Granby House
Inspection history, citations, penalties and survey trends for this long-term care facility in Granby, Missouri.
- Location
- 301 South Main, Granby, Missouri 64844
- CMS Provider Number
- 265468
- Inspections on file
- 19
- Latest survey
- April 24, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Granby House during CMS and state inspections, most recent first.
Two residents with intact cognitive skills, including one with mental health diagnoses, were only able to use a corded phone located at the nurses' station, where staff were frequently present and privacy was lacking. Staff confirmed that residents were routinely brought to this area for phone use, and there was no alternative location or cordless phone available, resulting in a failure to ensure private communication as required by facility policy.
A resident with severe cognitive impairment and a history of wandering exited the facility unsupervised after the front door alarm was found to be turned off, resulting in a fall and injuries outside. Staff were unaware of the resident's whereabouts, and the facility lacked a specific policy for door alarms. The investigation into the incident was incomplete, failing to address the root cause or document how the resident was able to leave the building.
Staff did not consistently perform hand hygiene or use required gowns and gloves during high-contact care activities for several residents with wounds or indwelling devices. Multiple CNAs were observed providing care without washing or sanitizing hands before donning gloves, after glove removal, or between care tasks, and did not always wear gowns as required for EBP. Staff interviews revealed inconsistent understanding of infection control protocols, and EBP signage was sometimes missing from resident rooms.
A resident with a history of hypothyroidism and other chronic conditions did not receive prescribed levothyroxine after admission because staff failed to enter the medication order into the electronic record. The medication card was present, but the omission went unnoticed until the resident reported not receiving the medication, and staff confirmed the error during interviews and record review.
The facility failed to implement enhanced barrier precautions (EBP) for residents with MDROs or chronic wounds, resulting in staff not wearing appropriate PPE and lacking training on EBP. Additionally, the facility did not complete the required two-step TB screening for several staff members, with missing documentation for TB tests. Interviews revealed a lack of awareness and training among staff regarding EBP and TB screening procedures.
The facility failed to maintain a sanitary environment in the kitchen and dining areas, with issues such as dead bugs in light fixtures, a rusted prep table, and a dirty ice machine. Staff interviews revealed a lack of awareness and communication regarding maintenance responsibilities, and the cleaning schedule did not adequately address these issues.
The facility did not follow its abuse prevention policy by failing to conduct timely Nurse Aide (NA) Registry checks for Federal Indicators on new hires, including a Maintenance Supervisor, an RN, and an Interim DON. Interviews revealed a lack of clarity and training for the Medical Record Staff responsible for these checks.
The facility failed to provide adequate grooming and personal hygiene services to dependent residents, as evidenced by three residents who did not receive timely showers and had unkempt hair. One resident, who was cognitively intact, reported feeling unclean due to infrequent showers, while another with severe cognitive impairment also experienced infrequent showers despite needing substantial assistance. A third resident, in isolation, did not receive any showers during their stay, highlighting inconsistencies in the facility's scheduling and documentation processes.
The facility failed to ensure that nurse aides completed their CNA training and certification within the required timeframe, resulting in eighteen aides working without proper certification. The facility's policy requires completion within four months, but delays in class availability and lack of enforcement led to aides working beyond this period. The administration acknowledged the issue but did not effectively implement reassignment or termination policies.
The facility's pest control program was ineffective, leading to a fly infestation affecting residents and common areas. Observations showed flies around residents and in dining areas, causing discomfort. Staff interviews confirmed frequent complaints, and despite pest control measures, the issue persisted.
A resident with major depressive disorder and other conditions did not receive routine showers since admission, as the facility lacked a consistent shower schedule and proper documentation. Staff interviews revealed confusion about the shower schedule and inadequate reporting of missed showers, leading to the resident feeling unclean and neglected.
A facility failed to complete the required PASARR screening for a resident with mental health diagnoses prior to or at admission, resulting in a significant delay. The Social Services Director, new to the position, did not complete the screening, and the Administrator acknowledged the oversight, indicating a lapse in the facility's process.
