some residents were transported by outside companies. In interviews, the van driver, an LPN, and the Administrator all acknowledged that the van’s license had expired the previous year, that administration knew about it, and that the van continued to be used for resident transport during this period.
A resident with dementia and anxiety, who was his/her own responsible party, was moved to a different room, including a locked memory care unit, without documented written notice or a signed agreement for the room change. The care plan indicated the room move had been discussed and agreed to, but the resident later reported not agreeing, becoming very upset and tearful, and feeling trapped in the locked unit. Staff, including CNAs and an agency LPN, stated that residents were supposed to receive written notice and that all parties should agree before a room change, but they were unsure if this occurred for this resident. EMR review showed no guardian or DPOA and no uploaded agreement related to the move, and the DON confirmed the resident had not been notified in writing and acknowledged unawareness of the regulatory requirement.
Two residents were affected when staff failed to follow and document physician orders for diagnostic testing. One resident with urinary retention, neuromuscular bladder dysfunction, and an indwelling catheter had multiple UAs ordered and marked as completed in the system, but the EMR contained no notes of urine collection attempts, refusals, or any UA results, despite care plan notes that the resident sometimes refused catheter care. Another resident with C. diff enterocolitis and morbid obesity fell while rising from a commode; after an X-ray could not be obtained, a CT of the back and right side was ordered, but the resident reported not being informed of the CT or a scheduled date, and the hospital scheduler stated the CT order was not received until days later and was initially invalid, preventing scheduling. Facility leadership and staff acknowledged that all MD orders should be followed and that attempts, refusals, and fax confirmations should be documented, but such documentation was absent in these cases.
The facility did not provide required behavioral health services, failed to implement PASRR processes, and did not ensure administration of psychotropic medications for several residents with serious mental illness. Staff lacked training in de-escalation and behavioral health, and did not document or address escalating aggressive behaviors, resulting in an unsafe environment for both residents and staff.
Two residents did not receive necessary medical care as ordered, including missed doses of anti-rejection and psychotropic medications and lack of required wound care. Staff failed to communicate with physicians and the transplant team, did not document or reconcile medications, and lacked training in caring for post-transplant and psychiatric residents. These failures led to severe health complications, including infection, hospitalization, and behavioral crises.
A resident who was recently admitted after a kidney transplant did not receive prescribed antirejection and immunosuppressive medications due to failures in medication reconciliation, ordering, and administration. Staff were unaware of the process for handling medications sent from the hospital, did not ensure timely pharmacy delivery, and failed to notify the physician or take action when medications were unavailable. The resident was readmitted to the hospital with sepsis and undetectable antirejection medication levels, confirming the missed doses.
Two residents were subjected to physical and verbal abuse by another resident with a history of mental health disorders, leading to one resident leaving the facility due to fear and humiliation, and another nonverbal, cognitively impaired resident suffering pain, visible injury, and emotional trauma after being struck and pushed in a wheelchair. Staff and witnesses confirmed the incidents, and the facility did not prevent or adequately intervene in the aggressive behaviors, despite policies prohibiting abuse.
Staff at the facility did not receive adequate training or education in behavioral health management, resulting in an inability to safely care for residents with complex psychiatric and behavioral needs. Multiple staff members reported feeling unprepared and fearful, and there was a lack of incident reporting, care plan updates, and behavioral interventions for residents exhibiting aggressive, violent, or self-harming behaviors. This led to repeated incidents of harm to both staff and residents, as well as frequent involvement of law enforcement.
A resident's dignity was violated when an LPN called the resident "dumb" during a care interaction, leading to the resident becoming visibly upset, expressing emotional distress, and requesting not to have the LPN as a caregiver. Multiple staff witnessed the incident and confirmed the resident's account, and the facility's policy on resident rights was not upheld.
The facility did not maintain a full-time DON or ensure RN coverage for at least eight hours per day, seven days a week. During a period between the termination of the previous DON and the hiring of a new DON, staff—including an LPN acting as ADON—confirmed that RN coverage was inconsistent and agency RNs were only used occasionally. Staff often relied on phone consultations with former DONs for guidance, rather than having an on-site RN or DON as required.
A resident with morbid obesity and complex care needs was transferred to a hospital without proper discharge documentation, reassessment, or a 30-day notice. The facility refused to readmit the resident after hospitalization, citing inability to meet care needs, and did not provide required notifications regarding appeal rights or bed-hold policies.
Two residents did not receive all prescribed medications, and required blood pressure monitoring was not completed for one resident with orders for as-needed antihypotensive medication. Missed doses were not documented on the MAR, and there was no evidence of physician notification or progress note entries explaining the omissions, despite facility policy and staff interviews indicating these steps were required.
Two residents received medications and water flushes via G-tube without verification of tube placement or measurement of external tube length, as an LPN did not check placement before administration. Facility leadership and staff were unaware of current best practices for G-tube placement verification, and no policy for G-tube medication administration was provided.
The facility failed to maintain cleanliness and proper food storage standards in the kitchen, with issues including debris buildup, improper food storage, unlabeled containers, and uncleanable cutting boards and spatulas. The Dietary Manager and Dietary Cook acknowledged these deficiencies during interviews.
The facility failed to provide required in-service training for dementia care and abuse prevention for three CNAs, with inconsistent training offerings and incomplete documentation of attendance, as confirmed by staff interviews and training records review.
The facility failed to ensure residents who allowed the facility to manage their funds received interest payments and did not have signed authorization forms for three residents. Bank statements showed no interest payments, and the Corporate Director of Fiscal Services was unaware of any changes. The Business Office Manager could not locate authorization forms for these residents, all of whom had legal guardians.
The facility failed to maintain water temperatures at handwashing faucets in several resident rooms at or above 105°F, with observed temperatures ranging from 84.5°F to 103.1°F. Additionally, the facility did not maintain clean sprinkler heads in various areas and failed to repair two stand-up lifts with cracked bases. Staff acknowledged these issues but did not take immediate corrective actions.
The facility failed to notify the ombudsman of resident discharges/transfers for three residents. The Social Services Designee had been emailing the list of discharges to an incorrect email address, resulting in the ombudsman not being informed as required.
The facility failed to ensure a resident's care plan included necessary PT, OT, and ST, despite orders and initiation of these therapies. The omission was due to incomplete documentation following a change in the facility's computer systems.
The facility failed to update care plans for five residents with changes in their conditions and needs, and did not invite a resident to their care plan meeting. Issues included unupdated hospice care, missing IV antibiotics, and overdue care plan goals. Interviews revealed that care plans were not consistently updated due to a change in computer systems.
The facility's Activity Director did not meet the required qualifications, lacking formal training and certification, leading to a deficiency identified by surveyors.
The facility failed to provide ordered Restorative Aide (RA) services to three residents, leading to a decline in their Range of Motion (ROM). Staff interviews and documentation revealed that RAs were frequently pulled to work as CNAs, resulting in inconsistent delivery of RA services.
The facility failed to ensure proper maintenance and sanitation of respiratory equipment for several residents with COPD and CHF. Observations revealed undated and improperly stored oxygen tubing and nebulizer masks, and interviews with staff highlighted inconsistencies in responsibilities and practices.
The facility failed to ensure an RN was on duty for at least eight consecutive hours a day, seven days a week, as required. The facility's staffing schedule and interviews revealed that there was no RN coverage on certain days, particularly weekends, despite the facility's policy and CMS reports indicating the need for adequate RN staffing.
The facility failed to ensure that the Medication Regimen Review (MRR) was responded to for four residents. The Consultant Pharmacist made recommendations regarding medication adjustments and assessments, but there were no documented responses from the physicians. This lack of response was observed for residents with complex medical histories, including mental health conditions and chronic pain, who were on multiple psychotropic and pain medications.
The facility failed to monitor medication refrigerator temperatures and remove expired medications in the Rehabilitation Unit. Observations showed a blank temperature log and expired medications, including Acetaminophen and glycerin suppositories. Staff interviews revealed a lack of knowledge about responsibilities for these tasks, and the DON confirmed that night shift staff were responsible for temperature logs, while the DON or ADON should audit for expired medications.
The facility failed to ensure that four residents with broken or missing teeth were seen by a dentist. Despite residents informing staff about their dental needs, no appointments were scheduled, and care plans did not reflect any dental issues. Staff were generally unaware of the residents' dental needs.
