Grove At Kirkwood, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Kirkwood, Missouri.
- Location
- 711 South Kirkwood Road, Kirkwood, Missouri 63122
- CMS Provider Number
- 265833
- Inspections on file
- 21
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Grove At Kirkwood, The during CMS and state inspections, most recent first.
The facility failed to follow physician orders for wound care and compression therapy for two residents with lower extremity wounds. One resident with multiple comorbidities had non‑pressure leg wounds with orders for specific cleansing, skin prep, xeroform, collagen powder, gauze, and Kerlix, as well as XXL knee‑high compression stockings. Observations showed saturated dressings left in place for several days, macerated surrounding skin, omission of ordered products, lack of collagen powder, and repeated failure to apply compression stockings despite an active order. Another resident with CHF, pneumonia, glaucoma, and diabetes had a skin tear on the left lower leg with orders for daily and PRN wound care, but staff did not document treatments for several days, and the dressing remained dated from the initial application. There was also no baseline care plan to guide staff on this resident’s care needs.
The facility failed to maintain required inventories of personal belongings for two cognitively intact residents who reported missing clothing, despite a policy requiring completion and updating of inventory sheets and staff acknowledgment that such forms should be present and scanned into the medical record. A resident with anxiety, DM, and glaucoma did not receive an admission packet on the day of admission and lacked a baseline care plan, with the admission packet only signed later. The facility also used a new admission agreement that did not address prior $6,000 security deposits required under a previous management contract; one resident’s family provided documentation of having paid such a deposit, but subsequent invoices showed no record of a refund after discharge, while leadership reported unawareness of the prior deposit terms and that deposit funds were not turned over during the ownership change.
The facility failed to manage finances and operations in a way that ensured timely payment to key vendors and adequate supplies and staffing for resident care. After a change in ownership, staff reported chronic shortages of wipes, towels, plates, gloves, and incontinence products, with downgraded product quality and no clear departmental budgets. Housekeeping used substitute cleaning chemicals with uncertain dilution, and dietary staff reported the dish machine lacked soap and rinse chemicals for an extended period, leading to hand-washing dishes and serving meals on Styrofoam plates and foam cups despite resident council requests for regular dishware. Corporate-controlled ordering resulted in reduced quantities and substitutions of cheaper food items, while the RD reported not being paid and difficulty working with corporate. Multiple vendors, including primary food suppliers, a staffing agency, an oxygen supplier, pest control, and other service providers, confirmed large unpaid, past-due balances with no payments made under new management. CNAs and LPNs described bounced or incorrect paychecks, missing hours, and unresolved payroll issues, along with frequent short staffing, extended shifts, and nurse turnover, while maintenance and housekeeping staff were reduced and multiple vendors remained unpaid, affecting services throughout the facility.
Surveyors found that the facility failed to complete a thorough facility-wide assessment, leaving all sections documenting monthly average ADL assistance needs (bed mobility, transfers, bathing, eating, toileting, and mobility) blank, despite a census of 91 residents. The assessment contained only general statements about staffing assignments and infection prevention practices and did not quantify resident care needs. During the survey, additional issues were identified, including lack of required 12-hour CNA training in abuse/neglect and dementia care for sampled CNAs, insufficient nursing staff resulting in missed treatments and ADL care, absence of a restorative program and speech therapy, incomplete TB testing for sampled residents, missing EBP signage and PPE for residents on enhanced barrier precautions, and housekeeping staff not using an EPA-registered hospital disinfectant. The administrator acknowledged responsibility and stated the assessment was expected to be fully completed with total numbers of residents requiring assistance.
Surveyors found that staff repeatedly failed to follow infection prevention and control policies, including not implementing Enhanced Barrier Precautions for residents with catheters, wounds, and nephrostomy tubes, not posting EBP signage, and not using gowns during high-contact care. Perineal care was performed on multiple residents with improper glove use and without required hand hygiene, and catheter care was omitted after bowel movements. A shared Hoyer lift was used on two residents consecutively without disinfection between uses. Several newly admitted residents and newly hired employees lacked required two-step TB testing or TB screening documentation. Housekeeping staff used a non–EPA-registered all-purpose cleaner on floors instead of a hospital-grade disinfectant and were unsure of correct dilution, while supply limitations and lack of a housekeeping leader contributed to inconsistent cleaning practices.
The facility did not maintain an active antibiotic stewardship program as required by its own policy. The written policy, dated 7/1/25, called for an antibiotic stewardship program integrated with infection prevention and control, led by the Medical Director, DON, IPC nurse, and consultant pharmacist, with support from the Administrator and governing officials, and intended to optimize infection treatment and reduce adverse events from antibiotic use. However, the Administrator reported that the program had not been updated for many months, the IPC nurse had recently left, and the program had only just been restarted, leaving the facility without established antibiotic use protocols or a system to monitor antibiotic use for its resident population.
The facility did not follow its own policy requiring that COVID-19 vaccines be offered, education provided, and vaccination status documented for all residents. Record review for five residents with significant conditions such as heart failure, kidney disease, asthma, diabetes, osteomyelitis, stroke, and dysphagia showed no documentation that they were offered or received the COVID-19 vaccine, nor that any education or refusals were recorded. The Infection Preventionist stated that vaccines, refusals, and related education are expected to be offered on admission or upon request and documented in the medical record, but this was not done for these residents.
Surveyors identified that an LPN provided hands-on care to a severely cognitively impaired resident while wearing earphones connected to a phone with music playing, and another resident reported that staff frequently had earbuds in and were on their phones during care, despite facility policies prohibiting such device use in resident care areas. In addition, residents reported and resident council minutes documented that they were being served meals on Styrofoam plates with plastic cutlery and foam cups instead of regular dishware and silverware, which they did not feel was homelike. Dietary staff and the Dietary Manager stated the dish machine had been without soap and rinse chemicals for an extended period due to a change in chemical vendors driven by cost concerns, leading to hand-washing of dishes and ongoing use of disposable products, while the Administrator reported not being aware that Styrofoam and plastic were being used in place of reusable dishware.