A resident did not receive scheduled lab tests in a timely manner due to the facility's failure to follow professional standards of practice. The resident, with a history of various medical conditions and on anticoagulant medication, had orders for lab tests every three months. However, the facility missed the scheduled tests in May. Interviews revealed inconsistencies in the process for tracking and obtaining lab tests, with staff unsure about the use of a newly implemented lab tracking book and the functionality of the computer system for recurring orders.
The facility failed to ensure proper communication and collaboration with the dialysis center for a resident with end-stage renal disease. Despite the care plan indicating dialysis sessions and transportation coordination, there was no documentation of communication or follow-up with the dialysis center. Interviews revealed that communication forms were not used or returned, contrary to the expectations of the Corporate Nurse and Administrator.
The facility staff failed to provide cornbread or a substitute to two residents on pureed diets during a meal, despite it being listed on the menu. The dietary aide forgot to puree the cornbread, and the dietary manager and registered dietician were unaware of the issue. Facility policy requires that residents on pureed diets receive the same food options as those on regular diets.
A resident's fentanyl patch went missing after a former CNA entered the facility and was seen leaving the resident's room. The resident, who was severely cognitively impaired and on a pain medication regimen, was found with their gown sleeve pulled down and the patch missing. Staff identified the former CNA through camera footage and personal observation.
Failure to Provide Private Telephone Access for Residents
Penalty
Summary
The facility failed to provide residents with reasonable access to a telephone in a private environment, as required by their own policy and resident rights. Observations and interviews revealed that the only available phone for resident use was a corded phone located at the nurses' station, an area with frequent staff presence and activity. Residents reported that they were unable to take the phone elsewhere, and staff and other individuals were often present during their calls, resulting in a lack of privacy. Staff interviews confirmed that residents were routinely brought to the nurses' desk to use the phone, and that there was no alternative location for private phone use. The facility previously had a cordless phone, but it was no longer available, and staff were unaware of its whereabouts. Two residents with intact cognitive skills, one with a history of schizophrenia, anxiety disorder, and cognitive communication deficit, and another with depression and anxiety disorder, specifically reported feeling that their phone conversations were not private and that staff could overhear their discussions. Staff acknowledged the lack of privacy and the high traffic at the nurses' station, and the administrator confirmed that there was no privacy for residents using the phone at that location. The deficiency was identified through observation, record review, and interviews with residents and staff.
Failure to Prevent Resident Elopement Due to Disabled Door Alarm
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards when the front door alarm was found to be turned off, allowing a resident to exit the building unsupervised. The resident, who had a history of severe cognitive impairment, Parkinson's disease, dementia, repeated falls, and was identified as a wanderer, was able to leave the facility without staff knowledge. The resident was later found outside on the parking lot pavement with injuries, including a bleeding abrasion to the back of the head and bruising to the right shoulder. Staff interviews confirmed that the door alarm did not sound and the door was not locked at the time of the incident, and the alarm system was later found unplugged by the DON. The resident's care plan documented poor safety awareness, a risk for falls, and a tendency to wander, with interventions such as frequent rounding and reminders to the resident. Despite these interventions, staff were unaware of the resident's whereabouts for a period of time, and the resident was able to exit the building without detection. Staff interviews indicated that the resident was last seen in the hallway and a search was initiated only after the resident was noticed missing. The facility did not have a specific policy regarding door alarms and locking mechanisms, and staff were unclear about the procedures for monitoring doors when alarms were not functioning. Following the incident, documentation and investigation into the root cause of the elopement and fall were incomplete. The fall documentation checklist did not address how the resident exited the facility or the circumstances leading to the fall outside. There was no evidence of a comprehensive investigation or root cause analysis to determine how the door alarm became disabled or to identify interventions to prevent future incidents. The facility's policy on accident and incident investigation was not fully followed, as key data and analysis were missing from the report.