The facility failed to ensure that food and drink were served at safe and appetizing temperatures, as evidenced by multiple observations and resident complaints. Residents reported receiving cold food almost every day, and the Dietary Manager did not take effective measures to address the issue. Observations showed that hot foods were not maintained at the required temperature of 120 F, and cold foods were not kept at or below 41 F. Staff confirmed that food temperatures were not monitored at the point of service.
The facility's administration failed to implement a plan of correction by the designated date, resulting in continued deficient practices affecting residents' well-being. The facility did not complete 12 out of 16 required audits due to the abrupt departure of the previous administrator, leading to a lack of continuity and oversight.
The facility failed to identify and correct quality deficiencies through its QAPI plan, leading to continued deficient practices affecting residents' well-being. The facility did not complete 12 out of 16 required audits, and the Corporate Administrator revealed that many completed audits went missing when the previous administrator abruptly left the position.
The facility failed to maintain an infection prevention and control program by not providing TB testing for five sampled residents. The facility's policy required TB screening for all residents, but records showed no evidence of TB testing or screening for the sampled residents. Interviews revealed that the responsibility for administering TSTs was assigned to nurses, but the tests were not conducted or documented properly.
The facility failed to offer and document pneumococcal and influenza vaccinations for five residents, despite policies requiring these actions. Interviews revealed a lack of follow-through and oversight by the admitting nurses and administration.
The facility failed to provide and document COVID-19 vaccinations for three residents, compromising the infection prevention and control program. Interviews revealed inconsistencies in the vaccination process and lack of proper documentation, leading to this deficiency.
The facility failed to update a resident's code status from full code to DNR despite having an advance directive indicating DNR. The admitting nurse did not ensure the resident's wishes were reflected on the chart, and there was no clear process for auditing code statuses.
The facility failed to provide two residents with a written summary of a baseline care plan within 48 hours of admission. Critical information was missing, and residents were unaware of their care plans. Interviews revealed that baseline care plans were not being printed, signed, or provided to residents or their families.
The facility failed to accurately document the administration of pain medication for one resident and ensure another resident had taken their prescribed medications. Discrepancies in the records for Oxycodone administration and improper handling of medications left at a resident's bedside were observed, indicating non-compliance with the facility's policies.
The facility failed to ensure that bathing/showers were completed at least once weekly and according to the residents' preferences for two residents. One resident with colostomy status and hypertension missed multiple weeks of showers, while another with hypertension and glaucoma did not receive showers for specific weeks. Staff interviews revealed inconsistencies in the shower schedule and documentation, and the facility's shower policy lacked specific guidelines on frequency.
The facility failed to ensure physician-ordered weekly weights were completed for a resident with significant weight loss and tube feeding. Staff interviews revealed that Restorative Aides responsible for weighing residents were often reassigned to other duties, resulting in missed weight measurements.
The facility failed to maintain proper communication and documentation with the dialysis center for a resident with end-stage kidney disease, as evidenced by missing dialysis sheets and lack of documentation. The facility's policy did not address communication protocols, leading to this deficiency.
The facility failed to ensure psychotropic medications were administered for specific conditions and that PRN orders were limited to 14 days without review. One resident did not have documented physician rationale for Lorazepam, and another did not receive a gradual dose reduction for Duloxetine and Lurasidone despite pharmacist recommendations. Interviews revealed inconsistencies in following medication management policies.
The facility failed to ensure the lids of the dumpsters were closed after staff placed trash in them. This was observed on multiple occasions, and the Dietary Manager stated that all departments were expected to keep the dumpsters closed to prevent raccoons from accessing the trash.
The facility failed to maintain the siding on the outside of the former dementia unit and behind the kitchen, creating openings that pests could get into. Observations revealed damaged siding with visible insulation and gaps, which the Maintenance Director confirmed existed before his tenure.
A facility failed to provide adequate pressure ulcer care for two residents, leading to deficiencies in treatment and documentation. One resident developed an infected pressure ulcer on the coccyx, with no weekly skin assessments or proper documentation in the EMR. Another resident had unstageable pressure ulcers, but the facility did not perform weekly assessments or document the wounds. The wound nurse mistakenly believed hospice nurses were responsible for documentation, resulting in a lack of proper tracking and assessment.
Use of Facility Van with Expired Registration for Resident Transportation
Penalty
Summary
The facility failed to ensure its transportation van was properly licensed in accordance with State law while continuing to use it to transport residents to medical appointments. Review of the facility’s transportation policy showed it committed to providing safe, non-emergency transportation with a well-maintained van and appropriate liability and insurance coverage. Emails between the facility’s administrative team and the parent company documented ongoing awareness that the van’s registration had expired and that the title was needed to complete registration, with multiple communications about tracking down or obtaining duplicate titles and identifying facilities with expired registrations. Observation of the van showed a license plate sticker indicating expiration in 2025, and review of the transportation log showed multiple instances over several days in which residents were transported to physician appointments using the facility van, while some residents were transported by outside transportation companies. During interviews, the van driver stated that the van was used several times a week to transport residents, confirmed the license had expired the previous year, and reported being told the facility would pay any ticket if the van was pulled over, adding that other transportation services were available and that they would not drive their personal vehicle with expired tags. An LPN similarly reported that the van’s license had expired the previous year, that administration was aware, that the van was used a couple of times a week for resident appointments, and that administration was responsible for keeping the license current and probably should not have been driving it with expired tags. The Administrator acknowledged that the van’s license had expired the previous year after the new company purchased the facility, that the parent company was having difficulty obtaining the title from the previous owner and had referred the matter to its legal department, and that the van continued to be used several times a week for resident transportation despite the expired license, even though other transportation companies were available.
Failure to Provide Written Notice and Obtain Agreement for Resident Room Change
Penalty
Summary
The facility failed to honor a resident’s right to be informed and to exercise self-determination regarding a room change. A resident with unspecified dementia of unspecified severity without behavioral disturbance and an anxiety diagnosis was admitted as his/her own responsible party, with no guardian or DPOA documented. The resident’s care plan noted dementia and documented that on 1/6/26 a room move was discussed and the resident agreed, and that on 1/7/26 staff were assisting with the move when the resident became upset and stated a desire to leave the facility. A quarterly MDS dated 1/8/26 showed the resident had severely impaired cognition and no wandering behavior. During a later interview, the resident reported not agreeing to the room move, becoming very upset and tearful, not understanding why he/she had been moved to a locked unit, and feeling trapped there, and was unable to state whether written notice of the room change had been received. Record review of the EMR showed the resident had no guardian or DPOA, was his/her own responsible party, and there was no signed agreement uploaded related to the room move. Multiple staff interviews (two CNAs and an agency LPN) confirmed that all residents were supposed to receive written notice of room moves and that all parties needed to agree before a room change, but they were unsure whether this resident had received written notice; the agency LPN reported the resident was upset and refused to move while being escorted down the hall. The DON confirmed the resident had not been notified in writing about the room move, was unsure why written notification had not been provided, and stated unawareness of the regulation, while acknowledging the resident should have been notified in writing. The facility’s own Resident Rights policy stated that information about resident rights and responsibilities would be given orally and in writing, but there was no documentation that written notice of the room change had been provided to this resident.
Failure to Follow and Document Physician Orders for UA and CT Imaging
Penalty
Summary
The deficiency involves the facility’s failure to ensure physician orders were followed and appropriately documented for two residents. One resident with urinary retention, neuromuscular bladder dysfunction, severely impaired cognition, and an indwelling catheter had physician orders for urinalyses in December 2025, with the electronic order status showing both tests as completed. However, review of the electronic medical record revealed no nursing notes related to collection of the ordered urine specimens and no laboratory results for any urinalysis in December. The resident’s care plan included monitoring and reporting signs and symptoms of UTI and noted that the resident had a fixation with the genital area and sometimes refused catheter care, but there was still no documentation that staff attempted to obtain the ordered UAs, that the resident refused, or that collection was otherwise unsuccessful. For the second resident, who had diagnoses including enterocolitis due to C. difficile and morbid obesity, an unwitnessed fall occurred while the resident was attempting to stand from a commode. An X-ray was ordered but could not be obtained due to the resident’s abdominal size, and the physician then ordered a CT scan of the back and right side. The facility’s order summary showed the CT scan order, and staff interviews indicated that the order was to be faxed to a local hospital. The resident later reported being unaware that a CT scan had been ordered and not being given a scheduled date for the procedure. A hospital scheduling manager reported not seeing a CT order for the resident until several days after the order date and stated that the CT had not been scheduled because the facility sent an invalid order that required correction before scheduling. The administrator, CNAs, LPNs, and the DON all stated that physician orders were expected to be followed as written and that failed attempts to collect UAs or send out imaging orders should be documented in the EMR, MAR, or TAR, including confirmation of fax receipt when applicable. The DON confirmed there was no documentation that the UAs for the first resident could not be collected and no documentation confirming that the CT order for the second resident had been sent or received before the date identified by the hospital scheduler.