The facility failed to maintain a safe, clean, and homelike environment for several residents and in a shared shower room. One resident with multiple medical conditions had a crumbling wall and stained ceiling tile around a window that allowed cold drafts into the room for at least two months, as confirmed by staff. Another resident with severe cognitive impairment was found by a family member shivering in bed with an open window, uncovered feet, and an untouched meal from the prior evening; a CNA later admitted opening the window due to odor and heat. A third resident’s room had dusty floors, a missing floorboard under the bed, and fall mats covered with food debris and trash, despite staff expectations that floors be clean and intact. Surveyors also observed a shower room with unlined trash cans containing used briefs, toilets and riser seats smeared with stool and brown matter, puddles of liquid on the floor, no toilet paper, and a strong urine odor, while housekeeping reported once-daily cleaning and leadership stated the area should be clean and adequately supplied.
The facility failed to follow its grievance policy by not investigating or resolving a grievance filed by a cognitively intact resident regarding an incident in a shower room, leaving the grievance form incomplete with no documented findings or resolution. Resident council representatives reported that staff rarely followed up on grievances and that responses took months. Grievance forms and secure submission boxes were not available in common areas as expected, and an Admissions Coordinator could not account for their absence. An LPN and a CNA were unfamiliar with the formal grievance process and only reported concerns to a charge nurse. The newly designated Grievance Official and the Administrator were unaware of the resident’s grievance, despite stating that grievances should be investigated and resolved within a set timeframe and that residents and families should have free access to grievance forms.
The facility failed to provide adequate ADL care, including bathing, nail care, oral hygiene, and assistance out of bed, for multiple residents. One resident with cognitive impairment and multiple comorbidities had no baseline care plan, was observed with oily hair and long, jagged fingernails, and reported not receiving a shower that week. Another cognitively intact, incontinent resident with heart failure, hip fracture, diabetes, and kidney disease, care planned for hands-on ADL assistance, was seen in stained clothing with unkempt hair and reported needing staff help with showers but receiving them infrequently, with missing shower documentation for an entire month. A third resident with muscle weakness and diabetes had no ADL needs in the care plan, was observed with overgrown toenails and caked debris on the teeth, and reported staff would not assist with nail care or toothbrushing, with a CNA citing lack of staffing. A fourth resident with heart and kidney disease, requiring extensive assistance and a Hoyer lift, had no care plan, was repeatedly observed in bed in a hospital gown, and reported wanting to get out of bed and into clothes but believing they were too much work for staff, despite therapy confirming no restrictions and a special wheelchair being available. Staff interviews confirmed expectations for twice-weekly showers or bed baths, hair washing, nail care, oral hygiene, and daily out-of-bed opportunities, which were not consistently met or documented.
Surveyors identified that staff did not follow facility policies for safe transfers and chemical storage. During Hoyer lift transfers for two residents with dementia and severe cognitive impairment who were dependent on staff for transfers, CNAs moved the lift with the legs closed and did not maintain appropriate contact or guidance, contrary to the facility’s Total Lift Transfer policy and staff expectations described by an LPN and the DON. In a separate incident, an LPN transferred a cognitively impaired resident with cardiac conditions from bed to wheelchair by lifting under the arms and pulling on the resident’s pants, without using a gait belt even though gait belts were available in the room, in violation of the facility’s Gait Belt Transfer policy and staff expectations. Additionally, an uncapped bottle of Dakin’s 0.125% solution, labeled for external use only, was repeatedly observed left out and accessible in the room of a cognitively impaired resident, including when the resident was not present, and there was no physician order for this solution.
The facility failed to provide adequate nursing and therapy staffing and proper orientation for new and agency staff, resulting in multiple residents not receiving basic hygiene and therapy services. A resident was observed with oily hair and long, jagged fingernails and reported not getting a shower that week; another incontinent resident, dependent on staff for bathing, was seen in stained clothing and reported infrequent showers despite a twice-weekly schedule and missing shower documentation. A third resident had overgrown toenails and caked debris on the front teeth and reported that staff would not assist with nail care or oral hygiene, requiring family help, while a CNA attributed missed hygiene care to short staffing. Facility records showed no speech therapy services or restorative program over several months, and the rehab director and DON acknowledged the absence of these services. Multiple LPNs reported working without orientation or training, being left to work alone on their first day, and ongoing short staffing, while an LPN and the administrator described heavy reliance on agency staff, limited RN coverage, loss of key nursing roles, frequent leadership turnover, and lack of structured handoff of regulatory duties.
Surveyors found that multiple residents did not receive ordered medications because the facility failed to obtain and administer drugs as prescribed, despite policies requiring timely ordering, use of an E-kit or Pyxis, and prompt transcription of physician orders. One resident with multiple sclerosis and sleep apnea missed most doses of modafinil and Glatopa, with documentation of drugs not available and an incorrect order entry after an EMR change. Another resident with muscle weakness and diabetes missed numerous tramadol doses for pain, while a resident with kidney and respiratory failure missed repeated doses of tramadol and ordered eye drops, which staff documented as unavailable and the resident reported not receiving. A resident with chronic kidney disease and depression did not have a midodrine order or administration documented after the EMR switch, and bags of ordered IV saline labeled for this resident were found unused in the med room. Additional residents with chronic pain, HTN, UTI, CAD, HF, hypothyroidism, PVD, and clotting risks had extensive missed doses of atenolol, Augmentin, statins, thyroid hormone, beta-blockers, midodrine, diuretics, anticoagulants, antiplatelets, and antiarrhythmics, often marked as not available or simply not given. Staff reported problems with the new medication ordering system and inadequate training, while leadership acknowledged that blank MAR entries indicated missed doses and that staff were expected to reorder and escalate after a single missed dose.