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to adhere to established infection prevention and control protocols, specifically regarding hand hygiene and the use of enhanced barrier precautions (EBP) for residents with wounds or indwelling medical devices. Multiple instances were observed where certified nurse aides (CNAs) did not perform hand hygiene before donning gloves, after glove removal, or between resident care activities. For example, CNAs were seen entering resident rooms, putting on gloves without washing or sanitizing their hands, and proceeding to provide direct care such as dressing, perineal care, and transferring residents. In several cases, staff also failed to change gloves or perform hand hygiene between different care tasks, and sometimes handled resident personal items or equipment without appropriate hand hygiene. The facility also failed to ensure proper implementation of EBP for residents with wounds or indwelling devices. Staff did not consistently wear gowns as required during high-contact care activities for residents on EBP, despite facility policy and CDC guidance. Observations included staff providing care to residents with wounds or surgical sites without donning protective gowns, and in some cases, EBP signage was missing from resident doors. Staff interviews revealed inconsistent understanding of EBP requirements, with some staff indicating they would only wear gowns if instructed by a nurse, and others unaware of the location of necessary PPE or the identity of the facility's Infection Preventionist. The deficiencies were observed among residents with significant care needs, including those with chronic wounds, surgical sites, and indwelling devices, who required assistance with activities of daily living such as dressing, toileting, and transfers. The facility census at the time was 51. Despite facility policies outlining clear expectations for hand hygiene and EBP, and the availability of hand hygiene products and PPE, staff did not consistently follow these protocols during resident care, as confirmed by direct observation, staff interviews, and record review.
Failure to Administer Prescribed Levothyroxine Due to Admission Process Error
Penalty
Summary
The facility failed to provide care in accordance with professional standards of quality by not administering a resident's prescribed levothyroxine for hypothyroidism as ordered. Upon admission, the resident, who had a history of systemic lupus erythematosus, epilepsy, hypothyroidism, major depression, and anxiety, was transferred from another facility with a documented physician's order for levothyroxine 88 mcg daily. However, review of the Medication Administration Record (MAR) and physician's orders revealed that the medication was not entered into the electronic medical record or administered until several weeks after admission. Interviews with staff indicated that the medication was overlooked during the admission process. The nurse responsible for entering medications into the electronic record failed to include levothyroxine, and the usual double-check process by the DON and ADON was not completed for this resident. The resident reported not receiving the medication, and staff confirmed that the medication card with levothyroxine was present but not administered, as the order was not in the system for the night nurse to follow. The facility's policy required medications to be administered as ordered and for medication errors to be documented and reviewed. In this case, the failure to verify and enter the resident's medication order resulted in the omission of a routine and necessary medication for hypothyroidism, as confirmed by both staff interviews and record review.
Inadequate Infection Control and TB Screening in LTC Facility
Penalty
Summary
The facility failed to maintain a complete infection prevention and control program by not implementing their policy regarding enhanced barrier precautions (EBP) for residents infected with multidrug-resistant organisms (MDROs) or those with chronic wounds and/or indwelling medical devices. Staff were not trained on EBP, and personal protective equipment (PPE) and signage were not present for residents meeting the guidelines for EBP. Specifically, staff did not wear PPE in accordance with CDC guidelines for a resident with a cutaneous abscess and knee effusion, who required wound care. Observations revealed that staff assisted the resident without wearing gowns, and there was no signage or PPE available outside the resident's room. Interviews with staff, including CNAs, LPNs, and the interim Director of Nursing, indicated a lack of training and awareness regarding EBP. Staff were not informed about the necessity of wearing gowns and gloves during high-contact resident care activities, such as wound care, for residents with wounds or indwelling devices. The facility's infection control policy had been updated to include EBP, but it was not yet implemented, and staff had not been educated on the process. Additionally, the facility failed to administer the required two-step tuberculosis (TB) screening test for six sampled staff members. Personnel records showed missing documentation for the first or second step TB skin tests for several employees. Interviews with the Corporate Nurse and Administrator revealed that the former Director of Nursing was responsible for completing employee TB skin tests, but the facility had experienced turnover in this position, leading to lapses in TB screening documentation.