Failure to Provide Behavioral Health Services and Medication Management
Penalty
Summary
The facility failed to provide appropriate treatment and behavioral health services to multiple residents with known mental health diagnoses and behavioral health histories. For three sampled residents, the facility did not implement required Preadmission Screening and Resident Review (PASRR) processes, failed to create or update care plans with necessary interventions for behaviors, and did not ensure the administration of prescribed psychotropic medications. One resident with a complex psychiatric history, including paranoid schizophrenia, anxiety disorder, and substance dependence, was admitted without the facility having the PASRR on file, and staff did not administer the resident's psychotropic medications as ordered. This resident exhibited escalating aggressive behaviors, including physical aggression toward staff and other residents, verbal outbursts, and attempts to elope, with no documented incident reports, care plan updates, or behavioral interventions during these episodes. Staff interviews revealed a lack of training and competency in managing behavioral health needs. Multiple staff members, including LPNs, CNAs, and housekeepers, reported not receiving education or in-service training on de-escalation techniques, behavioral health, or abuse and neglect prevention. Staff expressed feeling unprepared and unsafe when caring for residents with aggressive behaviors, and several reported that their concerns and requests for guidance from facility leadership were ignored. Documentation showed that staff were instructed not to document certain behavioral incidents, and there was a lack of behavior monitoring, incident reporting, and psychiatric follow-up for residents exhibiting significant behavioral symptoms. Other residents and staff reported feeling unsafe due to the aggressive behaviors of affected residents, with some residents stating they were traumatized or unable to sleep due to fear. Law enforcement was called multiple times to manage out-of-control behaviors, and police officers expressed concern about the facility's ability to manage residents with behavioral health needs. The facility's failure to provide required behavioral health services, medication management, and staff training resulted in an environment where both residents and staff were at risk, and appropriate care and oversight were not provided for residents with serious mental illness and behavioral challenges.
Failure to Administer Critical Medications and Provide Wound Care
Penalty
Summary
The facility failed to meet the medical needs of two residents, resulting in significant deficiencies. One resident was admitted with end stage renal disease and a recent kidney transplant, requiring strict adherence to a complex medication regimen including multiple immunosuppressants and specific wound care for a surgical site. Upon admission, the facility did not document a review of the medication list with the facility physician, failed to ensure the availability and administration of critical anti-rejection medications, and did not provide the ordered wound care for two and a half days. Staff documented that medications were not given because they were waiting for pharmacy delivery, despite the medications being sent with the resident from the hospital. There was also a lack of documentation and communication regarding the resident's transplant status, infection control needs, and high-risk medication protocols in the care plan. The facility's staff, including the DON, LPNs, and CMTs, demonstrated a lack of knowledge and training regarding the care of post-transplant residents and the importance of timely administration of high-risk medications. Interviews revealed that staff were unaware of the significance of missed doses, did not know who was responsible for ensuring medication availability, and failed to notify the resident's physician or transplant team about missed medications and wound care. The wound care nurse and other staff expressed discomfort and lack of experience with the required wound care, leading to further delays. Attempts by the resident's transplant team to communicate with facility staff were unsuccessful, and the transplant team was not informed of the missed medications or wound care lapses. As a result of these failures, the resident was admitted to the hospital with undetectable levels of anti-rejection medication, sepsis, and a necrotic surgical wound, requiring IV antibiotics and multiple surgeries. In a separate incident, another resident did not have their psychotropic medications reconciled or administered, leading to behavioral outbursts and eventual hospitalization for psychiatric care. The facility's policies for medication administration, wound care, and special needs management were not followed, and there was a breakdown in communication and documentation at multiple levels of staff responsibility.
Failure to Administer Critical Antirejection Medications Post-Transplant
Penalty
Summary
A significant medication error occurred when a resident, recently admitted following a kidney transplant, did not receive critical antirejection and immunosuppressive medications as ordered. The resident was discharged from the hospital with a supply of essential medications, including Tacrolimus, Myfortic, Prednisone, Valganciclovir, and Bactrim, and had a therapeutic level of antirejection medication at the time of discharge. Upon admission, the facility failed to document the presence of these medications, and the care plan did not address the need for post-transplant antirejection therapy. Facility staff did not administer the ordered medications on multiple occasions, citing that they were waiting for the pharmacy to deliver them. Medication Administration Records (MAR) and medication card observations confirmed that several doses were missed, and staff documented the absence of medication as the reason. Interviews with staff, including the DON, CMT, and LPNs, revealed a lack of knowledge regarding the process for reconciling and ordering medications upon admission, as well as uncertainty about who was responsible for ensuring timely medication availability. Staff also reported that the DON was informed about the missing medications, but no action was taken to resolve the issue or notify the attending physician. The resident was subsequently readmitted to the hospital with sepsis and a near-undetectable level of antirejection medication, as confirmed by laboratory results and the transplant team. Hospital and transplant staff confirmed that the resident had received all necessary medications prior to discharge and that missing even a single dose could result in serious harm. The facility's failure to ensure the resident received prescribed antirejection medications led to a significant medication error and placed the resident at risk for organ rejection and severe illness.
Failure to Prevent Resident-to-Resident Abuse Resulting in Physical and Emotional Harm
Penalty
Summary
The facility failed to protect two residents from physical and verbal abuse by another resident, resulting in both physical harm and emotional distress. One resident with a history of paranoid schizophrenia, anxiety disorder, delusional disorder, and personality disorder engaged in aggressive behaviors, including attempting to punch another resident and making verbal threats. This included threatening to slit the throat of another resident, which led to that resident leaving the facility out of fear, embarrassment, and humiliation. The affected resident reported feeling unsafe, which disrupted their rehabilitation and stroke recovery. Another incident involved the same aggressive resident physically assaulting a cognitively impaired, nonverbal resident with a history of stroke, hemiplegia, apraxia, dysarthria, aphasia, and major depressive disorder. The aggressive resident was observed pushing the nonverbal resident in a wheelchair at high speed, then striking the resident multiple times on the head and shoulders. Witnesses reported that the nonverbal resident was visibly scared, in pain, and left with a scalp bruise and red marks, requiring hospital evaluation. Multiple staff and a housekeeper witnessed the incident, and the nonverbal resident's responsible party confirmed the emotional and physical impact of the assault. The facility's policy required the prevention of all forms of abuse, including resident-to-resident altercations, and mandated staff intervention and protection of residents from harm. Despite these policies, the facility did not prevent or adequately intervene in the repeated aggressive behaviors of the resident with a history of mental health disorders, resulting in physical and psychological harm to two vulnerable residents. Staff interviews and resident accounts confirmed that the incidents were reported to administration, but the affected residents and others in the facility expressed fear and distress due to the ongoing threat posed by the aggressive resident.
Failure to Ensure Staff Competency in Behavioral Health Management
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to meet the behavioral health needs of residents, particularly those with complex psychiatric and behavioral conditions. Multiple staff members, including LPNs, CNAs, housekeepers, and medication technicians, reported not receiving training on behavioral management, de-escalation techniques, or abuse and neglect prevention. Staff expressed fear and a lack of confidence in their ability to safely care for residents exhibiting aggressive, violent, or self-harming behaviors. Interviews revealed that staff were not provided with guidance or interventions to manage residents with significant behavioral health needs, and some staff were assigned to one-on-one supervision without any relevant training or instructions. Several residents with serious mental illnesses, including schizophrenia, schizoaffective disorder, borderline personality disorder, and a history of substance abuse, exhibited frequent and severe behavioral disturbances. These included physical aggression toward staff and other residents, verbal outbursts, attempts to elope, destruction of property, and expressions of suicidal ideation. Documentation showed that these behaviors were ongoing and that staff and other residents felt unsafe. Despite these incidents, there was a lack of incident reporting, care plan updates, behavior monitoring, and documentation of nonpharmacological or pharmacological interventions in the residents' records. The facility's policies required annual in-service training for nurse aides, including behavioral health, and mandated that training be based on the special needs of the resident population. However, the report found that these policies were not implemented effectively, as evidenced by the lack of staff education and competency in managing behavioral health issues. The facility assessment identified a significant number of residents with behavioral health needs, but staff competencies did not align with these requirements. The absence of appropriate training and support led to repeated incidents where staff were unable to manage resident behaviors, resulting in harm to staff and residents, involvement of law enforcement, and ongoing distress within the facility.
