Gregory Ridge Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Missouri.
- Location
- 7001 Cleveland Avenue, Kansas City, Missouri 64132
- CMS Provider Number
- 265721
- Inspections on file
- 44
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Gregory Ridge Health Care Center during CMS and state inspections, most recent first.
The facility failed to protect two residents from abuse when they were physically assaulted by peers on separate occasions. In one event, a cognitively impaired resident with a history of aggressive behavior struck another resident multiple times, including to the head, after a disagreement related to smoking, with the victim reporting pain, fear, and needing to call for help while a CNA observed the aggressor beating the resident’s head in the room. In a second event, a severely cognitively impaired, psychotic resident with paranoid delusions and agitation picked up a dining room chair and struck another severely cognitively impaired, psychotic resident who was seated in the dining room, causing a laceration above the eye. Facility leadership and clinical staff, including the DON and a psychiatric NP, acknowledged that the chair incident met criteria for abuse, demonstrating that residents were not kept free from resident-to-resident physical abuse as required by facility policy.
The facility failed to provide individualized, resident-centered activities to meet the psychosocial needs of two residents with serious mental illness. Facility policy required assessment of resident interests, posting of activity calendars, and daily documentation of participation, but calendars were not posted, resident preferences were not clearly identified in care plans, and attendance records were incomplete. One resident, cognitively intact with schizophrenia, anxiety, and bipolar disorder, reported boredom, wanted activities beyond coloring and BINGO and opportunities to go outside, and was sent to the ER after expressing suicidal thoughts later attributed to boredom; staff acknowledged limited activities, especially at night and on weekends, and that the resident had not been specifically asked about preferred activities. Another resident with psychosis and bipolar disorder, with a PASRR Level II requiring a structured schedule, reported there was nothing to do, preferred 1:1 rather than noisy group activities, and had minimal documented activity participation over several months, while the Activity Director stated not knowing the resident’s interests and not consistently documenting attendance.
During a period of extreme outdoor cold and HVAC failure, several resident rooms experienced temperatures below the required 71°F minimum. Staff and maintenance responses were delayed or incomplete, with temperature logs lacking proper documentation. A resident reported feeling cold and had to dress warmly, while a guardian noted that staff did not offer a room move or additional blankets. The facility lacked a comprehensive policy for climate control outages and did not notify state authorities as required.
A resident with a significant psychiatric history and prior self-harm incidents was not provided with the required one-to-one, direct line-of-sight supervision as ordered. Instead, the assigned CNA sat outside the closed room, allowing the resident to access hidden scissors and inflict a serious laceration without immediate staff intervention. The deficiency was identified when the resident later sought help from an LPN, revealing the lack of adherence to supervision protocols.
A resident with a history of behavioral challenges physically assaulted another cognitively impaired resident in a common area, resulting in visible injuries. The attack was witnessed by staff and other residents, and the facility's abuse policy defined such actions as abuse. Despite care plans addressing behavioral risks, the facility did not prevent the incident, and there was uncertainty among leadership about whether the event constituted abuse.
A resident physically assaulted another resident, causing visible injuries. Although law enforcement was notified and the aggressor was taken into custody, facility leadership did not report the incident to the State Agency, citing a lack of malicious intent and significant injury. Staff interviews revealed a misunderstanding of abuse definitions and reporting requirements, resulting in a failure to comply with mandated reporting policies.
A resident with a significant history of self-harm and multiple psychiatric diagnoses did not receive consistent behavioral health services or intensive monitoring as required. Despite repeated incidents of self-injury, staff were often unaware of the resident's history, triggers, or care needs, and the care plan was not updated to reflect new interventions. The facility failed to provide trauma-informed care, counseling, or structured support services, resulting in multiple hospitalizations for the resident.
A receptionist opened a resident's package without permission and in the resident's absence, then discussed the incident with another resident, causing embarrassment and anger. The resident was aware of the correct protocol, which was not followed, and both the DON and Administrator confirmed the receptionist had been educated on resident rights and package handling procedures.
A resident with a history of spasmodic torticollis, schizophrenia, and PTSD had a personal package opened by a newly hired receptionist without their permission or presence, contrary to facility policy. The resident, who was their own responsible party and aware of the correct process, reported the incident after the receptionist argued about the procedure. Staff interviews confirmed the protocol was not followed, and the facility's policy required that residents' mail and packages be received unopened by staff.
A resident did not receive Eliquis as ordered following hospital discharge due to the facility's failure to transcribe the physician's order into the EMR and administer the medication, despite the pharmacy delivering the medication. Staff interviews revealed inconsistent processes for handling discharge paperwork and entering new orders, resulting in a significant medication error.
Two residents with significant mental health diagnoses experienced increased agitation and behavioral incidents due to staff failing to provide timely de-escalation techniques and meet their psychosocial needs, such as facilitating phone calls to family and repairing essential items like a TV and room lighting. Delays in addressing these needs led to property destruction, disruptive behaviors, and a false allegation, despite care plans and facility policies outlining the importance of early intervention and crisis prevention.
A resident with multiple psychiatric conditions was involved in a heated altercation with a CNA over cigarettes, leading to physical aggression. Another resident intervened by attempting to restrain the agitated resident. Video footage showed the CNA kicking at the resident, although contact was unclear. The facility's investigation was incomplete, lacking key interviews, and the incident was not initially classified as abuse, indicating a failure to protect residents from abuse.
The facility failed to ensure proper infection control practices during wound care and medication administration, including the use of Enhanced Barrier Precautions (EBP) and maintaining cleanliness in the medication room. Staff did not consistently change gloves or perform hand hygiene, and there was a lack of EBP signage and PPE availability for residents with open wounds. Additionally, the facility did not provide required TB testing for five residents.
The facility failed to store food properly, leaving opened bags of rice and brown sugar exposed, and a bag of au gratin mix was found with mouse droppings. Rusty shelf racks and uncovered Styrofoam cups on chipped surfaces were noted. Staff demonstrated poor hygiene, with Cook B using a glove dropped on the floor and Dietary Aide B not washing hands after drinking. The Dietary Manager and Administrator acknowledged these issues, highlighting inadequate storage and hygiene practices.
The facility failed to maintain an effective pest control program, resulting in a significant mouse infestation affecting multiple areas and residents. Observations revealed mouse droppings in various locations, including the kitchen and resident rooms. Despite weekly visits from an exterminator, the infestation persisted, with residents and staff reporting frequent sightings of mice. The facility's administration and maintenance were aware of the situation, but the measures taken were insufficient to resolve the infestation.
The facility failed to promote resident dignity by not knocking before entering rooms, affecting three residents. Despite being in-serviced on resident rights, staff, including CNAs, CMTs, and maintenance personnel, were observed entering rooms without knocking. Residents reported feeling disrespected, highlighting a deficiency in upholding dignity and respect.
The facility failed to manage resident trust funds properly, resulting in negative balances for several residents due to withdrawals without sufficient funds. The Business Office Manager acknowledged the issue, and the facility did not provide reconciled bank statements for eight months. The Administrator noted challenges with staff turnover and internet issues, but the facility's failure to adhere to its policies led to the deficiency.
The facility failed to provide privacy for resident phone calls, with the only available phone located at the nurses' station where conversations could be overheard. Two residents, both cognitively intact and with mental health diagnoses, reported discomfort and anxiety due to the lack of privacy and phone outages. Staff confirmed the issue, noting the phone's unreliability and absence of alternative communication methods.
The facility failed to ensure residents' privacy by requiring them to open mail in front of staff, affecting all residents receiving mail. Despite the facility's policy on privacy, staff interviews confirmed this practice, which was acknowledged as inappropriate by the DON.
The facility failed to provide a safe and clean environment, with multiple residents and staff reporting issues such as mouse infestations, damaged infrastructure, and inadequate maintenance. Observations revealed mouse droppings, damaged ceiling and floor tiles, and insufficient cleaning in residents' rooms and common areas. Despite weekly pest control visits, the facility struggled to address these issues, impacting the residents' living conditions.
The facility failed to ensure timely physician visits for residents, with three residents experiencing significant gaps in care. A resident with multiple psychiatric conditions did not receive timely visits, exceeding the required 30-day interval. Another resident had no documented visits between late September and late December. A third resident faced irregular visits, with a notable gap from December to February. The facility's recent change in physician services may have contributed to these oversights.
The facility did not ensure nurse staffing information was posted in accessible areas for all residents, staff, and visitors. Staffing data was only displayed in the lobby and main floor nurse's station, not on the medical, men's, or women's units. Interviews confirmed the lack of postings, particularly in locked units where residents could not access the lobby. The Director of Nursing and Administrator acknowledged the oversight, which violated the facility's policy.
The facility failed to ensure accurate narcotic medication counts and did not follow the policy requiring two nursing staff to count narcotics at shift changes. Discrepancies were found in the narcotic records for several residents, with missing signatures and incorrect counts. Staff interviews revealed that the Controlled Drugs - Count Record was not consistently signed by a second nurse, and the DON was not informed of these issues.
The facility failed to address pharmacy recommendations and ensure appropriate medication use for several residents. A resident's Ibuprofen and Levothyroxine orders lacked necessary instructions, while another resident's Pulmicort inhaler instructions were incomplete. Additionally, a resident was prescribed Valproic Acid without a documented diagnosis. Staff interviews revealed confusion over responsibility for updating medication orders, highlighting systemic issues in medication management.
The facility failed to implement gradual dose reductions (GDR) and non-pharmacological interventions for residents on psychotropic medications, as required by policy. Multiple residents were prescribed psychotropic drugs without documented attempts at GDR, and pharmacy recommendations were not addressed by physicians. Interviews revealed a lack of clarity and responsibility in processing pharmacy recommendations, with the DON identified as responsible but failing to ensure compliance.
The facility failed to properly dispose of garbage and refuse, leading to an overflowing roll-off dumpster and surrounding area with trash, equipment, and furniture. Observations showed the dumpster was full, with additional trash strewn around. Staff interviews revealed issues with dumpster size and removal, and the facility lacked a policy for proper disposal.