The facility failed to reasonably accommodate residents’ needs and preferences by not ensuring call lights were accessible and by not repairing a shower in a timely manner. One resident with severe cognitive impairment and Alzheimer’s disease, care planned to use the call light for assistance due to fall risk, was repeatedly observed in a recliner with the call light wrapped around the bed rail or under a pillow, out of reach, despite staff acknowledging the resident could use the call system and that it should be accessible. Another resident with severe cognitive impairment, dementia, heart disease, and heart failure, dependent on staff for hygiene and care planned to have the call light within reach at all times, was observed in bed while the call light lay on the floor behind the headboard. In addition, a cognitively intact resident with arthritis and spinal stenosis, who used a wheelchair and lacked an in-room bathroom, reported that the 200 hall shower room had been unusable for over a month, forcing use of a more distant shower room; staff confirmed the shower had been broken for about a month and had not yet been repaired.
The facility failed to maintain an effective process to track and refund a required $6,000 security deposit owed to a discharged resident under a prior admission agreement. Under the former management’s contract, a deposit was collected at admission and was to be refunded after discharge, but later invoices contained no record of the deposit. The resident, who had severe cognitive impairment and multiple diagnoses, was transferred to another facility with coordination involving the resident’s daughter. Interviews showed that current leadership, including a Regional Nurse Consultant and the Administrator, were unaware of the prior deposit/refund requirement or the specific deposit, and the current admission agreement did not address handling of deposits collected under the previous management, resulting in the deposit not being identified and returned at discharge.
Surveyors found that the facility failed to ensure safe, coordinated discharge planning for two residents, contrary to its own policy requiring IDT involvement, physician orders, referrals, and discharge summaries. One resident with multiple conditions, including diabetes and visual impairment, reported being told by the SW that it was not her job to find a new placement or assist with an appeal, and therapy staff stated the resident was non-ambulatory, required assistance with ADLs, and was unsafe to manage numerous stairs at home, yet the resident was still discharged after arranging personal transportation. Another cognitively intact resident with several chronic diagnoses was discharged home with medications but had no physician discharge order, no documented discharge planning, referrals, or discharge summary in the record, despite the DON’s stated expectation that such planning and documentation occur.
A resident with moderately impaired cognition and an ileostomy had documented diagnoses including Crohn’s disease and chronic kidney disease, but there were no physician orders or care plan for ostomy care despite facility policy requiring such orders. The resident’s family reported that staff were not assisting with emptying the ostomy bag, leading family members to perform the care and that concerns raised to a DON were not addressed. Two LPNs stated they were unaware the resident had an ostomy, and one LPN found the resident on the floor after an unwitnessed fall, with feces on the floor and the resident holding the ostomy bag after attempting to walk to the bathroom to empty it. The DON later acknowledged expectations that staff be aware of the ostomy, assist with care, and have appropriate orders and care planning, which had not occurred.
Surveyors found multiple failures in medication storage, labeling, and temperature control across several medication carts and a medication room. One cart contained personal items, and a medication refrigerator holding drugs for multiple residents was discovered unplugged and reading well above the required 36–46°F range, with no documented temperature checks for several days. Other nurse and CMT carts held insulin pens without proper labels or open dates, topical medications without resident names or open dates, loose and partially cut pills outside original packaging, expired urine collection tubes, and glatopa syringes labeled for refrigeration but stored on the cart. Staff interviews showed that an LPN did not verify refrigerator checks and was unfamiliar with policy, and the DON acknowledged that insulin pens should be fully labeled and that nurses are responsible for removing medications when residents are discharged.
A resident with multiple comorbidities and significant mobility limitations did not receive consistent in‑house PT or ST despite physician orders, and the facility did not document or care plan the extensive outside PT the resident attended. Following a change in ownership and therapy staffing turnover, PT/OT services were reduced, ST was not offered for several months, and the restorative nursing program was discontinued without replacement. Staff interviews confirmed there was no active restorative program, no in‑house ST, and that therapy coverage was limited, while the DON acknowledged awareness of outside therapy but the lack of corresponding documentation and care planning in the medical record.
A resident with severe pain from neuropathy, recent surgery, and pressure ulcers did not receive prescribed pain medication due to staff inaction and lack of access to the automated drug dispensing system. CNAs reported the resident's pain to an agency nurse, who did not administer the medication or notify facility leadership, resulting in unmanaged pain until the next shift. The facility's pain management procedures were not followed, and the physician was not informed of the issue.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or events that led to this failure.
The facility failed to provide complete and individualized care plans for residents on anticoagulants, increasing their risk of bruising and bleeding. Despite the residents' medical conditions, their care plans lacked specific interventions to address these risks. Staff interviews revealed an expectation for care plans to reflect residents' needs, but this was not consistently implemented.
The facility failed to discard outdated food, properly label and date food items, and maintain proper infection control practices during food preparation. Additionally, kitchen equipment was found to be heavily soiled, indicating a lack of regular cleaning and sanitization.
The facility failed to reconcile petty cash monthly and did not maintain sufficient funds in the resident trust account for three months. Discrepancies were found between reported ending balances and actual bank statement balances, with funds transferred to the corporate account, resulting in insufficient funds to cover residents' balances.