Sanitation and Maintenance Deficiencies in Kitchen and Dining Areas
Penalty
Summary
The facility staff failed to maintain a sanitary and comfortable environment in the kitchen and dining areas, as evidenced by several deficiencies observed during a survey. Light fixtures in these areas contained dead bugs, were not clean, and some were missing covers or not functioning. The facility's cleaning schedule did not include tasks for cleaning or maintaining these lights, and staff interviews revealed a lack of awareness and communication regarding the maintenance of these fixtures. The Dietary Manager and Maintenance Director were unaware of the issues, and there was no systematic process for reporting or addressing such maintenance needs. Additionally, the lower shelf of the prep table in the kitchen was found to be in poor condition, with visible grime, rust, and missing coating. Despite a cleaning schedule that included wiping down the prep table, staff interviews indicated that the table's condition was known but inadequately addressed. The Dietary Manager acknowledged the issue but relied on temporary measures like covering the table with plastic sheets, which did not resolve the underlying problem of rust and grime accumulation. The facility also failed to maintain the cleanliness of the ice machine and the stock room floor. The outside of the ice machine had white streaks and lint on the vent, with no clear responsibility assigned for its cleaning. Housekeeping and kitchen staff had conflicting views on who was responsible, leading to neglect. Similarly, the stock room floor was dirty, with no specific cleaning tasks outlined in the schedule. Staff interviews highlighted a lack of documentation and oversight in ensuring these areas were cleaned, with the Dietary Manager and Administrator acknowledging the oversight but not implementing effective solutions.
Failure to Conduct Timely NA Registry Checks
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not conducting timely checks of the Nurse Aide (NA) Registry for Federal Indicators, which are markers for potential employees who have committed abuse, neglect, or misappropriation of property against residents. Specifically, the facility did not check the NA registry for two staff members, the Maintenance Supervisor and a Registered Nurse (RN), prior to their employment. Additionally, the NA registry check for the Interim Director of Nursing (DON) was conducted six months after their hire date. These oversights occurred despite the facility's policy requiring registry checks before employment. Interviews with the Medical Record Staff revealed a lack of clarity and training regarding the process for conducting NA registry checks. The Medical Record Staff was unsure if the Maintenance Supervisor's registry check was necessary and could not locate documentation for the RN's check. Furthermore, the registry check for the Interim DON was delayed because the Medical Record Staff initially only consulted the nurse website. The Administrator confirmed that the Medical Record Staff was responsible for these checks and expected them to be completed before new employees began working.
Failure to Provide Adequate Hygiene Services to Residents
Penalty
Summary
The facility failed to provide adequate grooming and personal hygiene services to dependent residents, as evidenced by the cases of three residents who did not receive timely showers and had unkempt hair. Resident #7, who was cognitively intact and required assistance with mobility and transfers, reported feeling unclean due to infrequent showers. The resident's care plan indicated a need for assistance with bathing, yet documentation showed significant gaps between showers, with the resident receiving only two showers in June 2024. Interviews revealed that the resident preferred weekly showers, but the new shower aide did not consistently offer them. Resident #29, who had severe cognitive impairment and required substantial assistance with personal hygiene, also experienced infrequent showers. The resident's care plan highlighted the need for assistance with daily activities, yet documentation showed only two showers in June 2024. Observations confirmed the resident's hair was unkempt, and interviews with staff indicated that the resident did not refuse showers, suggesting a failure in the facility's scheduling and documentation processes. Resident #246, who had moderately impaired cognition and required assistance with bathing, did not receive any showers during their stay from early June until discharge. The resident was in isolation, and staff interviews revealed a lack of documentation for any bed baths offered. The facility's interim DON acknowledged the oversight, indicating a breakdown in communication and procedure adherence. Interviews with various staff members, including CNAs and LPNs, highlighted inconsistencies in the shower schedule and documentation, contributing to the deficiency in resident care.