Resident Dignity Violated by LPN's Derogatory Remark
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to respect a resident's dignity by calling the resident "dumb" during an interaction. The incident began when the resident requested a pain pill and subsequently became upset, raising their voice at a Certified Nurse Aide (CNA). The LPN and CNA assisted the resident with a Hoyer lift, during which the resident expressed that the nurse did not care about them. The LPN attempted to reassure the resident but ultimately responded to the resident's question about being dumb by saying, "are you dumb, no you are not," though the resident did not understand the response. Multiple witness statements confirmed that the LPN used the word "dumb" in reference to the resident, and the resident reported feeling hurt and upset by the comment, stating that being called dumb was particularly painful due to past experiences. Further witness accounts indicated that the LPN engaged in an argument with the resident, accusing the resident of making negative reports to management. The LPN was reported to have raised their voice, told the resident not to ask for anything further, and made additional derogatory remarks. The resident was visibly upset, expressed a desire to change rooms to avoid the LPN, and reported the incident to the facility's administration. Staff who interacted with the resident after the incident observed that the resident was crying, angry, and emotionally distressed, which was noted to be out of character for the resident. The facility's policy on resident rights, which mandates that all residents be treated with dignity and respect, was not followed in this instance. The Interim Director of Nursing acknowledged that calling a resident dumb would be a violation of the resident's dignity. The incident was reported and investigated, with staff and administrative interviews confirming the resident's account and the inappropriate conduct of the LPN.
Failure to Maintain Full-Time DON and Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, and did not have a Director of Nursing (DON) on a full-time basis for a period of time. Review of facility policies and the facility assessment confirmed that the expectation was to have a full-time DON, who is a RN, and to employ RNs for at least eight hours daily, every day of the week. Interviews with the Administrator, DON, LPNs, Social Services Director, Assistant Director of Nursing (ADON), and Administrator in Training (AIT) consistently revealed that the facility was without a full-time DON from the termination of the previous DON until the hiring of the new DON, and that RN coverage for the required hours was not consistently provided. The ADON, who is an LPN, filled in for some DON duties during this period, but was not a RN. Employee records confirmed the gap in DON coverage, with the previous DON terminated and the new DON starting nearly a month later. Staff interviews indicated that during this period, RN coverage was supplemented only occasionally by agency staff, and there were times when no RN was present in the facility for the required hours. Staff would sometimes call the previous DON or a PRN DON for guidance when needed, but this did not meet the requirement for on-site RN coverage or a full-time DON.
Failure to Follow Proper Discharge Procedures and Notification Requirements
Penalty
Summary
The facility failed to follow the required process for discharging a resident, specifically neglecting to reassess the resident and properly identify and document how the facility could not meet the resident's needs. The resident in question had a history of morbid obesity, localized edema, depression, anxiety, reduced mobility, and was bedbound. The resident required significant assistance with activities of daily living and had recently experienced a decline in condition, resulting in hospitalization. Despite these complex needs, the facility did not provide the necessary documentation or notification regarding the resident's needs, appeal rights, or bed-hold policies at the time of discharge. Upon the resident's transfer to the hospital, the facility failed to send appropriate discharge paperwork and did not issue a proper 30-day notice of discharge. The hospital attempted to return the resident to the facility, but the facility refused to readmit the resident, citing inability to meet the resident's care needs due to increased weight and lack of appropriate equipment and staffing. Communication between the hospital and the facility was inadequate, with the facility not responding to multiple attempts by the hospital to coordinate the resident's return. Interviews with facility staff confirmed that the decision not to readmit the resident was based on the facility's inability to care for the resident's increased weight and complexity of care. Staff acknowledged that a 30-day notice and appropriate placement should have been arranged prior to discharge, but these steps were not taken. The facility also did not reassess the resident for possible readmission after the hospital transfer, and no evidence was provided that the resident received required notifications regarding appeal rights or bed-hold policies.
Failure to Document and Notify Physician of Missed Medications and Incomplete Blood Pressure Monitoring
Penalty
Summary
The facility failed to ensure that physician notification was completed and documented regarding missed medications for two out of four sampled residents, and did not ensure blood pressure monitoring was completed for a resident with a physician's order to administer medication based on blood pressure readings. Facility policy required that medications be administered according to physician orders, and that any withheld, refused, or late medications be properly documented on the Medication Administration Record (MAR), with notification to the physician and documentation in the progress notes. For one resident with diagnoses including hypothyroidism and hypertensive heart disease, there were multiple instances where levothyroxine was not documented as given, and no blood pressure readings or administration of midodrine (ordered as needed for hypotension) were recorded over the review period. There was no documentation in the progress notes regarding the reasons for missed doses or any notification to the physician about these missed medications. The resident reported that nurses often did not give all prescribed medications and did not take blood pressure readings as required for medication administration. Another resident with epilepsy, schizoaffective disorder, and violent behaviors had several missed doses of antipsychotic medications (quetiapine and Zyprexa) that were not documented as given on the MAR. Interviews with staff confirmed that the expected procedure was to notify the pharmacy, DON, and physician when medications were not available or not administered, and to document these actions in the progress notes. However, there was no evidence that these procedures were followed, and the facility lacked a system for routine review of MARs for missed medications.
Failure to Verify and Document G-Tube Placement Prior to Use
Penalty
Summary
The facility failed to ensure and document the correct measurement and verification of gastrostomy tube (G-tube/PEG tube) placement prior to administering fluids, medications, and feedings for two residents. Observations showed that an LPN administered water flushes and medications through the G-tubes of both residents without first checking the tube's placement or measuring the external length, as recommended by current clinical guidelines. The LPN did not inspect the tube or verify its position before proceeding with care. Review of the residents' medical records revealed physician orders and medication administration records specifying the use of G-tubes for enteral feeding and medication administration. However, there was no documentation that tube placement was checked or verified prior to these procedures. The LPN admitted during an interview that placement was not checked and stated that the outdated method of injecting air and auscultating was the only method known, and was unaware of the current standard of measuring tube length at the entry point. Further interviews with facility leadership, including the Assistant Administrator and Assistant Director of Nursing, confirmed a lack of knowledge regarding the correct method for verifying G-tube placement. They acknowledged that placement should be checked before use but were unfamiliar with the recommended practice of measuring and documenting the tube's external length. Additionally, the facility was unable to provide a policy for administration of medication via G-tube when requested.
