Grandview Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, Missouri.
- Location
- 201 Grand Ave, Washington, Missouri 63090
- CMS Provider Number
- 265374
- Inspections on file
- 16
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Grandview Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to review and revise care plans when residents’ needs changed. Several residents experienced significant weight loss with physician orders for special diets, supplements, and increased weight monitoring, but these changes were not added to their care plans, and CNAs reported they were unaware of the weight loss. Other residents used bed rails or assist bars observed in daily care, yet their care plans contained no directions for this equipment. A resident with Alzheimer’s disease had the diagnosis documented in the MDS but not in the care plan, and no cognitive interventions were listed. The MDS nurse, who was inexperienced with MDS and care planning, was identified as responsible for updates, while the DON and Administrator stated they expected individualized care plans to reflect weight changes, nutritional interventions, cognitive status, assistive devices, and required assistance levels.
Staff failed to follow abuse and misappropriation protocols when a cognitively intact resident experienced multiple fraudulent charges on their credit card over an extended period, allegedly involving a housekeeper who was later observed by law enforcement using the resident’s card at a gas station. Although facility policy required prompt reporting to the state agency and a thorough investigation of alleged exploitation, there was no documentation that an investigation into this misappropriation was completed, and the current administrator was unaware of the incident until surveyors inquired.
Staff failed to provide adequate daily hygiene and clothing changes for three cognitively impaired residents who required assistance with ADLs. One resident had a care plan directing staff to monitor and remove facial hair as needed, yet was repeatedly observed with long facial hair. Another resident, assessed as needing extensive assistance with hygiene, dressing, and bathing and care planned for two-person assistance and clean clothing daily, was observed wearing the same sweatshirt over multiple days with long facial hair. A third resident, care planned to receive supervision and assistance for all ADLs and clean clothing daily, was also observed in the same sweatsuit over several days with long facial hair. An LPN, the DON, and the Administrator stated that aides are responsible for changing clothes and shaving, charge nurses must ensure cares are completed, and residents’ clothes should be changed daily, but they were unaware these cares had not been provided or documented as refused.
Staff failed to consistently monitor and document bowel movements for two residents at risk for constipation, resulting in prolonged periods without documentation or intervention. One resident was hospitalized with fecal impaction, and staff interviews revealed a lack of awareness and adherence to facility policy regarding bowel movement monitoring and administration of as-needed laxatives.
The facility failed to transmit MDS data for ten residents within the required timeframe. The MDS Coordinator completed the assessments, but the DON, responsible for submission, missed deadlines due to vacations and lack of a backup. The administrator was unaware of submission frequency, contributing to the deficiency.
A resident, who is cognitively intact and uses a motorized wheelchair, was restricted from independently visiting a nearby park, a preferred activity that helps manage their depression and anxiety. Despite being assessed as a safe smoker and having no documented safety issues related to this activity, the facility staff cited safety concerns due to incidents of the resident hitting objects with their wheelchair. The decision was made without proper documentation or communication among staff, leading to a failure in respecting the resident's right to self-determination.
Facility staff failed to maintain and label oxygen equipment properly, leading to a deficiency in infection control. Observations showed that oxygen tubing for several residents was not dated, and concentrator filters were unclean. Interviews with staff revealed a lack of adherence to the facility's policy for regular equipment maintenance and labeling, contributing to the risk of infection spread.
Facility staff failed to connect a resident's nasal cannula to the oxygen concentrator and did not turn it on, despite the resident's severe cognitive impairment and medical conditions requiring oxygen therapy. The resident's care plan lacked directions for oxygen therapy, and staff did not notify the physician of the resident's low oxygen saturation.