The facility failed to check the federal indicator for abuse, neglect, or misappropriation of resident property through the state Nurse Aide (NA) registry prior to hiring new employees. The policy did not direct staff to check the NA registry for all employees, only for CNAs. This oversight was identified in the files of a Dietary Aide, an RN, and an LPN, none of which contained documentation of the NA registry check. The Administrator confirmed this gap in the hiring process.
The facility failed to ensure that 10 randomly selected CNAs received the required annual 12-hour resident care training. A review showed that none of the CNAs met the required training hours, with some receiving as little as 34 minutes to 8 hours of education. The facility lacked a tracking system for in-service education, and the previous MDS coordinator responsible for education had left two weeks prior. The Administrator acknowledged the issue and stated that three nurse managers would now be responsible for tracking education hours.
The facility failed to follow infection control standards by allowing a resident's urinary catheter tubing to drag on the floor and not disinfecting a mechanical lift between uses for two residents. Despite staff presence, no one intervened to correct these issues, leading to deficiencies in infection prevention and control.
The facility failed to maintain a medication error rate below 5%, resulting in a 7.14% error rate. Two LPNs did not follow the manufacturer's recommendation to prime an insulin pen with 2 units before administering the prescribed dose to a resident with diabetes and other conditions.
Failure to Follow Wound Care and Compression Stocking Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care and compression therapy as ordered for two residents with lower extremity wounds. One cognitively intact resident with heart failure, hip fracture, diabetes, and kidney disease had non‑pressure wounds on the left anterior and lateral leg, caused by being struck with something. The resident’s care plan did not address wound care, despite active wound treatment orders specifying cleansing with wound cleanser or normal saline, application of skin prep, xeroform gauze, collagen powder, gauze, and Kerlix wrap secured with tape. Documentation showed wound treatments were not completed on certain ordered days. Observations revealed dressings dated several days earlier that were saturated with serous drainage, with surrounding skin macerated, and the resident reported having to change a wet sock due to drainage. During wound care observations, an LPN removed a saturated dressing that had been in place for multiple days and applied only a Mepilex dressing, omitting the ordered skin prep, xeroform, collagen powder, gauze, and Kerlix. The LPN also did not apply the resident’s ordered XXL knee‑high compression stockings, despite an active order for application in the morning and removal in the evening. On multiple subsequent observations, the resident continued to be without compression stockings, and the left leg dressing remained saturated with serous drainage and dated several days prior. The ADON later performed the wound treatment and stated the facility did not have collagen powder available, and she completed the dressing change without it. Facility leadership, including the ADON and DON, stated that nurses were responsible for completing wound treatments as ordered, ordering needed supplies, and accurately documenting treatment completion. A second resident, admitted with diagnoses including CHF, pneumonia, glaucoma, and diabetes, had no baseline care plan to direct staff on care needs. An order was in place to cleanse a skin tear on the left lower leg with normal saline, apply xeroform, and a dry dressing daily and PRN. From the date the order was initiated through several subsequent days, staff did not document completion of the ordered treatment. The resident reported having a wound on the left leg/ankle, and a CNA reported that the wound occurred when the resident’s leg became caught during a transfer with a PT. Observation later showed the dressing on the left leg still dated from the initial treatment date, indicating that ordered daily and PRN wound care had not been performed or documented during that period. The Regional Nurse Consultant confirmed that nurses were responsible for documenting completion of wound treatments and following physician orders.
Failure to Maintain Personal Property Inventories and Provide Accurate Admission and Deposit Information
Penalty
Summary
The deficiency involves the facility’s failure to maintain and update residents’ personal belongings inventories and to follow its grievance and missing property policy, as well as failures related to admission information and financial agreements. The facility’s policy dated 7/1/25 stated that residents and representatives have the right to report missing items, that staff may resolve grievances immediately or follow the grievance procedure if unable to do so, and that supervisory personnel are responsible for notifying residents and representatives of the outcome of missing property investigations. For one cognitively intact resident admitted on 6/3/25 with diagnoses including arthritis and spinal stenosis, there was no inventory of personal belongings sheet in the medical record despite observation of multiple personal items in the room. This resident reported missing specific clothing items, stated they had informed multiple staff members, and reported that no one followed up and that they had never been provided an inventory sheet at admission or afterward. Another cognitively intact resident admitted on 4/27/25 with diagnoses including heart failure, hip fracture, diabetes, and kidney disease also had no inventory sheet in the record, despite having numerous clothing items in the room, and reported multiple tops missing after being sent to laundry, stating they had never completed an inventory of personal belongings. Staff interviews confirmed that the facility’s process required inventory sheets to be completed on admission and updated when new items were brought in, with forms to be scanned into the medical record. A CMT stated that paper inventory sheets were available on each hall and should be completed and updated, and the Laundry Supervisor stated that an inventory sheet should exist for every resident and be located either in the medical record or in the resident’s room. The Laundry Supervisor reported not having seen inventory sheets for the two residents with missing clothing and being unable to locate their missing items. The Administrator and DON stated they expected staff to complete inventory sheets on admission and update them when new items arrived, and that staff should attempt to locate missing clothing and initiate an investigation if items were not found. Additional deficiencies involved admission information and financial agreements. One resident admitted on 1/5/26 with diagnoses including anxiety, diabetes, and open angle glaucoma did not have a baseline care plan in the record and reported not receiving a welcome/admission packet on admission; the admission packet on file was signed by the resident on 1/23/26, indicating it was not provided on the day of admission as expected by the Administrator. The facility’s prior admission agreement under the previous management company required a $6,000 interest-free security deposit, refundable within 45 days after discharge, and described how it would be treated for Medicaid and room-and-board charges. The current admission agreement under new management did not address the prior contract or deposits made under it. For a resident with severe cognitive impairment and multiple diagnoses including hypertension, non-Alzheimer’s dementia, and asthma, documentation from the family showed a $6,000 deposit paid at application along with room and board charges, and progress notes documented the resident’s transfer and discharge; however, invoices reviewed later showed no documentation of a refund of the $6,000 deposit. Interviews with the Regional Nurse Consultant and Administrator revealed unawareness of the prior deposit requirement, lack of documentation addressing previous deposits in the new agreement, and that funds related to deposits were not turned over during the ownership change, while the facility was still operating under the previous management company and honoring the original contract.