The facility failed to provide the required 12 hours of in-service training, including dementia care and ANE, for four CNAs. Despite having a computer-based system to track training, records showed discrepancies, with some CNAs lacking documentation of necessary training hours and topics. The DON and HR were responsible for ensuring compliance, but inconsistent documentation led to the deficiency.
A facility failed to involve a cognitively intact resident in their person-centered care planning process. The resident was not aware of care plan meetings, did not participate in setting goals, and had not seen their care plan. Staff interviews revealed that while invitations were sent to guardians, there was no documentation of invitations or care plan meetings involving the resident, contrary to facility policy.
A resident in a LTC facility was unable to purchase a tablet and headphones with funds provided by their guardian due to a lack of timely action and communication among staff. Despite the guardian sending $200 for the purchase, the items were not bought, and the funds remained in the resident's account. The Activity Director, responsible for the purchase, only visited Walmart once a month and did not have the items on the list for December. The Administrator was ultimately responsible for the purchase, but the delay was due to miscommunication and lack of coordination.
A facility failed to provide a resident with an up-to-date accounting of their trust account balance and delayed the return of funds after discharge. The resident was discharged but received a refund 31 days late, and was incorrectly charged for room and board. Staffing changes and technical issues in the business office contributed to this deficiency.
The facility failed to thoroughly investigate an altercation involving a resident with multiple psychiatric diagnoses and another resident with mental health conditions. The incident, which occurred at the nurse's station, involved a heated exchange over a cigarette box, escalating to physical aggression. The investigation lacked interviews with all involved parties and witness statements, contrary to facility policies on abuse and incident reporting.
The facility failed to notify two residents and their representatives of transfers, and did not inform the Ombudsman of a discharge. One resident was transferred without a discharge notice in their medical record, and another was sent to the hospital without a transfer notice or Ombudsman notification. Staff interviews revealed a lack of awareness and adherence to the facility's notification policy.
A facility failed to accurately assess a resident's dental status on the MDS, indicating no issues despite the resident having no natural teeth or dentures. Interviews and observations confirmed the inaccuracy, with staff acknowledging the MDS should have reflected the resident's true dental condition.
The facility failed to update a resident's care plan after a fall, despite the resident having diagnoses of difficulty in walking and unsteadiness on feet. The MDS Coordinator was responsible for updating care plans, but there was confusion among staff about the timing and process, leading to a deficiency in care planning.
A resident with multiple diagnoses, including paranoid schizophrenia and bipolar disorder, received medications late on several occasions, contrary to the facility's Medication Administration Policy. Interviews with the resident and staff confirmed that medications were frequently administered outside the prescribed time frame, impacting the resident's sleep and care routine.
A resident was discharged from the facility without a comprehensive discharge summary, including a recapitulation of their stay, medication reconciliation, and a post-discharge care plan. Interviews with staff revealed that the charge nurse was responsible for completing these summaries, but the facility policy was not followed, resulting in an incomplete discharge summary.
A resident with malignant neoplasm of the laryngeal cartilage and aphasia did not receive a recommended communication device, impacting their ability to perform activities of daily living. Despite the care plan's interventions, the facility failed to implement the Speech Language Pathology recommendation for a non-speech generating device. Staff were unaware of the recommendation, and the resident expressed a need for a communication board.
A resident with a cognitive impairment and a bothersome cyst on their face missed a dermatology appointment due to transportation issues. The Social Services Director failed to promptly reschedule the appointment and notify the resident's guardian, resulting in a delay of several months before a new appointment was made. The Director of Nursing confirmed the responsibility for rescheduling lay with the Social Services Director.
A facility failed to conduct weekly skin and wound assessments for a resident with a Stage III pressure ulcer on the left heel. Despite the resident's mild risk for pressure ulcers, documentation was inconsistent and lacked necessary details. Interviews revealed that the wound nurse was responsible for assessments, but there was no auditing to ensure compliance.
The facility failed to ensure respiratory equipment was cleaned and stored properly for two residents. Observations showed nasal cannula tubing and CPAP masks were not bagged or dated, and staff interviews revealed inconsistencies in procedures for changing and storing equipment. The DON confirmed the need for weekly changes and proper storage, indicating a lapse in policy adherence.
A resident with bipolar disorder had a low lithium level that was not reported to the physician, contrary to facility policy. The resident's lithium level was 0.4, below the normal range of 0.6 to 1.3, and there was no documentation of physician notification. Interviews revealed that the nursing staff should have reported the low level immediately, and there was no audit system to ensure communication of out-of-range lab values.
The facility failed to provide routine and emergency dental services to two residents, resulting in a deficiency. One resident had loose dentures and had not been seen by a dentist, while another had broken dentures and cavities but had not been scheduled for dental care. A third resident, who was edentulous, had not been offered dental services since admission. Staff interviews revealed a lack of awareness and communication regarding the residents' dental needs.
A resident in an LTC facility was verbally and physically abused by an LPN, resulting in a contusion and knee pain. The resident, with a history of mental health disorders, was subjected to derogatory remarks, hair-pulling, and kicking. Multiple staff witnessed the incident but did not intervene. The LPN, who lacked de-escalation training, was not supposed to be on the unit and was later detained by police. The resident expressed a desire to press charges and felt unsafe unless the LPN was removed.
A resident with a history of mental health disorders was not appropriately de-escalated during a behavioral crisis, leading to physical and verbal abuse by an LPN. The resident's care plan, which included interventions like calm redirection and decreasing stimulation, was not followed. Instead, the LPN engaged in arguments, used derogatory language, and physically abused the resident. Other staff, including agency CNAs, were present but did not intervene effectively due to a lack of training. The facility's failure to ensure staff were CALM certified and to follow protocols resulted in a serious deficiency.
A facility failed to transfer a resident's belongings after discharge to a new facility. The resident, who was cognitively intact, left behind totes of clothes, shoes, and personal items. Despite attempts by the Social Service Directors to arrange a transfer, the belongings remained at the original facility for several months. The Environmental Services Manager and Administrator admitted to a lack of documentation and follow-up, resulting in the resident's items being stored at the facility.
A resident in a long-term care facility was subjected to abuse by a CNA, who pushed the resident into a corner and pinned them against a wall. The incident was captured on video and witnessed by an LPN. The resident, who was cognitively intact, reported feeling sad and described the CNA as aggravating. The facility's policy on abuse was violated, as the CNA's actions were deemed abusive.
Two residents in a facility experienced significant medication errors due to delays in pharmacy delivery and inconsistent medication reordering practices. One resident with schizophrenia and seizures missed doses of Benztropine, Haloperidol, and Vimpat, while another with Diabetes Mellitus II missed doses of Januvia and Lantus, leading to elevated blood sugar levels. Staff interviews revealed a lack of timely medication reordering and communication with physicians.
A resident with a history of alcohol dependence and major depressive disorder was physically abused by the Dietary Manager (DM) in the dining room. The resident, who was cognitively intact, was involved in a verbal altercation and hit the DM, who then retaliated by hitting the resident on the head. The incident was captured on camera, and the DM was escorted out of the facility.
A resident with significant psychiatric issues was transferred to a hospital due to aggressive behavior and medication refusal. The facility failed to provide necessary documentation, including a 30-day bed hold notice and discharge summary. After over 30 days in the hospital, the facility did not accept the resident back, citing no available bed, leading to a deficiency in compliance with transfer and discharge regulations.
A resident with mental health conditions was transferred to a hospital for treatment, but the facility failed to provide a bed hold notice to the resident or their guardian. After stabilization, the facility did not readmit the resident, citing a lack of available beds and behavioral concerns. The absence of documentation regarding the bed hold policy and discharge contributed to the deficiency.
Failure to Protect Residents From Peer-to-Peer Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, specifically resident-to-resident physical abuse, in two separate incidents. Facility policy dated 6/12/24 states that the facility is committed to protecting residents from abuse by anyone, including other residents, and defines abuse as the willful infliction of injury with resulting physical harm, pain, or mental anguish. The policy also states the facility will identify events, patterns, and trends that may constitute abuse and investigate them thoroughly. Despite this policy, surveyors identified two sampled residents who were not kept free from abuse when they were physically struck by other residents. In the first incident, a resident with schizoaffective disorder, bipolar disorder, vascular dementia, severe cognitive impairment, and a documented history of exit-seeking and aggressive behaviors with staff and peers at a prior placement struck another resident. The aggressor resident had significant memory issues, mood swings, depression, and tended to stay away from others with slow verbal responses. The victim resident had PTSD, depression, anxiety, adjustment disorder, panic attacks, poor impulse control, poor insight and judgment, irritability, and required more supervision due to poor decision making and behaviors. According to the facility’s incident report, the aggressor resident approached staff requesting to smoke and was told it was not time; the victim resident also stated it was not time for a smoke break. As the victim resident walked away from a table outside the dining room, the aggressor resident hit the victim in the back of the head. The victim reported pain to the back of the head and forearm, stated that the aggressor hit him/her several times on the head, face, and arm, screamed for help, and tried to redirect the aggressor out of the room, expressing feeling scared around the aggressor and relief that the aggressor was gone. Additional information from staff interviews further described the first incident. A CNA reported that another resident called out and the CNA then observed the aggressor resident in the victim’s room “beating” the victim’s head while the victim was in bed and the aggressor was standing. The CNA stated that after getting the victim out of bed, the aggressor came toward them, and the CNA instructed the victim to count to three so they could back up and run out of the room to get away from the aggressor. The Administrator acknowledged that an incident of abuse occurred when the aggressor struck the victim in the back of the head. The aggressor later stated that the victim had hit him/her on the cheek, so he/she hit the victim back in the stomach while inside the smoke room. In the second incident, another resident with schizophrenia, psychosis, bipolar disorder with psychotic features, borderline personality disorder, severe cognitive impairment, mood lability, paranoid delusions, agitation, intrusiveness, and a history of medication non-compliance struck a peer with a chair. This resident had significant fixed delusional ideation, was preoccupied with being continuously raped, and exhibited labile mood, agitation, rapid pressured speech, paranoia, and internal preoccupation. The victim in this incident had schizophrenia, chronic paranoid schizoaffective disorder, alcohol dependence, polysubstance abuse, a long history of psychiatric treatment and LTC placements, legal problems associated with substance use, homicidal ideation, threatening behaviors, mood lability, agitation, depression, continual auditory and visual hallucinations (many command in nature), severe paranoia, and severe cognitive impairment. The victim required verbal direction for personal care, supervision due to disorganization, and monitoring of what the hallucinated voices were telling him/her to do. According to the progress note and incident report, the aggressor resident walked into the dining room where the victim was sitting with staff nearby and was observed pacing without clear evidence of anticipated aggression. Without provocation, the aggressor quickly picked up a dining room chair and threw or struck the victim with it. The victim raised an arm to block the chair while staff verbally directed the aggressor to stop. The victim sustained a small pin-sized scratch above the right eye with some swelling and bleeding that stopped after cleaning; later observation showed a laceration above the right eye that was well approximated with redness and swelling. At the time of surveyor observation, the victim was alert to self but unable to be interviewed, and the aggressor was displaying behaviors and could not be interviewed, with the Assistant Administrator stating it was not safe to be around the aggressor. The DON, Assistant Administrator, Regional Care Plan Coordinator, and psychiatric NP all stated that the incident in which the aggressor struck the victim with a chair met the criteria for abuse. These two events demonstrate that the facility did not ensure that residents were free from abuse by other residents, as required by its own policy and regulatory standards.