Facility Fails to Maintain Cleanliness and Proper Food Storage Standards
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage standards in the kitchen and food preparation areas. Observations revealed a heavy buildup of debris, including cups, paper, dust, and food debris behind and under the ice machine. Additionally, there was a heavy buildup of dust on the fan over the door across from the coffee station. Two bottles of soy sauce that required refrigeration after opening were found stored on a lower shelf instead of being refrigerated. A bowl of an unidentified yellow substance was found in the kitchen reach-in refrigerator without proper wrapping. Three cutting boards were observed with numerous stains and grooves, making them not easily cleanable, and three spatulas were found frayed or split open. Black debris was present on the pipes behind the dishwasher, and debris was found under the six-burner stove. Containers with brown and clear liquids were not labeled, and the blower vent cover over the door across from the coffee maker station had a heavy buildup of dust. The sprinkler heads were also found with grease buildup. Interviews with the Dietary Manager (DM) and Dietary Cook (DC) revealed that the DM had taken over management of the kitchen recently and was unaware of the condition of the pipes behind the dishwasher. The DM acknowledged that dietary staff should inspect the cutting boards and that an in-service regarding the cutting boards had not been conducted. The DM also stated that dietary staff were expected to clean behind and under the ice machine every night, clean the blower vent cover weekly, use labels for substances that were not easily identified, and follow the labels on condiment containers. The DM expected the night shift staff to clean and mop before leaving for the evening and to cover and protect food in the refrigerator. The spatulas should have been replaced when they started getting frayed. The DC admitted to placing syrup in a bottle without labeling it.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to provide the required nurse aide in-services that included dementia care and abuse prevention training for three sampled CNAs (CNA B, H, and J) from April 2023 through April 2024. The facility's policy mandated that all nurse aides participate in regularly scheduled in-service training classes, including at least 12 hours of training per year, covering topics such as dementia management and abuse prevention. However, the review of the facility's in-service training attendance records revealed that several training sessions were either not attended by the CNAs or no training records were provided for certain months. Specifically, CNA B, H, and J missed multiple training sessions, and there were no records for several months, indicating a lack of consistent training offerings by the facility. Interviews with facility staff, including the Incoming Administrator, Certified Medication Technician B, CNA D, CNA E, the Staffing Coordinator, and the DON, confirmed the inconsistencies in training. The Incoming Administrator acknowledged that the sign-in sheets provided were incomplete and that if staff did not sign in, it was assumed they did not receive the training. CNA D and CNA E reported not attending any in-service training since their employment at the facility, with CNA E specifically noting the absence of abuse, neglect, exploitation, or dementia training. The DON admitted that in-services had not been consistently offered in the past year and that the documentation of training hours was lacking. The facility's failure to provide the required in-service training for dementia care and abuse prevention for the sampled CNAs highlights a significant deficiency in ensuring that nurse aides have the necessary skills to care for residents. The lack of consistent training offerings and incomplete documentation of training attendance contributed to this deficiency, as confirmed by multiple staff interviews and the review of training records.
Failure to Manage Resident Funds Properly
Penalty
Summary
The facility failed to ensure residents who allowed the facility to manage their funds received interest payments and did not have signed authorization forms for three residents. Review of bank statements from April 2023 through March 2024 showed no interest payments. The Corporate Director of Fiscal Services confirmed the absence of interest and was unaware of any changes to the account. Additionally, there were no authorization forms found for three residents, all of whom had legal guardians. The Business Office Manager, who started in January 2023, stated that authorization forms were typically placed behind guardianship paperwork but could not locate them for these residents.
Facility Fails to Maintain Water Temperature, Cleanliness, and Equipment
Penalty
Summary
The facility failed to maintain the water temperature at the handwashing faucets in resident rooms 517, 520, and 523 at or above 105°F. Observations showed water temperatures ranging from 84.5°F to 103.1°F, which were below the required standard. The Maintenance Director admitted to not allowing the water to run for at least two minutes during temperature testing, which contributed to inaccurate readings. This deficiency potentially affected at least 30 residents who resided in those areas or used those facilities. Additionally, the facility failed to maintain the cleanliness of sprinkler heads in the therapy area, Main Dining Room, and side Dining Room, as well as the nurse's station, where dust was observed. The facility also failed to maintain two stand-up lifts, which had cracks in their bases. Staff members, including CNAs and the Maintenance Director, acknowledged the presence of these issues but did not take immediate corrective actions. The Director of Nursing indicated that staff were expected to report and create work orders for damaged equipment, but this protocol was not consistently followed, leading to the continued use of the damaged lifts.
Failure to Notify Ombudsman of Resident Transfers/Discharges
Penalty
Summary
The facility failed to notify the ombudsman of resident discharges/transfers for three residents out of 17 sampled residents. The facility's policy on transfer and discharge did not include the requirement to notify the ombudsman. Specifically, Resident #48 was sent to the hospital due to seizures and returned to the facility, but the ombudsman was not notified. Similarly, Resident #23 and Resident #268 were discharged to the hospital with their return anticipated, but the ombudsman was not informed of these transfers either. An email from the ombudsman indicated that they had not received transfer/discharge logs from the facility since September 2023. During an interview, the Social Services Designee (SSD) revealed that they had been working in the role for about six months and had been emailing the list of resident discharges to an incorrect email address. The outgoing Administrator confirmed that the SSD was responsible for sending the list of discharges/transfers to the ombudsman and that the SSD had been using an incorrect email address. This miscommunication resulted in the ombudsman not being notified of the resident transfers/discharges as required.
Failure to Include Required Therapies in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan reflected the need for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST). The resident, diagnosed with Cerebral Palsy, was admitted with orders for PT, OT, and ST evaluations and treatments. However, the care plan only included risks related to falls and the need for assistance due to Cerebral Palsy, without any mention of the required therapies. This omission was identified during a review of the resident's care plans and physician orders, which showed that the therapies had been initiated but not documented in the care plan. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed that the MDS Coordinator was responsible for writing and updating care plans. The MDS Coordinator admitted that some care plans were not completed or up to date due to a change in the facility's computer systems. The DON confirmed that the MDS Coordinator and department heads were responsible for updating their respective portions of the care plans. This lapse in documentation led to the deficiency noted in the report.
Failure to Update Care Plans and Invite Residents to Meetings
Penalty
Summary
The facility failed to update care plans for five residents with changes in their conditions and needs. Resident #65, who was moderately cognitively impaired, was admitted to hospice care, but the care plan was not updated to reflect this change. Resident #41's care plan indicated the need for IV antibiotics for a wound infection, but the resident was not receiving these antibiotics as observed over several days. Additionally, Resident #37, who was cognitively intact, was not invited to their care plan meeting, and there was no documentation to show that the resident or their family had been invited to any care plan meetings. Resident #13's care plan was last updated several months after admission, with all care plan goals overdue and no indication of whether goals had been achieved or new goals established. Similarly, Resident #19's care plan, which included psychoactive medication for anxiety and agitation, had overdue goals and no updates on goal achievement or new objectives. Resident #52's care plan, which included management for COPD, tracheostomy, hypertension, anxiety, and depression, also showed overdue goals with no updates or new objectives. Interviews with the MDS Coordinator and the DON revealed that care plans should be completed upon admission, quarterly, with any significant change, and annually. However, due to a change in computer systems, some care plans were not done or up to date. The MDS Coordinator and DON acknowledged that care plans were overdue and that there was no documentation of resident or family invitations to care plan meetings. The DON also noted that anyone on the Interdisciplinary Team could update care plans, but this was not consistently done.
Unqualified Activity Director
Penalty
Summary
The facility failed to have an activity program directed by a qualified Activity Director. The current Activity Director, who also handles Human Resources and Medical Records, did not meet the qualifications outlined in the facility's job description. The job description required a high school diploma or GED, two years of experience in a social or recreational program within the last five years, or completion of a state-approved training course. However, the Activity Director only had a high school diploma, was a Certified Nursing Assistant (CNA) and a Certified Medication Technician (CMT), and had been working part-time in activities for about a year without any formal training in activities or completion of the Activity Director class. The outgoing Administrator confirmed that the individual did not meet all the necessary requirements for the position. During interviews, the Activity Director admitted to not having any training in activities and not having taken the Activity Director class. The outgoing Administrator also acknowledged that while there was an Activities Director certificate available, the current Activity Director had not completed it. This lack of proper qualifications and training for the Activity Director role led to the deficiency identified by the surveyors.
Failure to Provide Ordered Restorative Aide Services
Penalty
Summary
The facility failed to ensure that Restorative Aide (RA) services were provided as ordered to prevent further decline of Range of Motion (ROM) for three residents. Resident #2, diagnosed with Cerebral Palsy, was supposed to receive RA services three times a week, but records showed that the resident only received services twice a week. The Director of Nursing (DON) and other staff members were unsure if the resident was receiving the required RA services, and the RA admitted to being frequently pulled to work as a Certified Nursing Assistant (CNA), which impacted the delivery of RA services. Resident #61, who had Hemiplegia and Hemiparesis following a stroke, was supposed to receive RA services five times a week for upper extremity exercises and splint management. However, there was no documentation of RA services being provided in March, and only four instances of RA services in April. Observations showed that the resident's hand braces were not applied as required, and staff interviews confirmed that the RA was often pulled to work as a CNA, leading to a lack of consistent RA services. Resident #37, with diagnoses including difficulty in walking and osteoarthritis of the knee, was supposed to receive RA services two to three times a week for upper extremity exercises. Documentation showed that the resident received minimal RA services, with several missed opportunities and instances of refusal without follow-up attempts. Interviews with staff and the resident indicated that the RA was frequently pulled to work as a CNA, resulting in inconsistent delivery of RA services. The DON acknowledged that the RA should have documented and performed the required services, but the RA was often reassigned to CNA duties.