Failure to Pay Vendors and Maintain Adequate Supplies and Staffing for Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a way that ensured timely payment to key vendors and adequate procurement of supplies and services necessary for resident care. Staff interviews revealed that after a change in ownership, the facility experienced significant budget and payment issues, resulting in limited supplies such as wipes, towels, plates, gloves, and incontinence products. Central Supply staff reported that prior to the ownership change there were no supply problems, but afterward corporate imposed strict limits on quantities, downgraded product quality, and removed departmental budgets. Staff described gloves that ripped when donned and a switch from higher-quality briefs to lower-quality ones that did not contain urine effectively, with residents complaining about the briefs and staff reporting increased odors and residents being soiled. Housekeeping staff reported that the facility stopped purchasing the usual floor-cleaning chemicals and that they were using an all-purpose cleaner instead, with uncertainty about correct dilution and the last bottle nearly gone. The facility also failed to ensure timely payment to multiple critical vendors, including food suppliers, a dietician, staffing agencies, oxygen suppliers, pest control, and other service providers, placing residents at risk for interruption of services and inadequate care as stated in the report. The dietary department reported that the dish machine had been without soap and rinse chemicals for over a month, leading staff to wash dishes by hand and serve meals on Styrofoam plates and foam cups instead of regular dishware, despite resident council requests for regular plates and bowls. The Dietary Manager stated that corporate controlled ordering, frequently pushed back on quantities, and substituted cheaper or different food items than those ordered, including lower-quality ground beef and reduced quantities of produce such as bananas and grapes. The Registered Dietician reported difficulty communicating with corporate, uncertainty about the food-ordering staff’s food service experience, and that he or she had not been paid for services since the new ownership took over. Vendor records and interviews confirmed large unpaid balances to primary food vendors and other suppliers over several months with no payments made under the new management. In addition, the facility’s financial and administrative failures extended to payroll and contracted services, affecting staffing and resident care. CNAs and LPNs reported bounced paychecks, incorrect pay rates, missing hours, and unresolved payroll discrepancies, with explanations referencing time clock issues and processing from an out-of-state corporate office. A staffing agency representative reported that after ownership changed, the facility used agency staff without making any payments on multiple invoices totaling approximately $179,000, leading the agency to stop providing staff. The Plant Operations Manager and other staff reported cuts to housekeeping and maintenance staff, unpaid pest control and snow removal vendors, and multiple vendors not being paid. A beautician reported not being fully paid and receiving no assistance from the facility in contacting private-pay residents’ families for payment. An oxygen vendor, an additional food vendor, and a pest control company each confirmed that no payments had been made since before the new management took over, with balances significantly past due. The report notes that the Department of Health and Senior Services attempted to contact the corporate business office manager without returned calls, while the facility census was 91 and the deficient practice was described as having the potential to affect all residents by placing them at risk for interruption of services and inadequate care. Staff also described how these financial and operational issues contributed to staffing instability and workload problems. CNAs and LPNs reported frequent short staffing, difficulty obtaining agency staff, and situations where nurses were unsure when they would be relieved, with some working extended hours such as 23 hours on a shift. The DON was reported to be working the floor extensively, contributing to burnout, and multiple nurses reportedly left due to uncertainty about relief and staffing. The Plant Operations Manager stated that staffing and supplies were an issue and that he was pulled in different directions, including filling in for housekeeping, while the transition in ownership had been hard on residents and families. The Administrator acknowledged that there had been multiple Administrators and DONs since the ownership change, that regulatory duties were not handed off between Administrators, and that agency staffing was used to meet minimum staffing requirements, while also indicating that a system for continuity of care was still being developed. These combined actions and inactions in financial management, vendor payment, supply procurement, and staffing administration led to the cited deficiency for failure to administer the facility in a manner that enabled effective and efficient use of resources to meet residents’ needs.
Incomplete Facility-Wide Assessment and Related Care Resource Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a complete and thorough facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. The written Facility Assessment, last updated on 12/18/25, included basic operational data such as licensed bed count, average daily census, and average admissions and discharges by shift, but left all sections for monthly average assistance with activities of daily living (ADLs) blank. Specifically, no data were recorded for residents’ needs in bed mobility (sit to lying), mobility (sit to stand), bathing, transfers, eating, toileting, or other care, and there were no entries for levels of assistance such as set up, supervision/partial/moderate assistance, or dependent/max assistance. The assessment also contained only general narrative descriptions of how staff assignments are determined and how the infection prevention and control program is evaluated, without tying these to quantified resident care needs. During the survey, additional problems were identified that related to staffing, training, and infection control, which were not reflected in or supported by the incomplete facility assessment. These included the absence of required 12-hour CNA competencies in abuse/neglect and/or dementia care for all sampled CNAs employed more than one year, insufficient nursing staff to meet resident needs as evidenced by staff interviews and reports of missed treatments and missed ADL care, and the lack of a restorative program or speech therapy. Infection control issues were also found, including missing tuberculosis testing for all sampled residents, residents on enhanced barrier precautions without appropriate signage or PPE supplies, and housekeeping staff not using an EPA-registered hospital disinfectant for floor cleaning. In an interview, the Administrator stated an expectation that the facility assessment be fully completed with total numbers of residents requiring assistance and acknowledged responsibility for ensuring the assessment’s completion.