Failure to Provide Resident-Centered Activities to Meet Psychosocial Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide an ongoing program of activities designed to meet residents’ interests and their physical, mental, and psychosocial well-being, as required by facility policy. The policy stated that the Life Enhancement/Activity Director would coordinate comprehensive assessments, identify residents’ likes and dislikes, post activity calendars on each unit, and ensure daily documentation of resident participation in activities. Surveyors found that activity calendars were not posted, resident-specific activity interests were not consistently identified or documented, and daily participation records were incomplete or missing. Staff interviews revealed that CNAs and nurses did not know where to find information on residents’ preferred activities and had not been educated on those preferences. For one resident with schizophrenia, anxiety, and bipolar disorder, who was documented as cognitively intact and had a legal guardian, the care plan referenced behavior problems and risk for anxiety, with instructions for staff to provide a program of activities of interest and to offer activities to prevent boredom and provide healthy outlets for energy. However, the care plan did not specify which activities the resident enjoyed. The resident had been sent to the ER after expressing suicidal and self-harm threats; the facility’s investigation documented that the resident later stated he was bored and wanted to get out of the building, and the conclusion of the investigation was that the resident was not engaged in meaningful activities. The resident reported hearing voices telling him to do something bad to himself and stated he would have liked to do something besides coloring or bingo and to do something outside the building. Multiple staff, including CNAs, an LPN, the SSD, and the Activity Director, acknowledged that there were limited activities, especially at night and on weekends, and that the resident had not been specifically asked what types of activities he would like. For another resident with psychosis and bipolar disorder, who had a legal guardian and a BIMS score indicating moderate cognitive impairment, the care plan stated that staff should offer activities to prevent boredom, ensure activities were compatible with the resident’s capabilities and interests, adapt activities as needed, and invite the resident to scheduled activities. The care plan did not identify specific activities of interest. A PASRR Level II evaluation required provision of a structured environment and a schedule of daily tasks or activities. The resident reported that there was nothing to do, that staff had never asked what activities he would like, that he preferred 1:1 activities rather than large noisy groups, and that he wanted more than bingo and more activities on weekends. Activity documentation showed the resident attended activities on only two dates over more than two months, with no documented participation after the second date. The Activity Director stated not knowing what the resident liked to do and admitted not always documenting attendance. Overall, interviews with the Activity Director, Administrator, DON, and other staff confirmed that residents were not consistently assessed for activity preferences, calendars were not consistently posted, and there were few structured activities in the evenings and on weekends, contributing to residents’ reports of boredom and lack of engagement.
Failure to Maintain Safe Room Temperatures and Notify Authorities During HVAC Outage
Penalty
Summary
The facility failed to maintain resident room temperatures within the acceptable range of 71 to 81 degrees Fahrenheit during periods of outdoor temperature extremes, specifically during a heating system failure. Documentation showed that several resident rooms had temperatures as low as 60.7 F, 62.1 F, and 63.6 F over multiple days, with temperature logs often lacking signatures, dates, or clear identification of responsible staff. The deficiency was further compounded by the lack of a comprehensive, facility-specific policy and procedure for climate control system outages, and the absence of clear guidance on when to notify state agencies or the Department of Health and Senior Services (DHSS) disaster line in the event of such failures. Interviews with staff and residents revealed that the heating issues began when a resident reported a malfunctioning unit via a QR code maintenance request. The Maintenance Director responded by contacting a heating company, but repairs were delayed due to unavailable parts. Additional rooms were later found to have similar heating issues, and staff began taking hourly temperature logs. Residents reported feeling cold, with one resident stating they had to cover up and dress warmly, and another's guardian expressing concern that staff did not offer to move the resident or provide additional blankets and warm clothing. The facility's emergency disaster manual referenced maintaining interior temperatures above 71 F and outlined steps for offering blankets or room moves in emergencies, but did not specify when to notify state authorities or provide a clear process for handling HVAC outages. The Administrator acknowledged the lack of a policy for contacting the disaster line and was unaware that multiple individual unit failures required state notification. These deficiencies had the potential to affect all residents, staff, and visitors in the facility.
Failure to Provide Ordered One-to-One Supervision for Resident with History of Self-Harm
Penalty
Summary
A deficiency occurred when facility staff failed to provide ordered one-to-one supervision in direct line of sight for a resident with a known history of self-harm. The resident, who had multiple psychiatric diagnoses including schizophrenia, bipolar disorder, borderline personality disorder, and a documented history of self-injury and suicide attempts, was placed on one-to-one monitoring per physician order and care plan. The care plan specified that staff were to supervise the resident at all times, especially when the resident had access to sharp objects, and to never leave the resident alone with such items. Despite these orders and the facility's policy requiring one-to-one supervision within eyesight, the assigned CNA sat outside the resident's room with the door closed during the night shift. The CNA reported being told by an unknown staff member that it was acceptable to sit outside the room and keep the door closed, and was unaware of the requirement to remain inside the room with the resident. During this period, the resident accessed a pair of small scissors hidden in a birthday gift and used them to inflict a 7 cm by 3 cm laceration on their left forearm. The incident was not immediately detected by staff, as the resident did not communicate their distress or the act of self-harm to the staff member assigned to monitor them. The failure to maintain direct line-of-sight supervision allowed the resident to self-harm without intervention. The incident was discovered only after the resident sought help from an LPN for a PRN medication, at which point the injury was noticed. Interviews with staff and the resident confirmed that the required supervision protocols were not followed, and that the resident was left unsupervised with the door closed, contrary to facility policy and physician orders.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when one resident physically assaulted another in a common area. The incident occurred when a resident with a history of disorganized schizophrenia, major depressive disorder, and substance abuse approached another resident from behind and struck them in the head and neck, knocking them to the floor, and then proceeded to kick and stomp on the resident's head and body multiple times. The assaulted resident sustained bruising on the forehead, minor swelling on the back of the head and neck, and a small scratch on the left cheek. Multiple staff and resident witnesses confirmed the violent nature of the attack, and the assaulted resident urinated on themselves during the incident. Both residents involved had significant psychiatric histories, including schizophrenia and anxiety disorders. The resident who committed the assault was documented as cognitively intact on the most recent assessment and had a care plan indicating a history of behavioral challenges requiring protective oversight. The assaulted resident was cognitively impaired and had a care plan addressing anxiety and behavioral symptoms, with interventions to monitor and de-escalate anxiety-related behaviors. Despite these documented risks and interventions, the facility did not prevent the physical altercation from occurring in a supervised area shortly before lunch. Interviews with staff and residents revealed that the altercation was witnessed by several individuals, including the Business Office Manager and the Activities Director, who described the attack as violent and unprovoked. The facility's abuse and neglect policy defined abuse as the willful infliction of injury or pain, including resident-to-resident altercations. However, some facility leadership expressed uncertainty about whether the incident constituted abuse, citing the aggressor's mental state and possible provocation. The police were called, and the aggressor was arrested and charged with assault. The incident was reported to the guardian of the assaulted resident and local law enforcement.
Failure to Report Resident-to-Resident Physical Abuse to State Agency
Penalty
Summary
The facility failed to report an incident of physical abuse to the State Agency as required by regulation. On 10/27/25, one resident approached another from behind in a common area, struck the individual in the head and neck, knocked them to the floor, and proceeded to kick and stomp on their head and body multiple times. The assaulted resident sustained bruising, minor swelling, and a scratch, and was attended to by facility nurses. Law enforcement was notified, and the aggressor was taken into custody and charged with assault. The incident was documented in progress notes and a facility investigation, and the victim's guardian was later informed. Despite the severity of the incident and the physical injuries observed, the facility leadership, including the DON, Regional Director of Operations, Regional Nurse Consultant, and Administrator, did not consider the event to be abuse. Their rationale was based on their interpretation that abuse requires malicious intent or significant injury, and they believed the aggressor's mental state or possible intoxication made the behavior unpredictable rather than willful. As a result, the team decided not to report the incident to the State Agency, even though the facility's policy and the State Operations Manual require reporting of such events within 24 hours if they are deemed reportable. Interviews with facility staff and consultants revealed a consistent misunderstanding or misapplication of the definitions of abuse and reportable events. Several staff members stated that, in their view, the absence of serious injury or clear malicious intent meant the incident was not reportable. The guardian of the assaulted resident expressed concern about not being fully informed and indicated that, had they known the extent of the incident, they would have requested further medical evaluation. The facility's failure to report the incident as required constitutes the identified deficiency.
