Gower Convalescent Center, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Gower, Missouri.
- Location
- 323 South Highway 169, Gower, Missouri 64454
- CMS Provider Number
- 265800
- Inspections on file
- 17
- Latest survey
- March 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Gower Convalescent Center, Inc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was physically assaulted by another cognitively impaired resident, who grabbed and shook their hair. Both had care plans requiring separation and supervision, but these were not effectively implemented, resulting in a failure to prevent the abuse. Staff were present but not directly supervising at the time, allowing the incident to occur before intervention.
The facility failed to follow professional standards for food safety and sanitation, with issues in food storage, labeling, and temperature monitoring. Staff did not consistently wash hands or change gloves between serving residents, and hairnets were not properly worn. The kitchen and dining areas were cluttered, and food items were improperly stored. Interviews revealed a lack of adherence to facility policies and expectations.
The facility failed to maintain resident dignity during meal service and personal hygiene care. Observations showed inconsistent meal service, with residents at the same table not being served simultaneously, causing frustration. Additionally, a cognitively impaired resident was not consistently shaved, despite preferences and facility policy. Staff interviews revealed inconsistencies in care and documentation, highlighting deficiencies in adhering to resident rights and care plans.
The facility failed to maintain privacy for two residents by not posting signage for 24-hour camera surveillance and not obtaining consents. One resident's care plan did not address video surveillance with audio, and there were no physician's orders. Observations showed video monitors in rooms without proper signage. Staff were unaware of the need for signage or orders, considering the devices as communication tools requested by families.
The facility failed to update and document care plans for several residents, leading to discrepancies between the residents' current needs and their care plans. A resident's care plan was outdated, not reflecting their non-ambulatory status, while another's did not include wheelchair use despite frequent observations of such use. Additionally, care plan meetings were not documented or held quarterly as required, affecting the quality of care provided.
The facility failed to ensure professional standards of care by not verifying electronic medical records before providing wound care and administering insulin. A resident received wound treatment without order verification, while two residents had their blood sugars checked and insulin administered without confirming orders. Staff relied on routine practice rather than checking current orders, leading to deficiencies in care.
Two residents with severe cognitive impairment and high risk for skin injury were not repositioned every two hours as required, leading to deficiencies in care. Observations showed extended periods in reclining wheelchairs without repositioning, despite staff expectations for repositioning every two hours. The facility lacked a policy on positioning, contributing to the deficiency.
The facility staff failed to ensure residents were free from accident hazards by pushing them in wheelchairs without foot pedals, affecting four residents. Observations showed residents' feet dragging on the floor, despite staff beliefs that residents could hold their feet up. The facility lacked a clear policy on wheelchair safety, leading to inconsistent practices and deficiencies in resident care.
The facility failed to provide proper respiratory care for two residents, leading to potential bacterial exposure and discomfort. Oxygen tubing was found on the floor, and humidifier water levels were inadequate. Staff interviews revealed lapses in maintenance and documentation of oxygen equipment cleaning and management.
The facility failed to maintain a medication error rate below five percent, resulting in an 8% error rate affecting two residents. A CMT improperly administered artificial tears by allowing the dropper tip to touch a resident's eyelids and eyelashes. Additionally, an LPN administered Fiasp insulin to a resident 31 minutes before they began eating, instead of within the required 15 minutes. Both incidents were acknowledged by the staff involved and the DON.
The facility failed to securely store medications, affecting two residents. Medications were accessible to unauthorized individuals, with keys left in the medication cart lock. Resident medications were found at bedside without proper orders, and expired medications were not destroyed. Staff confirmed these practices were against policy.
The facility did not provide state-approved training for paid feeding assistants, impacting 18 residents. Five feeding assistants lacked formal training, receiving only one-on-one instruction from the DON and staff. The DON was unaware of the state training requirement, leading to non-compliance.