Failure to Implement EBP, Maintain Aseptic Care Practices, Disinfect Equipment, and Complete TB Screening
Penalty
Summary
Surveyors identified multiple infection prevention and control deficiencies involving failure to implement Enhanced Barrier Precautions (EBP), improper perineal care technique, inadequate disinfection of shared equipment, and lack of required tuberculosis (TB) screening for residents and staff. Several residents with indwelling devices or open wounds did not have EBP signage or personal protective equipment (PPE) available, and staff did not use gowns during high-contact care activities as required by facility policy and CDC/CMS guidance. For example, a resident with a urinary catheter had no EBP order, no EBP signage, and no PPE available; CNAs performed incontinence and catheter care wearing only gloves, then used the same contaminated gloves to apply a clean brief, adjust bedding, and touch privacy curtains. Another resident with left leg wounds requiring dressing changes had saturated dressings and ongoing wound care performed by an LPN and the ADON without gowns, and without EBP signage or PPE supplies in or outside the room, despite the ADON acknowledging the resident was on EBP and that gowns were not available in the facility. Additional residents with indwelling urinary catheters and nephrostomy tubes also lacked EBP implementation. One cognitively intact resident with an indwelling catheter had no EBP orders and no EBP signage; a CNA entered the room, donned only gloves, and performed perineal care and catheter manipulation while leaning against the resident, without wearing a gown. Another resident with nephrostomy tubes and daily dressing changes had an EBP order, but repeated observations showed no EBP signage and no PPE at or near the room. A staff member entered, donned gloves, and changed the nephrostomy dressings without an isolation gown. A resident with pressure ulcers and a wound care order also had no EBP signage or PPE available over several days. Staff interviews revealed inconsistent understanding of EBP, with one LPN stating they were not exactly sure which residents required EBP and a CNA reporting that isolation gowns had not been seen for weeks. Surveyors also observed improper perineal care and hand hygiene practices. For one severely cognitively impaired resident, an LPN removed a soiled brief, cleaned the perineal area, then with the same gloved hands applied a clean brief, assisted the resident to dress, transferred the resident to a wheelchair, and propelled the resident to the dining room, without changing gloves or performing hand hygiene. Another resident with a catheter had perineal care performed without PPE, and catheter care was not completed after stool was cleaned from the rectal area; the CNA later stated they "guessed" they should clean the catheter and genitals. The facility’s own incontinent care policy required hand hygiene, glove changes, and use of clean surfaces of cloths for each wipe, which were not followed in these observations. The survey further documented failure to disinfect shared equipment and to complete required TB screening. A Hoyer lift was used to transfer one resident from bed to wheelchair and then immediately used to transfer another resident for weighing and back to bed, without any cleaning or sanitizing between residents. Staff, including an LPN, CNA, and the DON, acknowledged that the lift should have been wiped down between residents. Review of medical records for multiple newly admitted residents showed no documentation of two-step TB testing or TB screening, despite facility policy requiring TB screening at or before admission. Similarly, review of employee files for numerous newly hired staff showed no documentation of TB tests or chest x-rays, contrary to the facility’s Employee Tuberculosis Test policy. Environmental cleaning practices also failed to meet facility policy requiring use of an EPA-registered hospital disinfectant. Housekeeping staff reported that the facility had stopped purchasing the previous disinfectant product and were instead using Medorra Limpreza All Purpose Cleaner Lavender scent for floors, measuring it by eye into mop buckets without clear dilution instructions. The product container lacked an EPA registration number, and checks of EPA resources and the manufacturer’s website did not verify it as an EPA-registered or hospital-grade disinfectant. Housekeepers and other staff described supply limitations and lack of a Housekeeping Director, and the Regional Nurse Consultant confirmed there was no training on how much floor chemical to use, while the Administrator stated he expected housekeeping to use appropriate supplies and know correct chemical amounts.
Failure to Maintain an Active Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and maintain an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The written Antibiotic Stewardship policy, dated 7/1/25, stated that the facility would implement an antibiotic stewardship program as part of its overall infection prevention and control program, with the purpose of optimizing treatment of infections and reducing adverse events associated with antibiotic use. The policy identified the Medical Director, DON, IPC Nurse, and Consultant Pharmacist as leaders of the program, with support from the Administrator and governing officials. However, during an interview, the Administrator reported that the antibiotic stewardship program had not been updated since March 2025, that the IPC Nurse had recently quit, and that the facility had only just restarted the program on 1/22/26, despite the Administrator’s expectation that the program should have been in place for the facility’s census of 91 residents. No specific residents, their medical histories, or clinical conditions at the time of the deficiency were described in the report, and no resident-specific antibiotic use data or monitoring activities were documented. The deficiency is based on the lack of an active, updated antibiotic stewardship program and the absence of established antibiotic use protocols and a monitoring system as required by the facility’s own policy.
Failure to Offer and Document COVID-19 Vaccination for Multiple Residents
Penalty
Summary
The facility failed to follow its COVID-19 vaccination policy by not offering, educating about, or documenting COVID-19 vaccination for five reviewed residents. The written policy dated 7/1/25 required that COVID-19 vaccinations be offered to all residents unless medically contraindicated, that residents be educated in an understandable manner using CDC or FDA information about risks and benefits, that they be given an opportunity to ask questions, and that the facility maintain documentation of vaccination status, education, and refusals in the medical record. Record review for the sampled residents showed no documentation that any of them had been offered or received the COVID-19 vaccine, nor that any education or refusals had been recorded. The affected residents had multiple significant medical diagnoses. One resident had heart failure and kidney disease, another had asthma and kidney disease, another had diabetes and osteomyelitis of the foot, another had heart failure and a history of stroke, and another had stroke, dysphagia, and kidney disease. Despite these conditions, there was no documentation in any of their medical records regarding COVID-19 vaccination offers, administration, or refusals. In an interview, the Regional Nurse Consultant, who also serves as the facility’s Infection Preventionist, stated that he expected COVID-19 vaccinations to be offered on admission or upon resident request, and that all vaccinations, refusals, and related education should be documented in the medical record, which was not reflected in the reviewed records.