Failure to Provide Behavioral Health Services and Monitoring for Resident with Self-Harm History
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a known history of self-harm, as required by federal regulations and the resident's PASRR assessment. Despite clear documentation of the resident's extensive psychiatric diagnoses—including schizophrenia, bipolar disorder, borderline personality disorder, and a history of self-harm and suicide attempts—the facility did not consistently implement recommended intensive monitoring or individualized interventions. The resident experienced multiple incidents of self-harm, such as cutting with broken glass and razor blades, hitting walls, and banging their head, resulting in injuries that required emergency medical attention. These incidents were not consistently followed by updates to the care plan or the implementation of new interventions to address the resident's triggers or supervision needs. Staff interviews revealed a lack of awareness regarding the resident's behavioral health history, triggers, and required interventions. Several staff members were unaware of the resident's history of self-harm or the need for one-to-one monitoring, and some had not reviewed the care plan or received relevant behavioral health training. The facility's own policy required intensive or one-to-one monitoring for residents at risk of self-harm, but documentation showed inconsistent application of these measures, with periods where the resident was not under required observation despite recent incidents. Additionally, the care plan was not updated after repeated self-harm events, and did not include interventions related to supervision, known triggers, or parameters for pharmacological interventions. The resident's medical record lacked evidence of trauma-informed services, positive behavioral support, counseling, or other behavioral health services as indicated in the PASRR and required by the care plan. There was no documentation of daily living skills training, structured environment, or socialization supports. The failure to provide these services and to ensure staff were knowledgeable about the resident's needs resulted in repeated self-harm incidents and multiple hospitalizations for the resident.
Failure to Honor Resident Dignity and Rights During Package Handling
Penalty
Summary
Receptionist A failed to maintain a resident's dignity by opening the resident's package without permission and in the absence of the resident, contrary to facility protocol. The resident, who was moderately cognitively intact and his/her own responsible party, was aware of the correct process for package handling, which required the Activity Director or a designated staff member to allow the resident to open the package, log the contents, and update the inventory sheet. Receptionist A opened the package, placed the contents on top of the box, and argued with the resident when confronted about the breach of protocol, claiming to have been instructed to open packages. The resident reported the incident to the Activity Director and later called the hotline to report the issue, expressing feelings of anger and embarrassment. A second resident, who was cognitively intact, witnessed the incident and confirmed that Receptionist A told him/her that the first resident had gotten him/her into trouble. This public comment further embarrassed the resident involved. Interviews with the DON and Administrator confirmed that Receptionist A had been educated on resident rights and the correct process for handling packages, and both stated that the receptionist should not have opened the package or discussed disciplinary matters with residents. Receptionist A, who had only been employed for a few weeks, denied knowledge of the protocol and denied making comments to other residents, despite evidence to the contrary.
Resident's Package Opened by Staff Without Permission
Penalty
Summary
Facility staff failed to follow policy regarding residents' rights to privacy and access to their personal mail and packages. Specifically, a resident who was their own responsible party and had a history of spasmodic torticollis, schizophrenia, and PTSD, had a personal package opened by a newly hired receptionist without the resident's permission or presence. The resident, who was moderately cognitively intact and had no negative behaviors documented, was aware of the facility's process for handling packages, which required the Activity Department to be present so that items could be logged and added to the resident's inventory sheet. The incident occurred when the resident received an alert that a package had arrived and requested the receptionist to check for it. The receptionist initially denied the package's arrival, but upon checking, returned with the package already opened and its contents exposed. The resident expressed to the receptionist that packages should not be opened without the resident present, but the receptionist argued, claiming they had been instructed to open packages. The resident subsequently reported the incident to the Activity Director. Interviews with facility staff, including the Activity Director, DON, and Administrator, confirmed that the protocol was not followed and that the receptionist had been educated on resident rights and the correct process for handling packages. The receptionist, however, stated they were unaware of the policy and opened the package for the resident, only later being informed of the correct procedure. The facility's policy clearly stated that residents' mail and packages were to be received promptly and unopened by staff, and this protocol was not adhered to in this instance.
Failure to Transcribe and Administer Ordered Anticoagulant Medication
Penalty
Summary
A significant medication error occurred when the facility failed to transcribe and administer a physician's order for Eliquis, an anti-blood clotting medication, for one resident following their hospital discharge. The resident was readmitted to the facility with a hospital discharge order for Eliquis 5 mg twice daily, but this order was not entered into the facility's electronic medical record (EMR), and the medication was not administered throughout the month. The pharmacy delivered the medication to the facility, and it was signed for by an LPN, but there was no documentation of the medication being given to the resident or of the order being entered into the system. Interviews with facility staff revealed inconsistent processes for handling hospital discharge paperwork and entering new medication orders. Nurses were expected to input orders from hospital paperwork into the EMR and follow up with the hospital or physician if paperwork was missing. However, staff reported that residents sometimes returned without necessary documentation, and there was no clear accountability for ensuring orders were entered and medications administered. The LPN who received the Eliquis could not recall to whom the medication was given, and the facility was unable to determine which staff member took the medication to the resident's unit. Further interviews with the regional nurse, physicians, and the interim DON confirmed that the discharge order for Eliquis was present in the hospital paperwork and sent to the pharmacy, but not entered into the facility's records or communicated to the appropriate staff. The resident did not experience any adverse outcomes from not receiving the medication, but the failure to transcribe and administer the ordered Eliquis represented a significant medication error as per the facility's own policies and procedures.
Failure to Provide Timely De-Escalation and Psychosocial Support for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to provide timely de-escalation techniques and meet the psychosocial needs of two residents with known mental health diagnoses. For one resident with multiple psychiatric diagnoses, including bipolar disorder, schizoaffective disorder, schizophrenia, PTSD, and borderline personality disorder, staff did not respond promptly to requests to use the phone to contact family, despite the resident's known triggers of unmet needs and waiting. The resident became increasingly agitated, resulting in the destruction of personal property and the escalation of delusional behaviors, including a false allegation of sexual assault. Interviews with staff and the resident confirmed that the unit phone had been broken for an extended period, and staff did not consistently facilitate timely access to an alternative phone, contributing to the resident's distress and behavioral escalation. Another resident with schizoaffective disorder, schizophrenia, PTSD, major depressive disorder, and other mental health conditions experienced frustration and behavioral outbursts due to delays in repairing essential items in their environment, such as a broken television and a non-functioning light in their room. The resident reported increased agitation and disruptive behaviors, including throwing objects, as a result of not being able to watch sports or read in their room for several weeks. Staff interviews confirmed that the repairs were delayed, and the resident's needs were not met in a timely manner, which contributed to the escalation of behaviors. Both residents had care plans that identified their mental health needs and triggers, but there was a lack of timely intervention and communication from staff to address their requests and prevent escalation. The facility's own policies emphasized the importance of early intervention, crisis prevention, and meeting residents' needs to avoid behavioral emergencies. However, the failure to provide prompt attention to the residents' requests and environmental needs led to increased agitation, behavioral incidents, and, in one case, a false allegation requiring extensive investigation.
Failure to Protect Resident from Abuse During Cigarette Dispute
Penalty
Summary
The facility failed to protect a resident, identified as Resident #9, from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and another resident. On the day of the incident, Resident #9, who has a history of impulse disorder, borderline intellectual functioning, schizophrenia, bipolar disorder, anxiety disorder, and PTSD, was involved in a confrontation with CNA K over cigarettes. The situation escalated when Resident #9, after being denied cigarettes, became agitated and attempted to physically attack CNA K. During the altercation, another resident, Resident #89, intervened by attempting to place Resident #9 in a chokehold. The facility's video footage, although undated and without audio, showed CNA K and Resident #9 engaging in a heated verbal exchange, with CNA K forcefully pointing at Resident #9. The charge nurse intervened by positioning themselves between the two, but the situation further escalated when Resident #9 lunged at CNA K. Resident #89 then attempted to restrain Resident #9 by the neck. The video also captured CNA K kicking at Resident #9, although it was unclear if contact was made. The facility's investigation into the incident was incomplete, lacking interviews with key witnesses and involved residents. The facility's policies on abuse and neglect, as well as resident rights, were not adequately followed, as evidenced by the staff's inappropriate interactions with Resident #9 and the failure to conduct a thorough investigation. The Director of Nursing and the Administrator acknowledged the inadequacy of the investigation and the inappropriate behavior of the staff involved. Despite the video evidence and witness statements indicating potential abuse, the facility's leadership did not initially classify the incident as such, highlighting a significant deficiency in protecting residents from abuse.
Infection Control and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control practices during wound care for three residents, including the use of Enhanced Barrier Precautions (EBP) and appropriate signage and availability of Personal Protective Equipment (PPE). Observations revealed that staff did not consistently change gloves or perform hand hygiene between tasks, leading to potential cross-contamination. For instance, during wound care for a resident with multiple wounds, the LPN did not change gloves or sanitize hands between handling different wounds and touching various objects in the room. Additionally, there was a lack of EBP signage and PPE availability for residents with open wounds, which was acknowledged by the staff during interviews. The facility also failed to maintain cleanliness and hand hygiene in the medication room on the Men's Locked Unit. Observations showed that the medication room was dirty, with no hand soap or paper towels available, and staff did not perform hand hygiene during medication passes. The CMT did not have hand sanitizer on the medication cart and failed to cleanse hands before and after administering medications to residents. Interviews with staff indicated a lack of clarity on who was responsible for cleaning the medication room, and it was noted that housekeeping did not have access to the room. Furthermore, the facility did not provide Tuberculosis (TB) testing for five residents, as required by their policy. The policy mandates TB testing upon admission and readmission, but this was not conducted for the sampled residents. The Director of Nursing acknowledged the oversight and the responsibility to ensure compliance with infection prevention and control measures, including the use of EBP and maintaining a clean environment for medication administration.
Food Storage and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to store food in a manner that protected it from mice and other contaminants, as observed during a kitchen tour. Large, opened bags of rice and brown sugar were found under the main storage prep table without being closed or dated. Additionally, a bag of au gratin mix was found with a chewed-off corner, mouse droppings, and yellow stains, indicating a pest issue. The facility also had rusty shelf racks that were not easily cleanable, and uncovered Styrofoam cups were stored on chipped and peeling surfaces. Furthermore, a bag of breadcrumbs was left open, not sealed, and dated, with gnats present and black discolored areas on the bag. These practices were not in line with the facility's policy, which lacked specific guidelines on handwashing, glove use, and food storage. The facility's staff demonstrated poor hygiene practices, as observed with Cook B and Dietary Aide B. Cook B was seen picking up a glove from the floor and continuing to handle food without changing it. Dietary Aide B was observed handling food with gloves, removing them to drink from a personal soda bottle, and then returning to food preparation without washing hands. The Dietary Manager and Administrator acknowledged these issues, stating that handwashing should occur when transitioning from dirty to clean activities and that food should be stored in sealed containers to prevent exposure to pests. The facility had a known mouse issue, with an exterminator visiting weekly, but the storage and hygiene practices observed were inadequate to protect food from contamination.