Failure to Maintain and Sanitize Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper respiratory care for several residents, specifically in the maintenance and sanitation of oxygen tubing and nebulizer equipment. Resident #33, who has COPD, was observed with a nebulizer mouthpiece that was not stored in a bag and had a brown tinge around it. The resident was unaware if the staff ever washed the mouthpiece. Resident #268, who has CHF and COPD, had undated oxygen tubing and CPAP machine tubing that was not stored in a bag. The resident had not used the CPAP machine for a couple of weeks due to the absence of a mask and was unsure when the oxygen tubing was last changed. Resident #267, who also has COPD, had a nebulizer mask that was not stored in a bag or dated, and the resident had not seen the staff clean the mask since starting to use the nebulizer a few days ago. Resident #17, who has COPD and is on oxygen therapy, had oxygen tubing that was not stored in a bag or dated, and the resident declined to talk about it. Interviews with staff revealed inconsistencies and misunderstandings regarding the responsibilities for changing and cleaning respiratory equipment. LPN A stated that night CNAs were responsible for changing oxygen tubing weekly and that all oxygen equipment should be stored in a clean bag with the date written on it. CNA F mentioned that CNAs changed the oxygen tubing every few weeks and that nurses were responsible for cleaning nebulizer and CPAP masks. The Director of Nursing indicated that oxygen tubing should be changed weekly and stored in a clean bag with the date, and that nurses were responsible for cleaning CPAP and nebulizer masks after each use. The facility's failure to adhere to proper protocols for changing and cleaning respiratory equipment led to unsanitary conditions and potential risks for residents with respiratory conditions. The lack of a clear and consistent policy, as well as the absence of proper documentation and storage practices, contributed to the deficiencies observed during the survey.
Failure to Ensure RN Coverage 8 Hours Daily
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was providing services for at least eight consecutive hours a day, seven days a week. The facility had a census of 67 residents. The RN Coverage policy was requested but not provided at the time of exit. The facility's Staffing policy, dated April 2007, indicated that licensed RN staff were available to provide and monitor the delivery of resident care services. However, the Center for Medicare and Medicaid Services (CMS) Staffing Reports from April 1 to December 31, 2023, showed the facility triggered for a One Star Staffing Rating and excessively low weekend staffing. The facility's current employee list showed three RNs employed, including the Director of Nursing (DON), a Regional Director of Nursing PRN, and another RN. The staffing schedule from April 1 to April 14, 2024, revealed that on April 4, 2024, the DON was out of the facility, and no other RN was on the staffing schedule for that day. Interviews conducted on April 19 and April 22, 2024, confirmed the lack of RN coverage. The Staffing Coordinator stated that there was no RN in the building on April 4, 2024. The DON admitted that while there was always RN coverage from Monday to Friday, there was generally no RN at the facility on weekends, and he/she was on-call every other weekend. The DON acknowledged that there should be an RN in the building for at least eight hours a day, every day of the week, but this requirement was not consistently met.
Failure to Respond to Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that the Medication Regimen Review (MRR) was responded to for four sampled residents out of 17 sampled residents. The Consultant Pharmacist made recommendations regarding medication adjustments and assessments, but there were no documented responses from the physicians in the residents' electronic health records. This lack of response was observed for residents with complex medical histories, including mental health conditions and chronic pain, who were on multiple psychotropic and pain medications. For Resident #42, the Consultant Pharmacist recommended a gradual dose reduction (GDR) of psychotropic medications and the completion of the Abnormal Involuntary Movement Scale (AIMS) assessment. However, there was no response to these recommendations in the resident's electronic health record. Similarly, Resident #19 had no AIMS reports available despite the pharmacist's recommendation to update the AIMS assessment every six months due to antipsychotic use. Resident #24's MRRs showed repeated recommendations for dose reduction or discontinuation of certain medications, but there were no responses from the physician. Resident #41 had a potential duplicate order for pain medications, and again, there was no response from the physician. Interviews with facility staff revealed a lack of clarity and follow-through in the process of handling MRRs, with the Director of Nursing (DON) acknowledging that physicians should respond to all recommendations but failing to ensure this was consistently done.
Failure to Monitor Medication Refrigerator Temperatures and Remove Expired Medications
Penalty
Summary
The facility failed to monitor the medication refrigerator temperatures and remove expired medications in the Rehabilitation Unit. Observations revealed that the temperature log for the medication refrigerator was blank from January through April 18, 2024. Additionally, expired medications, including Acetaminophen suppositories with an expiration date of January 2023 and glycerin suppositories with an expiration date of March 7, 2024, were found in the refrigerator without open dates recorded. Interviews with staff members, including LPNs and CMTs, indicated a lack of knowledge regarding who was responsible for filling out the temperature log and checking for expired medications. The Director of Nursing (DON) confirmed that the night shift nursing staff was responsible for monitoring and recording the medication refrigerator temperatures daily. The DON or the Assistant DON (ADON) were supposed to audit the temperature logs to ensure compliance. The DON also stated that either he/she, the ADON, or a designee was responsible for auditing expired medications in the medication refrigerator and medication carts. However, the observations and staff interviews indicated that these procedures were not being followed, leading to the presence of expired medications and unmonitored refrigerator temperatures.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to ensure that four residents with broken or missing teeth were seen by a dentist. Resident #37 had broken dentures and had not seen a dentist since being admitted to the facility. Despite informing the nurse about the need for dental care, no action was taken. The resident's care plan and physician's visit records did not reflect any dental issues, and staff were unaware of the resident's need for denture repair. Resident #53 had broken teeth and had signed an authorization for dental care, but had not seen a dentist in over a year and a half. The resident expressed a desire to have all teeth pulled and dentures made, but no dental appointment was scheduled. The care plan and physician's orders did not indicate any dental issues, and staff were unaware of the resident's dental needs. Resident #267 had no top teeth and some bottom teeth, but had not seen a dentist in the 11 months of being at the facility. The resident had informed the nurse about the need for dental care, but no action was taken. Similarly, Resident #32 had broken or missing teeth and had not seen a dentist since admission. The resident had requested dental care, but no appointment was scheduled. The care plans for these residents did not address their dental issues, and staff were unaware of the need for dental appointments.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at safe and appetizing temperatures, as evidenced by multiple observations and resident complaints. Two residents, who were cognitively intact, reported receiving cold food almost every day and raised the issue during resident council meetings. The Dietary Manager (DM) acknowledged the problem but did not take effective measures to address it. Observations during meal service showed that hot foods were not maintained at the required temperature of 120 F, and cold foods were not kept at or below 41 F. For instance, a burger sandwich and tater tots were served at temperatures significantly below the required levels, and pineapple chunks were served at 59.5 F, which is 18 degrees above the acceptable limit. The DM admitted to not monitoring food temperatures at the point of service and was unaware of the required temperature standards for serving food to residents. Further observations and interviews revealed that the issue was particularly prevalent among residents receiving room trays. Staff members, including Certified Medication Technicians (CMTs) and Certified Nursing Assistants (CNAs), confirmed that they had not seen anyone from the dietary department checking the temperatures of room trays. The DM also confirmed that the dietary staff only took temperatures at the first serving of food and not at the last serving. This lack of monitoring and adherence to temperature standards led to residents consistently receiving cold meals, which was a significant concern raised during resident council meetings and individual interviews.