Failure to Ensure Timely Completion of CNA Training and Certification
Penalty
Summary
The facility failed to ensure that nurse aides completed their training, competencies, and testing within the required timeframe, resulting in eighteen nurse aides continuing to work without completing a state-approved certified nursing assistant (CNA) training program, competency evaluation, and certification test. The facility's policy mandates that nurse aides must complete their training and competency evaluation within four months of employment, or they may be reassigned to non-nursing roles or terminated. However, the facility did not adhere to this policy, allowing nurse aides to work beyond the four-month period without the necessary certification. Interviews and record reviews revealed that several nurse aides had not completed their final written/oral exams and practicum exams, despite having started the program months earlier. The Clinical Instructor was unaware of the 120-day regulatory timeframe for course completion and mentioned that students could work as nurse aides for up to a year while waiting to take their tests. This lack of awareness and enforcement of the regulatory timeframe contributed to the deficiency, as nurse aides continued to work without completing their required training and certification. The facility's administration acknowledged the delay in training and attributed it to a lack of available classes, which caused staff to wait up to four months to start the program. The administration stated that if the course is not completed within the required timeframe, nurse aides would be reassigned to non-nursing roles or terminated. However, this policy was not effectively implemented, leading to the deficiency where nurse aides continued to provide direct care without proper certification.
Ineffective Pest Control Program Leads to Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant fly infestation affecting residents and common areas. Observations revealed multiple instances where flies were present around residents, including one resident who experienced flies landing on their arm and food, and another resident who had to swat flies away from their face. The issue was prevalent in the dining room and hallways, with several flies observed buzzing around while residents ate their meals. Interviews with residents confirmed that flies had been a persistent problem, causing discomfort and annoyance. Staff interviews highlighted the inadequacy of the current pest control measures. Housekeeping and nursing staff reported frequent complaints from residents about flies, and staff resorted to using fly swatters to manage the situation. The Maintenance Director acknowledged the severity of the fly problem and mentioned that the pest control company had visited recently but was still working on a solution. Despite the presence of bug lights and blowers, the facility's efforts were insufficient to control the fly population effectively, as evidenced by the ongoing complaints and observations.
Failure to Provide Routine Showers to Resident
Penalty
Summary
The facility failed to uphold a resident's right to self-determination by not providing routine baths or showers to a resident, identified as Resident #196, since their admission. The resident, who has diagnoses including major depressive disorder, muscle weakness, and pain, was observed to have unkempt hair and facial hair, and expressed feeling unclean and wanting to be shaved. The resident's care plan, which was revised, did not specify the preferred frequency of showers or baths, and the shower sheets from the time of admission showed no documentation of showers being offered or provided. Interviews with staff revealed a lack of a consistent shower schedule and inadequate communication regarding shower refusals or completions. A CNA mentioned that the facility did not have a clear shower schedule and that refusals were not reported but rather attempted again later. Another CNA and an LPN were unaware of the shower schedule, and the LPN noted that residents had complained about missed showers. The interim DON and Corporate Nurse expected showers to be documented and reported if not completed, but there was a disconnect in the process, as evidenced by the resident's unmet needs.
Failure to Complete Timely PASARR Screening
Penalty
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASARR) for a resident prior to or at the time of admission. This deficiency was identified for one resident out of five sampled, who was admitted with diagnoses including recurrent major depressive disorder, dementia, bipolar disease, and Parkinson's Disease. The PASARR form, which is crucial for ensuring appropriate care and services, was completed almost six months after the resident's admission, indicating a significant delay in the screening process. Interviews with the Social Services Director (SSD) and the Administrator revealed that the hospital typically initiates the PASARR or level one screening, and if a level II screening is needed, the resident should remain in the hospital until it is completed. However, in this case, the SSD did not complete the PASARR upon the resident's admission, as they had only been in the position for ten months. The Administrator confirmed that the level one screening should have been completed at the time of admission, highlighting a lapse in the facility's process for ensuring timely completion of PASARR screenings.