Ineffective Pest Control Leads to Mouse Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant mouse infestation affecting multiple areas and residents. Observations revealed mouse droppings in various locations, including the front conference room, kitchen, and resident rooms. In the kitchen, food items such as a bag of au gratin mix were found chewed and contaminated with mouse droppings and stains. Large, opened bags of rice and brown sugar were improperly stored, increasing the risk of pest contamination. Interviews with staff confirmed the ongoing mouse problem, despite weekly visits from an exterminator. Residents reported seeing mice in their rooms, with droppings found along baseboards and near beds. One resident noted that their mattress was on the floor, allowing mice to get into their bed. Another resident mentioned holes under the heating unit and in the baseboards, which they believed were entry points for the mice. Despite daily housekeeping efforts, mouse droppings persisted, indicating an ineffective pest control strategy. Staff interviews highlighted the severity of the issue, with reports of mice running through the facility, including the dining room and hallways. The maintenance director acknowledged the problem, attributing it to the cold weather and proximity to a field. Although a new pest control company was engaged, the infestation continued, with sticky traps proving ineffective. The facility's administration and maintenance were aware of the situation, but the measures taken were insufficient to resolve the infestation.
Failure to Promote Resident Dignity by Not Knocking Before Entering Rooms
Penalty
Summary
The facility failed to uphold the dignity and respect of three residents by not adhering to the policy of knocking before entering their rooms. Resident #66, who was moderately cognitively intact, expressed feeling disrespected as staff entered without knocking. This was observed on multiple occasions, including when a Certified Medication Technician, a Certified Nursing Assistant, and maintenance staff entered the room without knocking. Similarly, Resident #78, who was moderately cognitively impaired, reported that staff entered without knocking, which was corroborated by observations of a CNA and an Environmental Services Assistant Supervisor entering without knocking. Resident #98, who was cognitively intact, also reported that staff did not knock before entering, and this was observed when maintenance staff entered the room without knocking. Interviews with various staff members, including a CMT, CNA, LPN, and the Director of Nursing, confirmed that they were in-serviced on resident rights and were instructed to knock and wait for an answer before entering rooms. Despite this training, the observations and resident reports indicate a failure to consistently implement this practice, leading to a deficiency in promoting resident dignity and respect.
Deficient Management of Resident Trust Funds
Penalty
Summary
The facility failed to properly manage and safeguard resident trust funds, resulting in the commingling of funds and negative balances for several residents. Specifically, six residents were identified with negative balances in their trust fund accounts, indicating that the facility allowed withdrawals without sufficient funds. The facility's policy mandates that resident trust fund money be safeguarded using separate accounting principles to prevent commingling, and that a reconciliation of the bank statement, checkbook, and electronic health records module be completed monthly by the corporation's staff accountant. However, the facility did not adhere to these policies, as evidenced by the negative balances and incomplete reconciliations. The facility's Business Office Manager (BOM), who had been in the position for only a week, acknowledged that negative balances occurred because residents were allowed to withdraw cash without having sufficient funds. The BOM also noted that corporate was responsible for completing bank reconciliations and maintaining documentation, but the facility failed to provide reconciled bank statements for eight of the past twelve months. The BOM highlighted residents with low account balances to prevent future negative balances, but this practice was not in place at the time of the deficiency. Interviews with the Administrator revealed that there had been significant turnover and issues within the business office, including the resignation of the previous BOM and temporary coverage by a regional person. The facility also experienced internet issues, which led to handwritten reconciliations. Despite these challenges, the Administrator stated that the resident trust fund account was supposed to be reconciled daily to ensure accurate balances. The facility's failure to maintain proper accounting and reconciliation practices resulted in the potential for all residents with trust fund accounts to be affected by these deficiencies.
Lack of Privacy for Resident Phone Calls
Penalty
Summary
The facility failed to provide privacy for residents using the facility telephone, affecting two sampled residents out of 23. The facility's policy on resident rights mandates that residents should have reasonable access to a telephone for private calls. However, observations revealed that the only available phone was located at the nurses' station in the hallway, where other residents could overhear conversations. This lack of privacy was confirmed through interviews with residents and staff, who reported that the phone lines and internet had been down for several days, further complicating communication. Resident #19, who was cognitively intact and had multiple diagnoses including schizoaffective disorder and PTSD, expressed discomfort with the lack of privacy when using the phone. The resident reported feeling nervous as other residents could hear their conversations, and there was no alternative phone available for private use. Similarly, Resident #112, also cognitively intact and diagnosed with bipolar disorder and anxiety, reported being unable to contact family due to the phone outage and lack of privacy, which increased their anxiety. Staff interviews corroborated the residents' concerns, with a Certified Medication Technician and an LPN acknowledging the lack of privacy and the phone's unreliability. The Director of Nursing confirmed that the men's unit lacked a private phone area, and there was no alternative communication method when the phone lines were down. The women's unit had a similar issue, with the only phone available being in a non-private area, and previous attempts to provide privacy had failed due to residents damaging the phones.
Failure to Ensure Privacy in Mail Handling
Penalty
Summary
The facility failed to ensure the right to open mail privately for two residents, potentially affecting all residents who receive mail. The facility's policy on resident rights emphasizes privacy and dignity, yet residents were required to open their mail in front of staff. Resident #99, who was cognitively intact, expressed discomfort with this practice, stating a preference for opening mail privately. Similarly, another resident, also cognitively intact, expressed dissatisfaction with having to open mail in front of staff, although they would be comfortable if the mail was addressed to them in care of the facility. Interviews with various staff members, including CNAs, the Activity Director, and the Social Services Director, confirmed that residents were required to open their mail in front of staff to prevent contraband and ensure receipt. The Director of Nurses acknowledged that residents should be able to open their mail privately unless there are specific restrictions placed by a guardian. Despite this acknowledgment, the practice of requiring residents to open mail in front of staff persisted, leading to a deficiency in maintaining residents' rights to privacy.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by multiple observations of damaged infrastructure and pest infestations. Several residents reported seeing mice in their rooms and throughout the facility, with mouse droppings found on floors, baseboards, and even on personal items such as oxygen equipment. The presence of mice was corroborated by staff, who acknowledged the ongoing pest issue despite weekly visits from a pest control company. Additionally, the facility's maintenance and housekeeping efforts were insufficient to address these problems, as evidenced by the persistent presence of mouse droppings and damaged infrastructure. Residents reported various issues with their living conditions, including damaged ceiling and floor tiles, leaking ceilings, and inadequate window coverings. These conditions were observed in multiple rooms, with some residents experiencing leaks from the ceiling due to plumbing issues in rooms above them. The maintenance director admitted that the building's age contributed to frequent leaks and that staffing shortages hindered timely repairs and maintenance. Residents also expressed concerns about the cleanliness of their rooms, with some reporting that housekeeping did not adequately clean areas such as heating and cooling registers. The facility's failure to maintain a clean and safe environment extended to the medication room on the Men's Locked Unit, which was not kept clean, and lacked hand hygiene products for staff. The facility's inability to provide a homelike environment was further highlighted by the presence of stained and loose floor tiles, broken ceiling tiles, and inadequate lighting in residents' rooms. Despite residents and staff reporting these issues, the facility did not take effective action to resolve them, resulting in ongoing safety and hygiene concerns for the residents.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at the required intervals, specifically every 30 days for the first 90 days and then at least every 60 days thereafter. This deficiency was identified for three residents out of a sample of 23, with a facility census of 111 residents. The report highlights that Resident #9, who was admitted with multiple psychiatric conditions, did not receive timely visits from their physician, with gaps exceeding the required 30-day interval. Similarly, Resident #108 experienced a significant lapse in physician visits, with no documented visits between late September and late December 2024. Resident #89 also faced irregular physician visits, with notable gaps in care, including a period from December 2023 to February 2024 without a physician visit. Additionally, Resident #107 did not have a documented physician visit upon admission and had not been seen by a physician or NP since early September 2024. These lapses in physician visits were compounded by a change in physician services in September 2024, which may have contributed to the oversight. During an interview, the Director of Nursing, who had been in the position for about two weeks, acknowledged the responsibility to ensure regular physician visits. The DON confirmed that the facility had recently changed physician services, which might have affected the scheduling and documentation of visits. The report underscores the facility's failure to adhere to regulatory requirements for physician visits, as evidenced by the documented gaps in care for the sampled residents.
Failure to Post Nurse Staffing Information in Accessible Areas
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a prominent and readily accessible area for all residents, staff, and visitors. The facility's policy required that staffing data, including the facility name, current date, resident census, and the number of hours worked by RNs, LPNs, and CNAs, be posted daily at the beginning of each shift in a location accessible to everyone. Observations revealed that staffing information was only posted on a wipe board in the lobby and at the nurse's station on the main floor, but not on the medical, men's, or women's units. Interviews with various staff members, including CNAs, LPNs, the Staffing Coordinator, and the Director of Nursing, confirmed that staffing information was not consistently posted across all units, particularly in locked units where residents could not access the lobby without assistance. The Director of Nursing and the Administrator acknowledged that staffing information should have been accessible to all residents, including those in locked units. The Administrator stated that the Staffing Coordinator and the receptionist were responsible for updating the staffing information. However, due to the lack of postings on certain units, residents in locked areas did not have access to this information unless they left the facility. This oversight resulted in a failure to comply with the facility's policy and ensure transparency and accessibility of staffing information for all residents and visitors.