Failure to Implement Plan of Correction
Penalty
Summary
The facility's administration failed to implement a plan of correction (POC) by the designated date, resulting in continued deficient practices that potentially affected the residents' physical, mental, and psychosocial well-being. The facility had a census of 64 residents at the time of the survey. The Administrator policy, dated April 2007, outlined that a licensed Administrator was responsible for the day-to-day functions of the facility, serving as a liaison to the governing board, medical staff, and other professional and supervisory staff, and for the evaluation and implementation of recommendations from the facility's Quality Assessment and Assurance Committee. However, the facility failed to complete 12 out of 16 required audits, including those for Ombudsman notifications, Medication Administration Records (MAR)/Treatment Administration Records (TAR), resident baths/showers, the Restorative Program, resident weights, oxygen, dialysis, psychotic medications, expired medications, dental appointments, food temperatures, and resident vaccines. During an interview, the Corporate Administrator revealed that many of the completed audits went missing when the previous administrator abruptly left the position about two weeks prior. The previous administrator had sent an email and left the next day, leading to a lack of continuity and knowledge about the audit process. As a result, the audits were not conducted in the last two weeks, contributing to the facility's failure to implement the POC by the correction date. This lapse in administrative oversight and audit completion directly led to the continued deficient practices within the facility.
Failure to Complete and Monitor QAPI Audits
Penalty
Summary
The facility failed to identify and correct quality deficiencies through its Quality Assurance and Performance Improvement (QAPI) plan, leading to continued deficient practices that potentially affected the residents' physical, mental, and psychosocial well-being. The facility's QAPI program was designed to establish data-driven processes to improve the quality of care and life for residents, but it was not effectively implemented. Specifically, the facility did not complete 12 out of 16 required audits, including those for ombudsman notifications, medication administration records, resident baths/showers, restorative programs, resident weights, oxygen, dialysis, psychotic medications, expired medications, dental appointments, food temperatures, and resident vaccines. During an interview, the Corporate Administrator revealed that many completed audits went missing when the previous administrator abruptly left the position about two weeks prior. The previous administrator's sudden departure left the facility without knowledge of the audit process, resulting in the audits not being conducted in the last two weeks. This failure to complete and monitor the audits as part of the QAPI process contributed to the ongoing deficient practices within the facility, affecting the overall quality of care provided to the residents.
Failure to Conduct TB Testing for Residents
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not providing Tuberculosis (TB) testing for five sampled residents. The facility's policy required TB screening for all residents, including a two-step TB skin test (TST) upon admission if no prior documentation existed. However, the records for Residents #33, #48, #60, #61, and #173 showed no evidence of TB testing or screening as per the facility's policy. Interviews with the outgoing administrator, Licensed Practical Nurses (LPNs), and the Director of Nursing (DON) revealed that the responsibility for administering TSTs was assigned to nurses, but the tests were not conducted or documented properly. Resident #33 had a documented first and second step TST in late 2019 and early 2020, but no further TB screenings were provided after January 2021. Resident #48 had an order for an annual Purified Protein Derivative (PPD) test, but no PPD was given as per the March 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR). Resident #60's hospital discharge paperwork indicated no current TB symptoms or contact, but there were no physician orders or records for a TST or screening. Resident #61 and Resident #173 also lacked physician orders and records for TB testing or screening. The outgoing administrator admitted to being unaware that TSTs were not being done, and the DON confirmed that no one tracked when the TSTs were given or read. The facility's failure to follow its own TB screening policy and ensure proper documentation led to the deficiency in maintaining an effective infection prevention and control program. The lack of TB testing and screening for the sampled residents indicated a significant lapse in the facility's adherence to its infection control protocols.
Failure to Offer and Document Vaccinations
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not offering pneumococcal and influenza vaccines to five sampled residents. The facility's policies required that all residents be offered these vaccines unless medically contraindicated or previously vaccinated, and that documentation of the offer, acceptance, or refusal be maintained in the resident's medical record. However, the facility did not provide records showing that the vaccines were offered or administered to Residents #33, #48, #60, #61, and #173, nor did they document any medical contraindications or refusals for these residents. Resident #33, who was cognitively intact and diagnosed with COPD, stroke, and hemiplegia, had no records of being offered or receiving the pneumonia vaccine. Resident #48, who was severely cognitively impaired, also had no records of being offered or receiving the pneumonia vaccine. Resident #60, who was cognitively intact and had type 2 diabetes, hemiplegia, and obstructive sleep apnea, had no records of being offered or receiving either the pneumococcal or influenza vaccines. Resident #61, who was severely cognitively impaired and had acute respiratory failure, a tracheostomy, and hemiplegia, had no records of being offered or receiving either vaccine. Resident #173, who was admitted following joint replacement surgery and had obstructive sleep apnea, also had no records of being offered or receiving either vaccine. Interviews with facility staff revealed that the responsibility for offering and documenting vaccinations was assigned to the admitting nurses, but there was a lack of follow-through and oversight. The outgoing administrator admitted to being unaware that the immunizations were not being done, and the Director of Nursing acknowledged that the expected documentation and follow-up were not completed. This failure to adhere to the facility's vaccination policies resulted in the deficiency noted by the surveyors.
Failure to Provide and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases by not providing the COVID-19 vaccine to three sampled residents. Resident #60, who was cognitively intact and had conditions such as Type 2 diabetes and obstructive sleep apnea, had no orders for a COVID-19 vaccine and no records of being offered the vaccine or education regarding its risks and benefits. Similarly, Resident #61, who was severely cognitively impaired and had acute respiratory failure and a tracheostomy, also had no orders for the COVID-19 vaccine and no records of being offered the vaccine or education. Resident #173, admitted with diagnoses including aftercare following joint replacement surgery and obstructive sleep apnea, had no orders for the COVID-19 vaccine and no records of being offered the vaccine or education either. The facility census was 67 residents at the time of the survey. Interviews with facility staff revealed inconsistencies and gaps in the process of offering and documenting COVID-19 vaccinations. The Outgoing Administrator admitted to being unaware that COVID-19 immunizations were not being done and mentioned that the responsibility had been shifted to the nurses without proper follow-up. The Assistant Director of Nursing (ADON) and Licensed Practical Nurses (LPNs) provided conflicting accounts of the vaccination process, with some stating that the ADON usually handled vaccinations and others indicating that the admitting nurse was responsible. The Director of Nursing (DON) confirmed that the COVID-19 vaccine and education were supposed to be offered to all new residents, but the process was not consistently followed, and documentation was lacking. The facility's policies on vaccination and infection control were not adhered to, leading to a failure in offering and documenting COVID-19 vaccinations for the sampled residents. The lack of a systematic approach and clear responsibility for administering and documenting vaccinations contributed to this deficiency. The facility's failure to provide the COVID-19 vaccine and proper education to the residents compromised the infection prevention and control program, as evidenced by the missing documentation and inconsistent practices among the staff.
Failure to Update Resident's Code Status to DNR
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately updated from full code to Do Not Resuscitate (DNR). Resident #61 was admitted with a full code status, but an advance directive dated 2/8/24 indicated a DNR status. Despite this, the resident's care plan dated 3/13/24 and the Physician's Order Sheet (POS) dated April 2024 still reflected a full code status. Interviews with staff revealed that the admitting nurse was responsible for ensuring the resident's wishes were reflected on the chart, but this was not done. Additionally, there was no clear process for auditing residents' charts to ensure the most up-to-date code status was documented. The Assistant Director of Nursing (ADON) acknowledged that the resident's code status should have been changed to DNR once the advance directive was received from the family, but this was missed. The Director of Nursing confirmed that the admitting nurse was responsible for ensuring the resident had a code status upon admission and that it should be listed on the face sheet and POS. The failure to update the resident's code status was a significant oversight, as it did not align with the resident's documented treatment preferences and advance directive.