A facility failed to implement proper infection control measures for a resident readmitted with influenza A, lacking transmission-based precautions and signage. Additionally, clean laundry was transported uncovered, contrary to CDC guidelines. The DON and Administrator acknowledged these lapses.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when another resident physically assaulted them by grabbing their hair and jerking their head. Both residents involved had severe cognitive impairments, with diagnoses including dementia, Alzheimer's disease, and anxiety disorders. The assaulted resident had a care plan specifying to keep them away from the aggressor, while the aggressor's care plan included instructions for seating at a distance from others, constant observation, and separation from the assaulted resident. On the evening of the incident, both residents were seated near the nurses' station. Staff members, including a CNA and an LPN, were present but not directly supervising the residents at the moment of the altercation. The CNA was cleaning a wheelchair and facing away, while the LPN was behind the desk. The incident occurred when the aggressor came up behind the other resident, grabbed their ponytail, and shook their head, causing the victim to scream. Staff intervened after hearing the scream and separated the residents. Documentation and interviews confirmed that the care plans for both residents included measures to prevent such interactions, specifically to keep them apart and to supervise the aggressor closely. However, these interventions were not effectively implemented at the time of the incident, resulting in a failure to prevent the physical abuse. The facility's policy required prompt reporting and intervention in cases of abuse, but the lack of direct supervision and failure to maintain separation contributed to the occurrence of the event.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as evidenced by multiple observations of improper food storage, preparation, and sanitation practices. Staff neglected to date the receipt of incoming products in the dry storeroom and failed to label and date used products in the freezer and refrigerator. Additionally, leftovers in the refrigerator were not labeled, dated, or disposed of in a timely manner. The facility also did not monitor refrigerator and freezer temperatures daily, and sanitation requirements for cleanliness, handwashing, and hairnets were not consistently followed in the kitchen and dining room. Observations in the kitchen revealed several deficiencies, including opened bags of cereal without dates or labels, plastic cups stored face up, and a cluttered and unorganized kitchen area with trip hazards. The temperature log for the refrigerator and freezer was not up to date, and there was no thermometer in the freezer to record temperatures. In the dry storeroom, several food items were opened and undated, and a dented can was used to hold a door open, posing a potential safety risk. The freezer contained opened and resealed food items without labels or dates, and some food items were stored directly on the floor. In the dining room, staff members were observed not changing gloves or washing hands between serving residents, and pre-staged drinks were left uncovered. Staff members also failed to follow proper hygiene practices, such as wearing hairnets and beard covers correctly. Interviews with the Dietary Manager, Dietician, Maintenance Supervisor, and Administrator revealed a lack of adherence to facility policies and expectations regarding food safety and sanitation practices. The facility's new temperature monitoring application was not fully operational, and there was no plan in place to address potential failures of the system.
Deficiencies in Meal Service and Personal Hygiene Care
Penalty
Summary
The facility failed to maintain the dignity of its residents during meal service and personal hygiene care. Observations revealed that during meal times, residents seated at the same table were not served simultaneously, leading to some residents watching others eat while they waited for their meals. This inconsistency in meal service was noted by several residents, who expressed frustration and confusion over the random manner in which meals were served. The facility's policy requires that all residents at a table be served at the start of dining service, but this was not adhered to, except in cases where diabetic residents needed to be prioritized. Additionally, the facility did not ensure that a resident, who was severely cognitively impaired and dependent on assistance for personal hygiene, was free of facial hair. Despite the resident's preference for being shaved during showers, observations showed that the resident had noticeable facial hair on multiple occasions. Interviews with staff indicated that shaving was supposed to occur during showers provided by hospice staff, but there was a lack of documentation and consistency in this care aspect. The Director of Nursing expected female residents to be free from facial hair, but acknowledged the resident's resistance to care at times. The facility's failure to adhere to its policies on resident dignity and personal care resulted in deficiencies that affected the quality of life for its residents. The lack of consistent meal service and personal hygiene care, particularly for a resident with cognitive impairments, highlights the need for improved adherence to care plans and resident rights as outlined in the facility's policies.
Failure to Maintain Privacy with Video Surveillance
Penalty
Summary
The facility failed to maintain the privacy of two residents by not posting signage indicating 24-hour camera surveillance and not obtaining consents from the responsible parties. Resident #73's care plan did not address the use of video surveillance with audio, and there was no physician's order for such surveillance. Observations showed video monitors in the resident's room and at the nurse's station, but no signs were posted to indicate video monitoring. The Director of Nursing (DON) and staff were unaware of the need for signage or physician's orders, considering the devices as communication tools requested by the family. Resident #43 also had a video monitor in the room without proper signage or consent from the responsible party. The resident's care plan mentioned a V-tech baby monitor for monitoring due to a history of falls, but there was no signed consent for 24-hour surveillance. Interviews with staff revealed a lack of awareness regarding the need for care planning, physician's orders, and signage for video surveillance. The DON stated that the family installed the monitors, and she did not consider them as requiring notification or orders.