Failure to Obtain Timely Lab Tests for Resident
Penalty
Summary
The facility failed to ensure that all residents received care according to professional standards of practice, as evidenced by the failure to obtain ordered blood tests in a timely manner for one resident. The resident, who was cognitively intact, had a history of hearing loss, osteoarthritis, cerebral atherosclerosis, anemia, and a personal history of transient cerebral ischemic attack. The resident was on anticoagulant medication and had a physician's order for a comprehensive metabolic panel (CMP), complete blood count (CBC), and lipid tests to be drawn every three months. However, the facility did not obtain these labs as scheduled in May, following the last draw in February. Interviews with facility staff revealed a lack of clarity and consistency in the process for tracking and obtaining lab tests. A Certified Medication Technician (CMT) confirmed that the last labs were completed in February, and a Licensed Practical Nurse (LPN) noted that the facility had recently implemented a lab tracking book to manage lab orders. However, there was uncertainty about whether the book included ongoing orders or only new ones. The LPN also mentioned that the computer system was supposed to notify staff when labs were due, but it was unclear how this functioned for recurring orders. Further interviews with the Director of Nursing (DON) and Corporate Nurse highlighted that the facility had recently introduced a lab tracking binder to ensure lab orders were followed. However, it was acknowledged that the system for monitoring lab orders was not being effectively utilized, as evidenced by the missed lab draw in May. The DON and Corporate Nurse confirmed that the medical records system did not provide notifications for lab draws, which necessitated the implementation of the lab draw binder to track and ensure compliance with lab orders.
Failure to Communicate with Dialysis Center
Penalty
Summary
The facility failed to ensure that all dialysis residents received services consistent with professional standards of practice by not routinely communicating and collaborating with the dialysis center after appointments. This deficiency was identified for one resident, who was diagnosed with end-stage renal disease, type 2 diabetes, and muscle weakness. The resident's care plan indicated dialysis sessions on Monday, Wednesday, and Friday, with the facility responsible for coordinating transportation. However, the medical record lacked documentation of communication between the facility and the dialysis center, and there was no evidence of follow-up contact after each dialysis visit. Interviews with the resident, transportation staff, and nursing staff revealed that communication forms were not being used or returned from dialysis appointments. The resident confirmed not taking a form to appointments, and transportation staff did not carry any communication forms. Licensed Practical Nurses acknowledged that forms were not sent with the resident, and the dialysis company did not return them. The Corporate Nurse and Administrator both expected communication forms to be completed and returned, but none were found for the resident's dialysis appointments.
Failure to Provide Pureed Menu Items to Residents
Penalty
Summary
The facility staff failed to follow approved menus for residents on pureed diets by not providing cornbread or a comparable substitute during a meal. This deficiency was observed when two residents, who were on pureed diets, did not receive the cornbread listed on the menu for the noon meal. The dietary aide responsible for preparing the meal admitted to forgetting to puree the cornbread, resulting in the residents not receiving it. The facility's policy requires that all pureed food must be used to deliver the correct nutrient density to each resident, and residents on pureed diets should receive the same food options as those on regular diets. The report highlights that the dietary staff, including the dietary manager and registered dietician, were unaware of the issue until it was brought to their attention. Interviews with the dietary aides and the dietary manager revealed that there is a book in the kitchen detailing how to puree all foods, and residents on pureed diets should receive the same foods as those on regular diets, considering their preferences and orders. However, the oversight in providing pureed cornbread was not communicated to the registered dietician or the administrator, who both emphasized the importance of following the menu and ensuring all residents receive the same food choices.
Misappropriation of Resident's Fentanyl Patch by Former Employee
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a fentanyl patch went missing. The resident, who was severely cognitively impaired and had a history of atrial fibrillation, congestive heart failure, shoulder disorder, depression, and convulsions, was on a scheduled pain medication regimen. The resident's care plan included managing pain medication for optimum control and observing for non-verbal signs of pain. On the day of the incident, a Licensed Practical Nurse (LPN) documented the placement of a fentanyl patch on the resident's left upper arm. Later that day, camera footage showed a former employee, identified as a Certified Nurse Aide (CNA), entering the facility through the back door and heading towards the resident's hall. The LPN reported seeing someone run out of the resident's room and out the back door. The LPN and another CNA identified the individual as the former CNA. Upon checking the resident, they found the left gown sleeve pulled down and the fentanyl patch missing, with a slight red outline where the patch had been. Interviews with staff confirmed the procedure for checking the placement of pain patches every shift and documenting their location. The nursing staff also confirmed that the resident's pain patches do not come off easily, and the resident usually refuses to change positions in bed. The Administrator was notified of the incident and confirmed the identity of the former employee through camera footage and staff statements.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