Failure to Ensure Dignified Care and Homelike Dining Environment
Penalty
Summary
The deficiency involves failures to honor residents’ rights to dignity, respect, and a homelike environment. Surveyors observed an LPN walking down a resident hallway with earphones in, connected to a phone with music audible from approximately six feet away, and then entering a severely cognitively impaired resident’s room and providing incontinence care, dressing, and transfer assistance while continuing to wear the earphones and play music. Another resident reported that staff were always on the phone when providing care and that earbuds could be seen in staff members’ ears. The facility’s Resident Rights policy required that residents be treated with kindness, respect, and dignity, and the employee handbook explicitly prohibited the use of cell phones and headphones/Bluetooth devices in resident care areas or while providing care. Staff and leadership interviews confirmed that cell phone and earbud use during resident care was not allowed. The deficiency also includes the facility’s failure to provide meals on reusable dishware and utensils as requested by residents, instead serving food on Styrofoam and using plastic cutlery and cups for an extended period. Resident council minutes documented residents’ requests for regular plates and bowls rather than plastic or Styrofoam, and residents later reported that they knew the dishwasher was not in use when plastic cutlery began to be used and that plastic cutlery did not feel homelike. Dietary staff reported that the dish machine had been without soap and rinse chemicals for over a month, and that the facility had not had the required chemicals for about two months. The Dietary Manager stated the dish machine worked but lacked soap and rinse because the new owners did not want to use the previous, more expensive brand and were changing vendors, resulting in dishes being washed by hand and meals being served on disposable dishware. The Administrator later stated it was not appropriate to suspend use of the dish machine due to not purchasing sanitizer and rinse and that he or she had not been aware that Styrofoam plates and cups were being used instead of reusable dishware.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms and Shower Area
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment for multiple residents and in a shared shower room. For one cognitively intact resident with diagnoses including acute kidney failure, major depressive disorder, and type 2 diabetes, surveyors observed on multiple dates that the wall surrounding the windowsill was broken and crumbling, allowing outside air to enter the room, and that the ceiling tile above the window was stained yellow/orange. The resident reported feeling cold from the draft, was unable to get out of bed without assistance, and expressed a desire to have the stained ceiling tile replaced. Facility staff, including an LPN, a maintenance associate, and the Plant Operations Manager, acknowledged that the wall and window had been in this condition for at least two months, were not homelike, and should have been repaired to prevent drafts. Another resident, with severe cognitive impairment and diagnoses including traumatic brain dysfunction, dementia, and anxiety disorder, was observed via a time-stamped photograph provided by a family member lying in bed with an open window in the room, uncovered feet, and shivering. The family member reported that the resident felt cold to the touch and that a tray of food from the previous night, consisting of mashed potatoes and gravy, remained untouched and wrapped in aluminum foil. A CNA later admitted to opening the window due to odor and heat in the room, was unsure how long it remained open, and stated that the resident had been completely covered with a sheet and two blankets when the CNA left. The DON confirmed being informed of the situation by the family member and stated the window should not have been opened. The Regional Nurse Consultant/IP reported there was no policy explicitly covering a safe and homelike environment. A third resident, with chronic kidney disease, major depressive disorder, anxiety, and moderately impaired cognition, was found on several observations to have dusty floors around the bed, a white powdery substance on the floor, a large wood floorboard missing under the bed, and fall mats covered with food debris and trash. Facility staff, including an LPN, the Administrator, and the Plant Operations Manager, stated they expected resident room floors to be clean, free of debris, and with intact flooring, and the Plant Operations Manager acknowledged awareness of the missing flooring. Additionally, repeated observations of a second-floor shower room showed used briefs in trash cans without liners, toilet riser seats smeared with stool and brown matter beneath them, no toilet paper in the dispenser, puddles of clear liquid on the floor near toilets, and a strong urine odor. A housekeeper reported that shower rooms were cleaned once daily, including toilets, floors, toilet paper refills, and trash removal, while the Administrator and DON stated the shower room should be clean, odor-free, and adequately supplied.
Failure to Maintain Effective Grievance Process and Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective grievance process that honored residents’ rights to voice grievances and receive prompt resolution. The facility’s written Grievance and Missing Property policy stated that residents, representatives, and families could present grievances to any staff member, that grievances would be documented on a grievance form, reviewed by the IDT within 10 working days, and that residents and representatives would be notified of the resolution. However, a grievance filed by Resident #44, who was documented as cognitively intact on a quarterly MDS dated 1/6/26, was not investigated or resolved. The resident reported filing a grievance on 1/5/26 regarding an incident in the 200 hall shower room and stated they had not heard back from the facility and felt that no one cared. Review of the grievance book showed a grievance form dated 1/5/26 with the resident’s name and a description of the shower room incident, but the sections for investigative findings, resolution, results reported to, and completion by the due date remained blank. Additional evidence showed systemic issues with the grievance process. During a resident council meeting, all five resident council representatives reported that staff very seldom contacted residents after grievances were filed and that it took months to hear back. Observations showed no grievance forms available in the lobby or on the 200 hall, and the Admissions Coordinator stated there used to be grievance forms and locked boxes on each floor and in the lobby but did not know what happened to them. An LPN and a CNA both reported they were not familiar with the grievance process and only informed the charge nurse of resident concerns. The Social Worker, newly designated as the Grievance Official, stated she was not aware of Resident #44’s grievance, and the Administrator also reported being unaware of that grievance, despite both indicating an expectation that grievances be investigated and resolved within five days and that residents and families have free access to grievance forms and a secure submission box.