Deficiencies in Care Plan Development and Documentation
Penalty
Summary
The facility failed to ensure that care plans were developed and updated in accordance with the specific conditions and needs of the residents. This deficiency affected five residents, with issues ranging from outdated care plans to the lack of documentation of care plan meetings. For instance, Resident #23's care plan had not been updated since September 2024, despite changes in their condition, and there was no record of care plan meetings being held since March 2023. The resident expressed uncertainty about attending care plan meetings, and the facility staff did not document whether the resident or their family was invited or attended these meetings. Resident #47's care plan did not accurately reflect their current non-ambulatory status, as it still included instructions for using a sit-to-stand lift, which had not been used for over a year. Observations confirmed that the resident was dependent on a mechanical lift for transfers, yet the care plan had not been updated to reflect this change. Interviews with facility staff, including a Licensed Practical Nurse and a Certified Nursing Assistant, corroborated the resident's decline and the need for updated care planning. Additionally, Resident #71's care plan failed to address the use of a wheelchair, despite multiple observations of the resident being transported in one. The facility also did not document care plan meetings for Residents #6 and #12, with both residents unsure if they had been invited or attended such meetings. The facility's MDS Coordinator and Social Services Designee acknowledged the lack of documentation and the failure to hold quarterly care plan meetings, as required. These deficiencies highlight significant lapses in the facility's care planning processes, impacting the quality of care provided to the residents.
Failure to Verify Medical Orders for Wound Care and Insulin Administration
Penalty
Summary
The facility failed to ensure professional standards of quality in care by not utilizing the electronic medical record to verify orders when providing wound care and administering medications. Specifically, staff did not verify orders for wound care for a resident, and did not check the electronic medical record before obtaining blood sugars and administering insulin for two other residents. This lack of verification was observed during the administration of insulin and wound care, where staff relied on memory or routine practice rather than confirming current orders. One resident, who was diabetic and required blood sugar monitoring and insulin administration, had their blood sugar checked and insulin administered without the nurse verifying the orders on the electronic medical record. The nurse admitted to not using a computer to verify orders due to the resident's long-term stay at the facility. Another resident, also diabetic, had their blood sugar checked and insulin administered without order verification, with the nurse acknowledging the lack of a portable device to check orders during the process. Additionally, a resident with a wound on the right posterior hip received treatment without the nurse verifying the specific order for the amount of collagen powder to be used. The nurse, who was responsible for wound care, did not check the electronic medical record before proceeding with the treatment, relying instead on their familiarity with the resident's care needs. Furthermore, another resident with a wound on the right calf did not have a physician's order for wound care, and the primary physician was unaware of the lack of orders, indicating a communication gap in the facility's care processes.
Failure to Reposition and Provide Incontinent Care
Penalty
Summary
The facility failed to provide adequate care and treatment in accordance with professional standards for two residents, leading to deficiencies in repositioning and incontinent care. Resident #47, who had severe cognitive impairment and was dependent on staff for mobility and repositioning, was observed to remain in a reclining wheelchair for extended periods without being repositioned. Despite being at high risk for skin injury and pressure sores, the resident was not laid down or repositioned as required, and staff interviews confirmed that the resident stayed in the chair most of the day. Similarly, Resident #72, who also had severe cognitive impairment and was dependent on staff for all activities of daily living, was not repositioned every two hours as required. The resident had a documented stage 4 pressure ulcer and was at high risk for further skin injury. Observations showed that the resident remained in a reclining wheelchair for several hours without repositioning, and staff interviews indicated that the resident was typically kept in the chair until after lunch. Interviews with various staff members, including CNAs, LPNs, and the DON, revealed a general expectation that residents should be repositioned every two hours. However, the observations and interviews indicated that this standard was not consistently met, particularly for residents in reclining wheelchairs. The facility did not provide a policy on positioning, contributing to the deficiency in care for these residents.
Failure to Ensure Wheelchair Safety for Residents
Penalty
Summary
The facility staff failed to ensure residents remained free from accident hazards by pushing residents in their wheelchairs without foot pedals. This deficiency affected four residents, who were observed being pushed with their feet dragging on the floor. The facility did not provide a policy on accidents, which contributed to the lack of consistent safety measures for residents in wheelchairs. Resident #1, with severe cognitive impairment and a history of falls, was observed being pushed without foot pedals, causing their feet to drag on the floor. Despite having an anti-roll back device on their wheelchair, the resident's care plan did not address the absence of foot pedals during transport. Interviews with staff revealed a belief that the resident could hold their feet up, but observations showed otherwise. Similarly, Resident #58, who was dependent on a wheelchair and required substantial assistance, was pushed without foot pedals on multiple occasions. Staff interviews indicated that residents were asked if they could hold their feet up, but this practice was inconsistent and not documented in care plans. Resident #68, with functional limitations and a history of falls, was also pushed without foot pedals, despite their care plan specifying the need for foot rests. Lastly, Resident #71, who was independent with walking but used a wheelchair, was pushed without foot pedals, with no care plan addressing wheelchair use. The facility's lack of a clear policy and inconsistent staff practices contributed to these deficiencies.