Narcotic Count Discrepancies and Policy Non-Compliance
Penalty
Summary
The facility failed to ensure accurate narcotic medication counts and did not adhere to the policy requiring two nursing staff to count narcotics at the beginning and end of each shift. The facility's Administration and Accountability Policy mandates that all controlled substances be accounted for, with two licensed nurses responsible for counting and signing off on the narcotic count at the end of each shift. However, the review of the Controlled Drugs - Count Record for the Men's Locked Unit revealed significant discrepancies. On the day shift, out of 38 opportunities, four were blank, and 30 shifts were signed by the same person without a second signature. On the night shift, 35 out of 36 opportunities were blank. Additionally, there was a discrepancy in the count of controlled substances, with four cards unaccounted for. Further review of individual patient narcotic records showed inconsistencies in medication counts for several residents. One resident's Pregabalin count was off by one capsule, while another resident's Lorazepam count was correct despite discrepancies in the recorded doses given. A third resident's Hydrocodone/Tylenol record lacked signatures, dates, or times for medication administration between specific dates. Interviews with staff revealed that the Controlled Drugs - Count Record was not consistently signed or counted by a second nursing staff member, and the Director of Nursing was not informed of these discrepancies. The Director of Nursing stated that spot checks had not revealed any issues, indicating a lack of awareness or oversight of the ongoing problems.
Failure to Address Pharmacy Recommendations and Ensure Appropriate Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications and that pharmacy recommendations were addressed in a timely manner. For Resident #9, the facility did not incorporate pharmacy recommendations into the medication orders for Ibuprofen and Levothyroxine, despite repeated monthly reminders from the pharmacy. The recommendations included administering Ibuprofen with food and ensuring Levothyroxine was taken with plenty of water on an empty stomach. These recommendations were not followed for several months, indicating a lack of timely action on pharmacy reviews. Resident #108's medication regimen also showed deficiencies. The pharmacy recommended adding instructions to rinse the mouth after using the Pulmicort inhaler and assessing the use of both Famotidine and Omeprazole for GERD. These recommendations were not implemented, and the orders remained unchanged for several months. The failure to update the medication orders as per pharmacy recommendations persisted despite multiple reminders, showing a pattern of inaction. For Resident #19, the facility did not include the instruction 'Do Not Crush' for Levothyroxine on the POS and MAR, despite pharmacy notes requesting this addition. Resident #25 was prescribed Valproic Acid without a documented diagnosis or reason for its use, which was not addressed by the facility. Interviews with staff revealed a lack of clarity on who was responsible for ensuring medication orders were updated with corresponding diagnoses and pharmacy recommendations, indicating systemic issues in medication management and communication within the facility.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, as evidenced by the lack of gradual dose reductions (GDR) and non-pharmacological interventions for five sampled residents. The facility's policy required that residents using psychotropic drugs receive GDRs and behavioral interventions unless clinically contraindicated. However, the facility did not adhere to this policy, as demonstrated by the cases of Residents #9, #108, #66, #102, and #7, where GDRs were not attempted or documented, and pharmacy recommendations were not addressed by the physicians. Resident #9 was prescribed Divalproex for bipolar disorder, but the pharmacy's recommendation to add a 'do not crush' instruction was repeatedly ignored. Additionally, there was no documentation that the resident's physician reviewed the appropriateness of the psychotropic medication, despite multiple pharmacy recommendations. Similarly, Resident #108 was prescribed Divalproex for major depression and schizophrenia, but the pharmacy's recommendations to add 'do not crush' instructions and to follow up on previous recommendations were not addressed. Resident #102 was receiving multiple psychotropic medications, including olanzapine, quetiapine, trazadone, and buspirone, but there was no documentation of a GDR attempt, despite the pharmacist's recommendation. Resident #7 was also on several psychotropic medications, and the pharmacist recommended a GDR, but the physician did not respond, and no GDR was attempted within the last 12 months. Resident #66 was on Haloperidol, Hydroxyzine, and Divalproex, and the pharmacist requested a GDR, but the psychiatrist or physician did not respond or provide a rationale for not reducing the medications. Interviews with facility staff revealed a lack of clarity and responsibility in processing pharmacy recommendations and ensuring GDRs were completed, with the Director of Nursing (DON) being identified as responsible for these tasks but failing to ensure they were carried out effectively.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, resulting in a roll-off dumpster and surrounding area overflowing with trash, equipment, and furniture. Observations over several days revealed a roll-off dumpster that was completely full, with trash bags visible over the top and additional trash, including two toilets, two mattresses, an office chair, and wood pallets, strewn around the parking lot and nearby field. The facility did not have a policy related to this deficiency. Interviews with facility staff revealed that the roll-off dumpster was used by everyone, including non-facility personnel, and was not being emptied due to a shortage of flatbed truck drivers. The Maintenance Director had instructed staff to stop using the roll-off dumpster and had contacted the rental service to have it removed, but the issue persisted. The Administrator admitted to ordering the wrong size dumpster and was in the process of ordering a new one to manage the overflow, but no documentation of these actions was provided by the time of the survey exit.
Deficiency in CNA Training Hours and Topics
Penalty
Summary
The facility failed to provide the required 12 hours of nurse aide in-service training, including essential topics such as dementia care and Abuse, Neglect, and Exploitation (ANE), for four out of five sampled Certified Nursing Assistants (CNAs) from January 2024 through December 2024. The facility's policy mandates that each CNA receive at least 12 hours of in-service training annually, covering topics like effective communication, dementia management, ANE, and others. However, a review of training records revealed that CNA A, CNA B, CNA E, and CNA G did not receive the necessary training hours or specific training in dementia and ANE. Interviews with the CNAs and facility staff highlighted discrepancies in training documentation and tracking. CNA A and CNA B mentioned receiving training through in-services and computer-based programs, but their records did not reflect the required training hours or specific topics. CNA E's records showed no documented training hours, and CNA G had only three hours of documented training. The facility's Director of Nursing (DON) and Human Resources (HR) staff were responsible for ensuring the completion of required training, but the documentation was inconsistent, with sign-in sheets not reflecting the length of training sessions. The facility's training program relied on a computer-based system to track training hours and topics, with notifications sent to employees when training was due. Despite this system, the facility failed to ensure that all CNAs completed the mandated training hours and specific topics. Interviews with the Administrator and Regional Director of Operations confirmed that the DON and HR Director were responsible for ensuring compliance with training requirements, but the lack of proper documentation and tracking led to the deficiency.
Failure to Involve Resident in Person-Centered Care Planning
Penalty
Summary
The facility failed to ensure that a resident was involved in the development and implementation of their person-centered care plan. The resident, who was cognitively intact, reported not being aware of care plan meetings, not being involved in setting goals, and not having seen their care plan. The facility's policy required that residents be the focus of control in their care planning process, which was not adhered to in this case. Interviews with staff, including the Licensed Practical Nurse (LPN), Social Service Director (SSD), and Minimum Data Set (MDS) Coordinator, revealed that while invitations were sent to guardians, there was no documentation of written or verbal invitations being provided to the resident, nor was there documentation of care plan meetings that included the resident. The SSD was responsible for coordinating care plan meetings and notifying residents, but failed to document these actions in the resident's electronic medical record. The Director of Nursing (DON) expected residents to participate in their care planning and for the interdisciplinary team to document these meetings in the clinical chart. However, the lack of documentation and involvement of the resident in the care planning process indicates a failure to adhere to the facility's policy on person-centered care, resulting in the deficiency noted in the report.
Failure to Timely Purchase Resident's Requested Items
Penalty
Summary
The facility failed to ensure a resident was able to purchase items with funds provided by their guardian in a timely manner. The resident, who was cognitively intact and had some behavioral issues, was admitted to the facility and had requested a tablet and headphones. The guardian had sent $200 to the resident's account for this purpose, but the items were not purchased. The resident's Progress Notes and Interdisciplinary Team Notes indicated the resident's request, but there was no documentation of the purchase or any communication with the guardian about withholding the purchase. Interviews revealed that the guardian was unaware of any instructions to withhold the purchase due to the resident's behavior, and the funds remained in the resident's account. The Activity Director, who was responsible for purchasing the items, only visited Walmart once a month and did not have the items on the list for the December trip. The Director of Nursing and the Administrator were also involved, with the Administrator being responsible for the purchase. The delay in purchasing the tablet and headphones was due to a lack of communication and coordination among the staff.
Failure to Timely Return Resident Trust Funds
Penalty
Summary
The facility failed to adhere to its policy regarding the timely notification and return of a resident's trust account balance upon discharge. Specifically, the facility did not provide Resident #168 with an up-to-date accounting of their trust account balance and delayed the return of the resident's funds. The resident was discharged on October 1, 2024, but the refund was not sent until November 5, 2024, which was 31 days late according to state requirements and facility policy, and five days late according to federal requirements. Additionally, the resident was incorrectly charged for room and board for October 2024, despite having been discharged at the beginning of the month. Interviews with the Business Office Manager (BOM) and the Administrator revealed a lack of continuity and oversight in the business office, contributing to the deficiency. The BOM had only been in the position for a short time and acknowledged the delay in returning the resident's funds. The Administrator noted that there had been several changes in the business office personnel, including a resignation and temporary coverage by a regional person, which led to disruptions in managing resident accounts. These staffing issues, compounded by technical difficulties with internet systems, resulted in the failure to follow the facility's policy for managing discharged residents' trust accounts.
Incomplete Investigation of Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse involving two residents and a staff member. The incident involved Resident #9, who has multiple psychiatric diagnoses, and Resident #89, who also has mental health conditions. The altercation occurred at the nurse's station, where Resident #9 engaged in a heated exchange with CNA K over a cigarette box. The situation escalated when Resident #9 attempted to physically attack CNA K, and Resident #89 intervened by trying to restrain Resident #9. The video footage of the incident lacked a timestamp and audio, making it difficult to ascertain the exact details of the verbal exchange. The facility's investigation into the incident was incomplete, as it did not include interviews with all involved parties, such as Resident #9, Resident #89, CNA L, and CMT E. The investigation also lacked witness statements and a Registered Nurse Incident (RNI) report. The Administrator and Director of Nursing acknowledged that the investigation was incomplete and did not meet the facility's policy requirements for abuse investigations, which should include comprehensive interviews and documentation from all witnesses and involved individuals. The facility's policies on abuse and neglect, as well as incident reporting, emphasize the importance of thorough investigations, including root cause analysis and obtaining written documentation from witnesses. However, these procedures were not followed in this case, leading to a deficiency in the facility's handling of the incident. The lack of a complete investigation raises concerns about the facility's ability to ensure protective oversight and address potential abuse situations effectively.