Failure to Provide Baseline Care Plans
Penalty
Summary
The facility failed to provide two residents with a written summary of a baseline care plan within 48 hours of their admission. For Resident #41, the nursing admission screening was partially completed, missing critical information such as medications and the identity of the person who completed the screening. The resident reported not knowing anything about a care plan, and the Director of Nursing (DON) confirmed that the baseline care plan was not done. Similarly, for Resident #60, although a baseline care plan form was completed, it lacked signatures and evidence that the resident was provided with a copy. The resident also reported not being aware of a baseline care plan meeting. Interviews with the DON, Assistant DON, and MDS nurse revealed that the baseline care plans were typically done in the resident's room but were not being printed, signed, or provided to the residents or their families. The facility's policy required a baseline care plan to be developed within the first 48 hours of admission to meet the resident's immediate care needs, but this was not adhered to in these cases. Both residents had significant medical needs, including wounds, high-risk medications, and mobility impairments, which were not adequately addressed due to the lack of a proper baseline care plan.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to accurately document the administration of pain medication for one resident and ensure another resident had taken their prescribed medications. For Resident #41, the facility's records showed discrepancies in the administration of Oxycodone. The Medication Administration Record (MAR) indicated that the medication was not administered on two specific dates, but the narcotic count sheet showed it was given 26 more times than documented on the MAR. Interviews with the LPN and the Director of Nursing (DON) confirmed that proper documentation was not maintained, and there were no nurses' notes explaining the discrepancies on the MAR. For Resident #33, the facility failed to ensure the resident took their prescribed medications. Observations revealed that the resident had pills left at their bedside, which they had forgotten to take. The resident confirmed that the nurse had left the pills the previous night. The facility's policy and interviews with staff, including a Certified Medication Technician (CMT) and an LPN, indicated that medications should not be left at the bedside without a physician's order, and staff should observe the resident taking the medication. The DON confirmed that the resident did not have an order to leave medications at the bedside and that staff should have ensured the medications were taken. These deficiencies highlight the facility's failure to adhere to its medication administration policies, leading to improper documentation and potential risks for the residents involved. The lack of proper documentation and failure to ensure medication intake could have serious implications for resident care and safety.
Failure to Ensure Weekly Showers for Residents
Penalty
Summary
The facility failed to ensure that bathing/showers were completed at least once weekly and according to the residents' preferences for two sampled residents out of 17. Resident #13, who had diagnoses including colostomy status and essential hypertension, did not have shower sheets for multiple weeks between 3/1/24 and 4/13/24. The resident expressed a preference for weekly showers, and a CNA confirmed that the resident usually did not refuse showers. Similarly, Resident #54, with diagnoses including essential hypertension and unspecified glaucoma, did not have shower sheets for specific weeks and reported not receiving a shower between 3/30/24 and 4/12/24. The resident also preferred weekly showers and kept track of activities in a notebook, confirming the missed showers. A CNA corroborated that the resident seldom refused showers and liked them regularly. Interviews with staff, including CNAs, LPNs, and the DON, revealed inconsistencies in the shower schedule and documentation. The facility had two shower aides responsible for giving showers twice a week, but there were gaps in coverage and documentation. The DON stated that residents should be offered showers at least weekly, and shower sheets should be filled out even if a resident refused. However, the audit process by the ADON did not catch these deficiencies, leading to missed showers for the residents. The facility's shower policy lacked specific guidelines on the frequency of showers, contributing to the oversight.
Failure to Complete Physician-Ordered Weekly Weights for Resident
Penalty
Summary
The facility failed to ensure physician-ordered weekly weights were completed for a resident who had lost weight and was receiving tube feeding. The resident, who had multiple diagnoses including respiratory failure, hemiplegia following a stroke, gastrostomy status, and tracheostomy status, was admitted to the facility and required weekly weight monitoring as per physician orders. Despite this, there was no documentation of the resident's weight from early March to mid-April, during which the resident experienced a significant weight loss of 5.55% over three months. Interviews with staff revealed that the responsibility for weighing residents fell to Restorative Aides (RAs), who were sometimes reassigned to work as Certified Nursing Assistants (CNAs) on the floor, leaving the weighing tasks uncompleted. The Director of Nursing (DON) confirmed that residents with feeding tubes should have been weighed weekly and that the weights should have been documented in the computer system. However, due to the reassignment of RAs and lack of follow-up by other nursing staff, the required weekly weights were not consistently performed or recorded.
Failure to Ensure Proper Communication with Dialysis Center
Penalty
Summary
The facility failed to maintain ongoing communication and collaboration with the dialysis center for a resident with end-stage kidney disease. The facility's policy on the care of residents with end-stage renal disease did not address communication protocols between the facility and the dialysis center. This deficiency was identified during a review of the care plan and physician's orders for a resident who was cognitively intact and received dialysis twice a week. The Director of Nursing (DON) and Assistant DON confirmed that the facility did not have the resident's dialysis sheets, which were supposed to be filled out by the nurse before the resident went to dialysis and returned with the resident after the session. The DON and Assistant DON stated that if the dialysis form did not come back with the resident, the nurse should document the information in a nurse's note or call the dialysis facility. However, this procedure was not followed, as evidenced by the missing dialysis sheets and lack of documentation. The facility's failure to ensure proper communication and documentation regarding the resident's dialysis care led to this deficiency being cited by the surveyors.
Deficiency in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure psychotropic medications were administered for specific conditions and that PRN orders were limited to 14 days without review. For one resident, the facility did not have documented physician rationale for the use of Lorazepam, and the medication was not re-evaluated after 14 days. The Assistant Director of Nursing (ADON) acknowledged that the nurse should call the physician to clarify diagnoses for medications like Amitriptyline and Depakote, and that PRN antianxiety medications should be re-evaluated after 14 days. However, this process was not followed, leading to a deficiency in medication management for the resident involved. Another resident did not receive a gradual dose reduction (GDR) for psychotropic medications despite recommendations from the pharmacist. The pharmacist had reviewed the resident's medications, including Duloxetine and Lurasidone, and requested a dose reduction or discontinuation multiple times. However, there was no documented response from the physician to these recommendations. The Director of Nursing (DON) confirmed that the pharmacist's recommendations should be addressed and signed by the physician, but this was not done, resulting in a failure to follow through on the GDR process. Interviews with facility staff, including the DON and ADON, revealed that the facility had policies in place for medication management and MRRs, but these were not consistently followed. The DON admitted that the process for reviewing new admission medication orders was not official, and the ADON stated that they usually monitored PRN orders for antianxiety medications. The lack of adherence to these policies and procedures led to deficiencies in the administration and management of psychotropic medications for the residents involved.
Failure to Close Dumpster Lids
Penalty
Summary
The facility failed to ensure the lids of the dumpsters were closed after staff placed trash in them. This deficiency was observed on multiple occasions: on 4/15/24 at 9:59 A.M. and 11:21 A.M., both outdoor dumpsters were left open; on 4/16/24 at 2:20 P.M., two lids of one dumpster were left open; and on 4/17/24 at 12:36 P.M., the lids of both dumpsters were left open. During an interview on 4/17/24 at 12:38 P.M., the Dietary Manager stated that all departments within the facility were expected to keep the dumpsters closed to prevent raccoons from accessing the trash.
Facility Failed to Maintain Exterior Siding, Creating Pest Entry Points
Penalty
Summary
The facility failed to maintain the siding on the outside of the former dementia unit and the siding on the outside wall behind the kitchen in good repair, creating openings that pests could get into. On 4/15/24, a bird was observed entering one of the gaps in the missing siding on the outside wall of the dementia unit. On 4/16/24, the Maintenance Director confirmed that an approximately 6 feet wide by 2 feet high section of siding behind the air conditioning unit outside the kitchen was damaged, with visible insulation. The Maintenance Director stated that the damage existed before his tenure and was exacerbated by water from a damaged downspout. Additionally, a 47 feet long section of siding on the outside wall of the former dementia unit was observed to be damaged with several gaps. The Maintenance Director confirmed that this damage also predated his tenure, which began in February 2022.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their treatment and documentation. One resident, who was admitted to hospice services prior to facility admission, developed a facility-acquired pressure ulcer on the coccyx that became infected, requiring antibiotic therapy. The facility did not conduct weekly skin assessments or document the wound's stage, measurements, or characteristics in the resident's electronic medical record (EMR). Additionally, the resident's care plan did not address the pressure ulcer or its infection, and there was no physician's order for the use of calcium alginate, which was used without proper documentation. Another resident was admitted with unstageable pressure ulcers on the ischial areas, but the facility failed to perform weekly skin assessments or document the wounds in the EMR. The resident's care plan indicated the need for weekly skin assessments, but these were not completed. The facility's Weekly Wound Report did not include the resident's pressure ulcers, and there was a lack of progress notes describing the wounds' stage, measurements, or characteristics. The facility's wound nurse mistakenly believed that hospice nurses were responsible for documenting the residents' wounds, leading to a lack of proper documentation and tracking of the pressure ulcers. The wound nurse did not enter assessments in the EMR or on the Weekly Wound Report, and the facility's Director of Nursing and Administrator were unaware of the residents' pressure ulcers until questioned by the state surveyor. The facility's failure to adhere to its wound care policy and ensure proper documentation and assessment of pressure ulcers resulted in deficiencies in the care provided to these residents.
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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