Failure to Update Care Plans for Weight Loss, Cognitive Status, and Bed Rail Use
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans when residents’ needs changed, as required by facility policy and federal regulations. The policy states that individualized care plans must be based on thorough assessments, including the MDS, and must be updated with significant changes in condition, at least quarterly, and when changes occur that impact care. Surveyors found that for multiple residents, care plans did not reflect significant weight loss, new or ongoing nutritional interventions, use of bed rails or assist bars, or cognitive diagnoses, despite these being documented elsewhere in the record and observed in practice. For one resident with severe cognitive impairment, stroke, dementia with agitation, anxiety, depression, violent behavior, and stage III chronic kidney disease, the MDS and physician orders showed a soft and bite-sized diet, nutritional supplements (Boost Breeze and Super Cereal), and weekly weights due to weight loss from 155.4 lbs to 140.4 lbs. However, the care plan dated 12/03/25 was not updated to include the recent weight loss, the ordered supplements, or the increased frequency of weights. A CNA reported not knowing the resident had weight loss and stated that if aware, they would have tried to encourage more intake. The MDS Coordinator confirmed that weight loss and related interventions, including supplements and assistance level with eating, should be on the care plan. Another resident with anoxic brain damage, diabetes, stroke, dementia, schizophrenia, gastroparesis, depression, and anxiety experienced a weight decrease from 179.2 lbs to 151.6 lbs over five months. Physician orders included a Level Six soft and bite-sized diet, yogurt twice daily, weekly weights, and a high-calorie supplement. Despite this, the care plan dated 12/15/25 did not document the significant weight loss, the use of nutritional supplements, or the change in weight-monitoring frequency. The CNA who assisted with feeding did not know about the weight loss, and the DON described needing to encourage this resident to eat, while the MDS Coordinator again stated that weight loss and interventions should be reflected in the care plan. A resident assessed as cognitively intact was repeatedly observed in bed with a right grab bar/bed rail in the upright position on multiple days, yet the care plan dated 10/03/25 contained no direction for the use of bed rails. The MDS Coordinator stated that if a resident used bedrails, this should be listed on the care plan. Another resident with severe cognitive impairment, delusions, daily behavioral symptoms, and dependence on staff for eating had a documented weight drop from 129.8 lbs to 103.6 lbs over five months, with physician orders for a regular diet, house supplement, and weekly weights. The care plan dated 12/22/25 did not include the significant weight loss, the nutritional supplement, or the change in weight frequency. The CNA did not know the resident had weight loss and described variable assistance with eating, while the MDS Coordinator reiterated that weight loss and related interventions should be care planned. A further resident with severe cognitive impairment and a diagnosis of Alzheimer’s disease had an admission MDS reflecting this condition, but the care plan dated 11/12/25 did not document the Alzheimer’s diagnosis or include any interventions related to cognitive impairment. The MDS Coordinator stated that the diagnosis should be on the care plan so staff know how to care for the resident. Another resident, cognitively impaired and requiring substantial/maximal assistance for bed mobility and transfers, was repeatedly observed with a left assist bar in the upright position on the bed, yet the care plan dated 10/23/25 did not document direction for use of the assist bar. A CNA stated that bed rails should be listed on care plans and that dementia or Alzheimer’s diagnoses should be included so staff know how to care for residents. Interviews with leadership confirmed expectations that care plans be individualized and updated with changes. The MDS Coordinator reported having worked at the facility for only a couple of months, with no prior experience in MDS or care planning, and acknowledged that care plans should be updated with every change of condition, quarterly, and annually. The DON and Administrator both stated that the MDS nurse is responsible for updating care plans and that they expect care plans to direct resident care and include bed rails, weight loss and interventions, frequency of weight checks, nutritional supplements, cognitive status, and the amount of assistance needed. The Administrator also noted that the facility holds a morning meeting to discuss incidents or changes and expects care plans to be updated when needed based on those discussions.