Improper Respiratory Care and Oxygen Tubing Management
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, resulting in potential exposure to bacteria and minor discomfort. For one resident, the oxygen tubing was observed lying on the floor, and the water container in the oxygen humidifier was only one-third full, with no dates indicating when the tubing or water bottle was last changed or cleaned. The resident reported slight discomfort due to a dry nose. Additionally, there was no record of oxygen administration or cleaning of tubing in the resident's Medication Administration History or Treatment Administration Record. For another resident, the oxygen tubing was also found lying on the ground with the nasal cannula exposed and in contact with the floor. There was no care planning for oxygen therapy at night, and no dates were taped to the tubing to indicate the last change or cleaning. Interviews with staff revealed that maintenance is responsible for cleaning the filters on oxygen humidifiers, and tubing and water cannisters are supposed to be cleaned weekly. However, the tubing should not be left on the floor, and staff are expected to use a Ziplock bag to prevent contact with the floor. The administrator and DON confirmed that oxygen tubing and nasal cannula should not be on the ground and should be dated when changed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 8%. This affected two residents. The first incident involved a Certified Medication Technician (CMT) administering artificial tears to a resident. During the administration, the tip of the eye dropper touched the resident's eyelids and eyelashes, which is against the facility's policy and standard practice for administering eye drops. Both the CMT and the Director of Nursing (DON) acknowledged that the tip of the eye dropper should not touch the resident's eyelids or eyelashes. The second incident involved a Licensed Practical Nurse (LPN) administering Fiasp insulin to a resident. The insulin was given 31 minutes before the resident began eating, contrary to the requirement that a meal should be served within 15 minutes of administering fast-acting insulin. The LPN and the DON both confirmed that the resident should have been served their meal immediately after receiving the insulin. These errors contributed to the facility's medication error rate exceeding the acceptable threshold.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to store medications securely, affecting two residents. Medications for these residents were found to be accessible to unauthorized staff and residents. Specifically, medications were not stored in a locked area, and the key was left in the lock of the medication treatment cart. Additionally, expired and loose medications were found in the medication room and cart, which were not destroyed as required. Resident #44, who has multiple diagnoses including anemia, heart failure, and diabetes, was found to have a bottle of Refresh Tears at their bedside without a physician's order to self-administer medications. The resident's care plan did not include any orders for self-administration of medication, and the resident reported that their daughter had provided the eye drops after a medical procedure. Similarly, Resident #5, who requires staff assistance for medication administration, was found with a plastic med cup containing three pills at their bedside. The resident reported that staff had left the pills without explaining what they were, and the resident refused to take them until they knew their purpose. The medication treatment cart was repeatedly observed with the key left in the lock, unattended, and accessible to residents. Staff interviews confirmed that the key should not be left in the lock and that the cart should be secured when not in use. Additionally, expired medications and a loose pill were found in the medication cart and room, which should have been destroyed according to facility policy. The DON confirmed that expired and loose medications should not be present and should be destroyed.
Lack of State-Approved Training for Feeding Assistants
Penalty
Summary
The facility failed to provide state-approved training for paid feeding assistants, affecting 18 residents out of a census of 78. A review of the facility's list of paid feeding assistants revealed that five individuals had not completed the required formal training. During interviews, a nurse aide admitted to not attending a state-approved course, instead receiving one-on-one training from the Director of Nursing (DON) and experienced staff. The DON confirmed that each feeding assistant underwent one-on-one training on specific topics but was unaware of the requirement for state-approved training courses, indicating a lack of compliance with regulatory standards.
Infection Control and Laundry Transport Deficiencies
Penalty
Summary
The facility failed to implement proper infection control measures for a resident who was readmitted with a positive test for influenza A. Upon the resident's return, there were no transmission-based precautions in place, and no signage was posted to indicate the need for such precautions. The resident, who had been hospitalized for influenza, was not isolated immediately, and the necessary personal protective equipment was not utilized by staff. Observations showed that the resident's room lacked appropriate signage, and the infection preventionist was unaware of the resident's return and the need for precautions. Additionally, the facility did not ensure that clean laundry was protected from contamination during transport. Observations revealed that clean laundry, including resident gowns and underpads, was transported on uncovered metal carts through the facility's hallways. Interviews with laundry aides confirmed that the carts used for transporting clean laundry were not covered, contrary to CDC guidelines for environmental infection control. The facility's Director of Nursing and Administrator acknowledged the lapses in infection control and the failure to protect clean laundry from contamination. Despite the facility's policy and CDC guidelines, the necessary precautions and protective measures were not implemented, leading to deficiencies in infection prevention and control practices.
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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