Failure to Notify Residents and Ombudsman of Transfers
Penalty
Summary
The facility failed to provide timely notification of transfer or discharge to residents and their representatives, as well as to the Ombudsman, as required by policy. For Resident #116, who was his/her own responsible party, there was no notice of discharge documented in the electronic medical record when the resident was transferred to another facility. Interviews with the Licensed Practical Nurse, Social Services Director, and Administrator confirmed that the facility policy was not followed, and the notice of discharge was not completed or uploaded into the resident's medical record. For Resident #115, who was transferred to the hospital due to severe pain, there was no transfer notice of discharge documented, nor was there any evidence that the Ombudsman had been notified of the discharge. Interviews with the Administrator, LPN, Social Services Director, and Director of Nursing revealed that the notice of transfer had not been initiated, and the Ombudsman was not informed. The staff members were unaware of these omissions, indicating a breakdown in communication and adherence to the facility's discharge notification policy.
Inaccurate Dental Assessment on MDS
Penalty
Summary
The facility failed to accurately assess a resident's dental status on the Minimum Data Set (MDS), a federally mandated assessment tool used for care planning. The deficiency was identified in one resident out of a sample of 23, within a facility census of 111 residents. The resident in question was cognitively intact and reported having no natural teeth or dentures upon admission. However, the admission MDS inaccurately indicated that the resident had no issues with their teeth. This discrepancy was confirmed through interviews and observations, which showed the resident had no natural teeth or dentures. Interviews with facility staff, including the Social Services Director, Licensed Practical Nurse, MDS Coordinator, and Director of Nursing, revealed that the MDS Coordinator was responsible for ensuring the accuracy of the MDS assessments. All staff members acknowledged that the resident's MDS should have accurately reflected the absence of natural teeth and dentures. The failure to do so was considered an inaccuracy in the MDS assessment, as confirmed by multiple staff members.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, including Resident #72, who was admitted with a diagnosis of difficulty in walking and unsteadiness on feet. Despite having no history of falls upon admission, the resident's care plan was not updated to include falls after an incident where the resident fell in their room and was sent to the hospital for evaluation and treatment. This oversight occurred despite the facility's policy requiring care plans to be updated with measurable objectives and time frames to meet residents' needs as identified in their comprehensive assessments. Interviews with facility staff, including the LPN, MDS Coordinator, Social Services Director, and Interim DON, revealed a lack of clarity and responsibility regarding the updating of care plans following a fall. The MDS Coordinator was identified as responsible for updating care plans after a fall, which is considered a change in condition. However, there was confusion about the timing and process for updating care plans, as the Interim DON was unaware of when updates should occur, although they expected updates after a fall. This lack of coordination and adherence to policy contributed to the deficiency in care planning for Resident #72.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to ensure that medications prescribed by the physician were administered within the designated time frame for one resident. The resident, who was diagnosed with paranoid schizophrenia, bipolar disorder, insomnia, and chronic pain, experienced multiple instances where medications were administered late. The medications included Buspirone Hydrochloride, Chlorpromazine, Sodium Chloride, Atorvastatin Calcium, Baclofen, Hydroxyzine, Lorazepam, Trazodone, Loratadine, and MedroxyProgesterone Acetate. These medications were given outside the one-hour window before or after the scheduled time, as per the facility's Medication Administration Policy. Additionally, some medications were administered without a corresponding diagnosis listed on the resident's face sheet. Interviews with the resident and facility staff revealed that medications were frequently administered late, sometimes hours after the scheduled time. The resident expressed difficulty sleeping due to the late administration of medications. Staff interviews confirmed that there were occasions when medications were not administered within the prescribed time frame, and the Director of Nursing acknowledged that medications were occasionally late. Furthermore, it was noted that the pharmacy's monthly checks were not effective in ensuring that the diagnosis matched the reason for the medication.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a comprehensive discharge summary for a resident who was discharged to another facility. The resident, who was their own responsible party, was admitted to the facility and later discharged without a recapitulation of their stay, including diagnosis, course of illness/treatment, therapy, pertinent labs, radiology, and consultation results. Additionally, there was no reconciliation of pre-discharge medications with post-discharge medications, nor was there a post-discharge plan of care developed to assist the resident in adjusting to their new living environment. Interviews with facility staff, including an LPN, the Social Services Director, the Administrator, and the Director of Nursing, revealed that the charge nurse was responsible for completing discharge summaries, which should be documented in the resident's electronic medical record. However, the discharge summary for this resident was incomplete, and the facility policy was not followed. The Director of Nursing acknowledged that all departments were responsible for ensuring discharge summaries were completed and uploaded into the resident's electronic medical record, but this was not done in this case.
Failure to Provide Communication Device for Resident with Aphasia
Penalty
Summary
The facility failed to provide a communication device for a resident diagnosed with malignant neoplasm of the laryngeal cartilage and aphasia, which affected their ability to perform activities of daily living related to communication. The resident was admitted with a communication problem, and the care plan included interventions such as allowing adequate time to respond and using alternative communication tools as needed. However, the care plan did not include the Speech Language Pathology (SLP) recommendation for a non-speech generating device, which was necessary for the resident's communication needs. Observations and interviews revealed that the resident had difficulty with speech and relied on nodding or shaking their head to communicate. Staff members, including a Certified Medication Technician and the Administrator, were unaware of the SLP's recommendation for a communication device, and no such device was found in the resident's room. The resident expressed a desire for a communication board to better express their needs. The Director of Nursing expected therapy recommendations to be implemented and was unaware that the resident did not have a communication device.
Failure to Reschedule Dermatology Appointment for Resident
Penalty
Summary
The facility failed to ensure that a resident was seen by a dermatologist as required. The resident, who was moderately cognitively impaired and had a guardian, was observed with a golfball-sized cyst on the left side of their face, which was bothersome and should have been addressed months ago. An appointment with a dermatologist was initially scheduled but was canceled due to transportation issues, and the appointment was not rescheduled promptly. The resident's guardian was not informed of the canceled appointment, and a new appointment was not made until several months later. The Social Services Director (SSD) was responsible for scheduling the resident's medical appointments and ensuring transportation, but admitted to missing the rescheduling of the appointment. The SSD acknowledged that the appointment should have been rescheduled the same week as the original appointment and that the guardian should have been notified of the missed appointment. The Director of Nursing (DON) and a Registered Nurse (RN) confirmed that the SSD was responsible for rescheduling missed appointments and ensuring transportation, and that the rescheduling should have occurred immediately after the cancellation.
Failure to Conduct Weekly Wound Assessments
Penalty
Summary
The facility failed to ensure weekly skin and/or wound assessments were completed for a resident with a left heel Stage III pressure ulcer. The resident, who also had diabetes, was readmitted to the facility with blisters on both lower extremities and a left heel pressure ulcer. However, the documentation lacked detailed descriptions or measurements of the wounds. Despite the resident's Braden Risk Assessment indicating a mild risk for developing pressure ulcers, there was no documentation of a detailed assessment or measurements of the wounds since the resident's readmission. The resident's care plan was updated to reflect the presence of a Stage III pressure ulcer on the left heel, and the wound nurse was supposed to follow up. However, subsequent skin and wound assessments were inconsistent and lacked necessary details. For instance, a Skin Check documented a diabetic foot ulcer as a new skin issue, but the description was inconsistent with other records. Additionally, there was no documentation of skin/wound assessments on specific dates in October, November, and December, indicating a failure to conduct regular assessments. Interviews with staff revealed that the wound nurse was responsible for weekly assessments, but there was no auditing to ensure compliance. The Director of Nursing acknowledged the expectation for weekly assessments and documentation but admitted to not auditing the process. This lack of consistent documentation and assessment highlights a deficiency in the facility's wound care management for the resident.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary condition for two residents, leading to deficiencies in care. Resident #72, who was admitted with a diagnosis of obstructive sleep apnea, had orders for oxygen therapy and CPAP use. However, observations revealed that the nasal cannula tubing was not stored in a sanitary manner, as it was not bagged or dated and was wrapped around a portable oxygen tank. Additionally, the CPAP mask was found on the floor and not in a bag. The resident reported that the nasal cannula tubing was never cleaned or changed by staff, and the CPAP mask was found covered in mice droppings, indicating a lack of proper maintenance and storage. Resident #27, who did not have a respiratory-related diagnosis on record, was observed using oxygen therapy at 2 liters per minute via nasal cannula. Similar to Resident #72, the nasal cannula tubing was not dated or stored properly when not in use. The resident stated that they had never seen staff clean or change the nasal cannula tubing, and it was never covered when not in use. Observations confirmed that the tubing was left on the bed and not bagged, with the oxygen tank running continuously. Interviews with facility staff, including a CMT, LPN, CNA, and the DON, revealed inconsistencies and a lack of clarity regarding the procedures for changing and storing respiratory equipment. Staff members were unsure of the exact frequency for changing oxygen tubing and the proper storage methods when not in use. The DON confirmed that oxygen tubing should be changed weekly, stored in a zip lock bag, and dated with the last change date, highlighting a failure in adherence to the facility's policy and manufacturer recommendations.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician of abnormal laboratory values for a resident diagnosed with bipolar disorder. The resident was prescribed Lithium Carbonate Extended Release to manage their condition. A laboratory test conducted on November 1st revealed a low lithium level of 0.4, which was below the normal range of 0.6 to 1.3. However, there was no documentation indicating that the physician was informed of this low level, which was a requirement according to the facility's policy. Interviews with the Nurse Practitioner and the Director of Nursing confirmed that the nursing staff should have reported the low lithium level to the physician immediately. The Nurse Practitioner stated that if the difference was more than 0.1 from the normal range, the physician's office should have been notified, and the lab should have been rechecked within a week. The Director of Nursing acknowledged that the nursing staff should have reported the low level on the same day and that there was no audit system in place to ensure that out-of-range laboratory values were communicated to the physician.