Failure to Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
Facility staff failed to initiate and complete a thorough investigation into an allegation of misappropriation of a resident’s funds. The facility’s Abuse Prohibition Protocol Manual directed staff to thoroughly investigate alleged violations of abuse, neglect, exploitation, or mistreatment, to prevent further incidents while an investigation was in process, and to take appropriate corrective action based on findings. The policy also required the Administrator or designee to report allegations to the state survey agency within two hours. A cognitively intact resident, as documented on a Significant Change MDS dated 04/23/25, had multiple fraudulent charges made on their credit card over an extended period. A detective reported that a housekeeper employed by the facility was caught using the resident’s credit card at a gas pump and then using their own personal card inside the gas station. The facility’s prior abuse and neglect investigation records did not contain documentation that an investigation into this misappropriation allegation had been completed. The former Administrator stated that the facility was not made aware of any incidents involving the resident’s credit card until after the resident had been discharged and that an investigation was started, but they did not know what happened to it or whether it was finished. The former Administrator also reported that when they spoke with the housekeeper, the housekeeper denied making the fraudulent charges. The current Administrator, who began employment after the incident period, reported having no knowledge of the incident or any facility-reported incident until the survey team began the annual survey and stated that a detailed investigation and timely report to the state agency would have been expected if a misappropriation report had been made. The facility had a practice of discouraging residents from keeping valuables in their rooms and maintained a lock box in the business office for residents’ valuables, but there was no documented investigation into whether other residents were affected or into the specific misappropriation allegation involving this resident.
Failure to Provide Daily Hygiene and Clothing Changes for Dependent Residents
Penalty
Summary
Facility staff failed to provide adequate assistance with activities of daily living (ADLs), specifically personal hygiene, grooming, and clothing changes, for three cognitively impaired residents. For one resident, the Quarterly MDS dated 12/02/25 documented severe cognitive impairment, no behaviors or care refusals, and independence with ADLs, with a care plan directive for staff to monitor and remove facial hair as needed. Despite this, repeated observations from 01/11/26 through 01/14/26 showed the resident consistently had long facial hair, indicating that staff did not follow the care plan related to grooming. A second resident’s admission MDS showed severe cognitive impairment, no behaviors or refusals, and a need for extensive assistance with hygiene, dressing, and bathing, with a care plan dated 12/02/25 directing staff to provide assistance from two staff for all ADLs and to provide clean, appropriate clothing daily. Observations over four consecutive days showed this resident wearing the same grey sweatshirt and having long facial hair. A third resident’s Quarterly MDS documented severe cognitive impairment, no behaviors or refusals, independence with dressing, and moderate assistance needed for hygiene and bathing, with a care plan dated 09/26/25 requiring supervision and assistance for all ADLs and clean clothing daily. Observations over multiple days showed this resident wearing the same green sweatsuit and having long facial hair. In interviews, an LPN, the DON, and the Administrator each stated that aides are responsible for assisting residents with changing clothes and shaving, that charge nurses are responsible for ensuring these cares are completed, and that they were not aware these residents’ clothes were not changed and their faces not shaved, despite expectations for daily clothing changes and shaving as needed, particularly with showers and with documentation of any refusals.
Failure to Monitor and Document Bowel Movements Leads to Fecal Impaction
Penalty
Summary
Facility staff failed to monitor and document bowel movements for two residents, both of whom were assessed as being at risk for constipation and dehydration. The facility's policy required staff to determine daily if residents had a bowel movement, document this information, and notify the charge nurse if a resident had not had a bowel movement in three days. For one resident with impaired cognition and a history of opiate use, staff did not document any bowel movements for over a week, nor did they administer prescribed as-needed laxatives. This resident was ultimately sent to the hospital and diagnosed with fecal impaction. For the second resident, who also had a diagnosis of constipation and was prescribed multiple medications with constipating side effects, staff failed to document bowel movements for several extended periods, including gaps of seven, eight, and eleven days. There was no documentation that as-needed laxatives were administered during these times. Interviews with staff revealed a lack of awareness regarding the residents' bowel movement status and inconsistent monitoring and documentation practices. Staff interviews confirmed that CNAs were responsible for documenting bowel movements each shift and notifying licensed staff if a resident had not had a bowel movement in three days. However, both CNAs and licensed staff were unaware of the prolonged periods without bowel movements for the affected residents, and there was no evidence that appropriate interventions were implemented as required by facility policy and physician orders.
Failure to Transmit MDS Data Timely
Penalty
Summary
The facility failed to transmit the required Minimum Data Sets (MDS) for ten residents within the mandated timeframe. According to the Centers for Medicare and Medicaid Services (CMS) guidelines, all MDS assessments must be transmitted electronically within 14 days of completion. However, the facility did not meet this requirement for ten residents, including those with quarterly, annual, and Significant Change of Status assessments. The facility's census was 48, and the deficiency was identified through interviews and record reviews. Interviews with facility staff revealed that the MDS Coordinator was responsible for completing the MDS, while the Director of Nursing (DON) was responsible for submitting the data. The DON admitted to submitting the data every other week but failed to do so due to taking vacations in June and forgetting to submit upon return. The administrator was unaware of the submission frequency and confirmed that there was no backup person to handle submissions in the DON's absence. This lack of a backup plan contributed to the failure to transmit the MDS data as required.
Failure to Support Resident's Right to Self-Determination
Penalty
Summary
Facility staff failed to respect and promote the rights of a resident to make choices about significant aspects of their life, specifically the choice to independently go outside the facility. The resident, who is cognitively intact and uses a motorized wheelchair, expressed a preference to visit a nearby park independently, which was previously allowed. However, the facility staff recently prohibited this activity, citing safety concerns, despite the resident's ability to operate the wheelchair independently and use a cell phone for assistance if needed. The resident's family member also supported the resident's choice, noting its importance for managing depression and anxiety. The facility's decision was based on an assessment that deemed the resident an unsafe smoker and noted incidents of the resident hitting objects with their wheelchair. Despite these concerns, the resident's medical record did not document any specific safety issues related to the preferred activity of going to the park. Interviews with various staff members, including the Assistant Director of Nursing, MDS coordinator, and Director of Nursing, revealed a consensus on the safety concerns, leading to the restriction of the resident's unsupervised trips. However, there was a lack of communication among staff, as some were unaware of the restriction, highlighting a gap in the implementation of the resident's rights policy.
Deficiency in Oxygen Equipment Maintenance and Infection Control
Penalty
Summary
The facility staff failed to properly manage and maintain oxygen equipment for four residents, leading to a deficiency in infection prevention and control. Observations revealed that oxygen tubing for these residents was not labeled with dates, indicating that it had not been changed as per the facility's policy. Additionally, the oxygen concentrator filters were found to be covered with a white residue, suggesting they were not cleaned regularly. The facility's policy, dated March 2015, requires regular checks and cleaning of oxygen equipment, including changing humidifiers and tubing according to cleaning guidelines. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that oxygen tubing should be changed monthly and labeled with the date of change. However, it was noted that there was no preventative maintenance plan for cleaning oxygen filters. The DON acknowledged the responsibility to ensure tubing changes, while the administrator was uncertain about the frequency of changes, indicating a lack of clarity and adherence to the facility's policy. This lack of compliance with established procedures contributed to the risk of infection spread among residents using oxygen therapy.
Failure to Properly Administer Oxygen Therapy
Penalty
Summary
Facility staff failed to connect a resident's nasal cannula tubing to the oxygen concentrator and did not turn the concentrator on. The resident, who had severe cognitive impairment, was dependent on staff for various activities and had medical conditions including atrial fibrillation, heart failure, and dementia. The resident's care plan did not include directions for oxygen therapy, despite a physician's order for two to five liters of oxygen per minute as needed. On the day of the incident, the resident was found with an oxygen saturation of 55%, and there was no documentation that the physician was notified of this change in condition. Interviews revealed that the CNA working with the resident believed the nasal cannula was connected and the concentrator was on, but later it was found disconnected and off. The LPN confirmed that the resident was too lethargic to have removed the cannula independently. The Director of Nursing and the facility administrator both expected staff to follow physician orders and ensure proper oxygen administration, but this was not done in this case.
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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