Failure to Provide Routine and Emergency Dental Services
Penalty
Summary
The facility failed to provide routine and emergency dental services to meet the needs of two residents, resulting in a deficiency. Resident #26, who was admitted to the facility without any teeth, had dentures that were too loose and had not been placed on the list to see a dentist. Despite being cognitively intact and having no documented dental issues in the Minimum Data Set (MDS), the resident expressed difficulty in keeping dentures in place and had not been seen by a dentist since admission. Resident #98, who had his own teeth and was cognitively intact, had broken or loose-fitting dentures and cavities. Despite a physician's order to see a dentist, the resident had not been seen by a dental provider and expressed concerns about teeth falling out. Observations confirmed multiple missing teeth and poor dental condition, yet the resident's care plan did not adequately address these issues, and the resident had not been scheduled for dental care. Additionally, Resident #27, who was edentulous and had no dentures, had not been offered dental services since admission. The Social Services Director (SSD) was responsible for scheduling dental appointments but was unaware of the residents' dental needs. Interviews with staff, including the SSD, Certified Medication Technician (CMT), Licensed Practical Nurse (LPN), and Director of Nursing (DON), revealed a lack of awareness and communication regarding the residents' dental concerns, contributing to the deficiency.
Resident Abuse by LPN in LTC Facility
Penalty
Summary
The facility failed to protect a resident from abuse when an LPN was verbally and physically abusive towards the resident. The incident occurred when the LPN called the resident derogatory names, pulled the resident's hair, and kicked the resident while they were on a mattress on the floor. This resulted in a contusion to the resident's right hip and pain in their left knee. The resident, who has a history of mental health disorders including PTSD, bipolar disorder, and schizophrenia, was heard yelling and crying during the altercation and required an injection to calm their agitation. Multiple staff members witnessed the altercation but did not intervene. The resident's care plan indicated a need for a safe environment free from judgment and danger, and interventions for managing their mental health conditions. Despite this, the staff failed to follow the care plan and did not use de-escalation techniques or call for additional support. The resident's behavior escalated, leading to further aggression and property damage, but the staff did not effectively manage the situation. The facility's investigation revealed that the LPN was not supposed to be working on that unit and had not received de-escalation or CALM training. The LPN was eventually detained by the police and taken to jail. The resident expressed a desire to press charges against the LPN and stated they felt unsafe unless the LPN was removed from the unit. The incident highlights a significant failure in the facility's ability to protect residents from abuse and ensure a safe environment.
Failure to De-escalate Resident Leads to Abuse
Penalty
Summary
The facility failed to appropriately de-escalate a resident with known behavioral health needs, leading to a significant incident involving physical and verbal abuse by staff. The resident, who had a history of major depressive disorder, anxiety disorder, PTSD, bipolar disorder, schizophrenia, and intermittent explosive disorder, exhibited behaviors of agitation, yelling, and physical aggression. Despite the resident's care plan outlining specific interventions such as calm redirection and decreasing stimulation, staff failed to follow these guidelines. Instead, staff engaged in arguments with the resident, used derogatory language, and did not respect the resident's personal space. On the night of the incident, the resident was left alone with an LPN who had not been trained in de-escalation techniques. The LPN called off a Code [NAME], indicating they would handle the situation alone, and proceeded to physically and verbally abuse the resident. Witnesses reported that the LPN kicked, slapped, and verbally abused the resident, contrary to the facility's policies and the resident's care plan. Other staff members, including agency CNAs, were present but did not intervene effectively, partly due to a lack of training in de-escalation techniques. The facility's policies required all staff working with behavioral residents to be CALM certified, yet this was not adhered to, as evidenced by the lack of training for agency staff. The incident was reported to the police, and the LPN involved was detained. The facility's failure to ensure staff were adequately trained and to follow established protocols for managing behavioral crises resulted in a serious deficiency in the care provided to the resident.
Failure to Transfer Resident's Belongings After Discharge
Penalty
Summary
The facility failed to ensure that a resident's belongings were sent to their new facility after discharge. The resident, who was cognitively intact and had coping issues, was discharged to a different facility approximately 80 miles away. The facility's policy required that residents be prepared for a safe and orderly transfer, including ensuring their belongings were sent with them. However, the resident's belongings, including totes of clothes, shoes, a nightstand with crocheting items, and various food packets, were left behind at the original facility. The Social Service Director (SSD) at the new facility contacted the SSD at the former facility to inquire about the missing belongings. The former facility's SSD acknowledged the oversight and attempted to arrange a meeting to transfer the items. Despite these efforts, the belongings remained at the original facility for several months. The Environmental Services Manager and the Administrator admitted that there was not enough room in the van to transport all the belongings during the initial transfer, and the facility did not have a van driver for a period, which contributed to the delay. Interviews with facility staff revealed a lack of documentation and follow-up regarding the resident's belongings. The Environmental Services Manager was responsible for ensuring the belongings were sent within 72 hours, but this was not done. The Administrator and Director of Nursing acknowledged their ultimate responsibility for ensuring the resident's belongings were transferred, but the items remained at the facility for an extended period, with more than 100 items still in storage as of August.
Resident Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) identified as CNA E and a resident. On the night of the incident, CNA E was observed on video surveillance charging at the resident and pushing them into a corner, pinning them against the wall. This incident occurred after the resident allegedly pushed a trash can towards CNA E. The resident, who was cognitively intact, reported feeling sad and described CNA E as aggravating and hateful. The incident was witnessed by an LPN who confirmed that CNA E pushed the resident into the corner and held them there for a few seconds. The incident was reported to the facility administration, and the local police department was contacted. The resident was assessed and found to have no injuries. During interviews, CNA E claimed that the resident had previously thrown a chair at them and was attempting to tip over trash barrels, prompting CNA E to restrain the resident against the shower room door. The resident was not injured during the incident and did not request pain medication. The facility's policy on abuse and neglect defines abuse as the willful infliction of injury or punishment resulting in harm or mental anguish, which was violated in this case.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents out of a sample of 26. Resident #12, who was diagnosed with seizures, schizophrenia, and schizoaffective disorder, did not receive multiple doses of prescribed medications, including Benztropine, Haloperidol, and Vimpat, due to delays in pharmacy delivery. The resident expressed concerns about not receiving medications, which could potentially affect their mental health and seizure management. Resident #13, diagnosed with Diabetes Mellitus II, also experienced medication errors. The resident's blood sugar levels were not consistently monitored as required, and doses of Januvia and Lantus were missed due to the medications being on order. The resident reported that the lack of medication led to elevated blood sugar levels, impacting their overall health. Interviews with facility staff revealed inconsistencies in medication reordering practices and communication with the pharmacy. Staff members acknowledged the need to reorder medications in a timely manner and to notify physicians when medications were missed. However, there was no documentation of these actions being taken for the affected residents, indicating a breakdown in the facility's medication management processes.
Resident Physically Abused by Dietary Manager
Penalty
Summary
The facility failed to protect a resident from physical abuse when the Dietary Manager (DM) hit the resident in the head. The incident occurred in the dining room where the resident, who was cognitively intact and had no behaviors during the look-back period, was involved in a verbal altercation with a pastor. The resident, who had a history of alcohol dependence with alcohol-induced mood disorder and major depressive disorder, was known to have the potential to be physically aggressive towards others. During the incident, the resident was arguing with the pastor about scripture and was asked to leave the dining area by the Medical Records Manager. The resident initially complied but returned to the dining room, continuing to argue and expressing a desire to hit something. The DM attempted to calm the resident, but the resident swung and hit the DM. In response, the DM hit the resident on the head with a closed fist. The incident was captured on facility camera footage, and the DM was immediately escorted out of the building. The resident later confirmed being hit by the DM. The Director of Nursing (DON) and the Regional Registered Nurse both acknowledged that residents should not be abused by employees, and the incident was reported to the police.
Failure to Document and Communicate Resident Discharge and Transfer
Penalty
Summary
The facility failed to ensure appropriate documentation and procedures were followed regarding the transfer and discharge of a resident with significant psychiatric issues. The resident, who had a history of schizoaffective disorder, mood disorder, and anxiety disorder, was admitted to the facility with a legal guardian and had been evaluated for placement in a long-term care facility. Despite being alert and oriented, the resident exhibited psychosis, hallucinations, delusions, and aggressive behaviors, leading to multiple psychiatric hospitalizations during their stay. On several occasions, the resident displayed physical aggression towards staff and other residents, refused medications, and engaged in destructive behavior. The facility documented these incidents and attempted to manage the resident's behavior through medication adjustments and behavioral therapy. However, on one occasion, the resident was transferred to the hospital for evaluation and treatment due to increased aggression and refusal to take medications. The facility failed to provide a 30-day bed hold notice or discharge summary, and there was no documentation of the resident's discharge or appeal rights. The resident remained in the hospital for over 30 days, during which time the facility did not document any plans for the resident's return. When the hospital attempted to discharge the resident back to the facility, they were informed that there was no available bed, and the facility did not accept the resident back. The lack of documentation and communication regarding the resident's discharge and potential readmission led to a deficiency in the facility's compliance with transfer and discharge regulations.
Failure to Provide Bed Hold Notice and Readmission Issues
Penalty
Summary
The facility failed to provide a bed hold notice to a resident or their guardian upon the resident's transfer to a hospital, as required by their policy. The resident, who had a legal guardian, was transferred to a behavioral health center for evaluation and treatment following a paranoid episode. The facility's records did not contain documentation of a bed hold notice being provided to the resident or their guardian at the time of transfer. The resident was initially admitted to the facility with diagnoses including schizoaffective disorder, mood disorder, anxiety disorder, high blood pressure, and hyperthyroidism. The resident was alert and oriented with minimal confusion and was independent in daily activities. However, the resident experienced psychosis, hallucinations, delusions, and behavioral symptoms, which led to the transfer to the hospital. The facility's policy required that a bed hold notice be given to the resident or their legal representative upon discharge to the hospital, but this was not documented. After the resident was stabilized in the hospital, the facility did not accept the resident back, citing the absence of a bed in the same-sex unit and concerns about the resident's behavior. The hospital's social worker and the resident's guardian were informed that the facility would not readmit the resident, and the resident was returned to the hospital after being dropped off at the facility. The facility's failure to provide the bed hold notice and the lack of documentation regarding the resident's discharge and potential readmission contributed to the deficiency.
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.