Failure to Provide Adequate ADL Care, Hygiene, and Out-of-Bed Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate activities of daily living (ADL) care, including bathing, nail care, oral hygiene, and assistance out of bed, as required by facility policy and resident needs. The facility’s ADL and oral hygiene policies required staff to assist with bathing to promote cleanliness and dignity, to provide oral care per the care plan, and to notify the DON and reschedule if showers were refused. For one resident with chronic kidney disease, major depressive disorder, anxiety, and moderately impaired cognition, there was no baseline care plan in the record. This resident was observed in the dining room with oily, stringy hair and long, jagged fingernails and reported not having received a shower that week and wanting nail trimming. Another cognitively intact resident with heart failure, hip fracture, diabetes, kidney disease, and urinary incontinence was care planned for hands-on assistance with bathing and other ADLs, but was observed in stained clothing with frizzy, messy hair and reported being supposed to receive showers twice weekly, needing assistance to shower, and desiring more frequent showers due to incontinence and odor. Shower documentation showed only three showers in January and no shower records for December. A third cognitively intact resident with muscle weakness and diabetes had no ADL care needs included in the care plan. This resident was repeatedly observed in bed with toenails on both feet approximately one-eighth of an inch long and jagged, and with a whitish-yellow substance caked on the front teeth on consecutive days. The resident reported having asked staff for help with nail trimming without receiving assistance and stated that children had to come in to help with toothbrushing because staff were too busy. A CNA stated that nail care should be provided after showers and that lack of staffing was the reason the resident was not being assisted with oral hygiene, and confirmed the resident required staff assistance with showers and personal hygiene. Staff interviews, including with an LPN and the DON, confirmed expectations that residents receive at least two showers or bed baths weekly, that hair be washed during showers, that nails be kept clean and trimmed, and that staff assist with oral hygiene. Another cognitively intact resident with heart disease, kidney disease, and high blood pressure, requiring substantial to maximum assistance for bed mobility and transfers, had no care plan completed. This resident was repeatedly observed in bed on the back, wearing a hospital gown, and reported wanting to get out of bed and wear clothing but being reluctant to ask because staff left the resident up in a chair too long. The resident stated not having gotten out of bed on one observed day, believed being too much work for staff due to needing a Hoyer lift, and expressed a desire to see outside the room. The Director of Therapy reported the resident had no restrictions, should be transferred with a Hoyer lift, and had a special high-back wheelchair in the room. A CNA stated the resident was offered to get out of bed but would refuse, and the DON stated the expectation that the resident get out of bed daily and as requested, with refusals to be reported to the nurse and documented in the record and care plan. These observations and interviews demonstrate failures to provide and document ADL care, including bathing, nail care, oral hygiene, and assistance out of bed, in accordance with resident needs and facility policy.
Improper Transfer Techniques and Unsafe Storage of Antiseptic Solution
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfer techniques with a mechanical lift and during assisted transfers, as well as failure to safely store a topical antiseptic solution. The facility’s Total Lift Transfer policy required staff to position the lift near the receiving surface, lock bed or chair wheels, open the legs of the lift, and maintain contact with the resident to guide and steady them during transfers. Despite this, surveyors observed that during a Hoyer lift transfer for a resident with dementia, anxiety disorder, depression, and total dependence for transfers, staff did not open the legs of the lift and did not maintain physical contact or guidance while the resident was being moved from the bed. The resident’s care plan specified use of a Hoyer lift with extensive to total assistance, but there was no specific transfer order in the electronic physician order sheet. In another case, a resident with severe cognitive impairment, traumatic brain dysfunction, dementia, and dependence on staff for transfers was observed being weighed using a Hoyer lift. The resident’s care plan required a Hoyer lift with two staff members for transfers. During the observation, staff positioned the wheelchair between the legs of the lift and locked the wheelchair, but after lifting the resident, one CNA moved the Hoyer lift with the legs closed while another CNA stood beside the resident with hands barely touching the resident. In interviews, one CNA stated that he/she typically closed the legs of the Hoyer when the resident was in the air because it felt like better balance, while an LPN and the DON both stated that the legs of the Hoyer should be opened during transfers to provide a stable base and that two staff should be involved, with one guiding the resident. The facility also failed to follow its Gait Belt Transfer policy, which required use of a gait belt for residents needing one-person assist with transfers. A resident with severe cognitive impairment, dementia, heart disease, heart failure, and a need for maximum assistance with transfers was observed being transferred by an LPN from bed to wheelchair without a gait belt, despite two gait belts hanging above the bed. The LPN lifted the resident under the arms and by pulling on the resident’s pants to pivot them into the wheelchair. Staff interviews confirmed that gait belts should be used for residents requiring assistance with transfers and ambulation, and the DON stated that pulling on a resident’s pants to transfer them was not acceptable. Additionally, a cognitively impaired resident with dementia, anxiety disorder, and depression was observed multiple times with an uncapped bottle of Dakin’s 0.125% solution sitting on a television stand in the room, despite the product’s warning that it was for external use only and should not be taken internally. The solution remained open and accessible in the room even when the resident was not present, and there was no physician order for the Dakin’s solution in the electronic physician order sheet.
Insufficient Nursing, Therapy Staffing, and Orientation Leading to Unmet Basic Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on a 24-hour basis to meet residents’ basic care needs, as well as insufficient therapy staffing and inadequate orientation for new and agency staff. The facility’s own Facility Assessment, updated in December 2025, lacked completed data fields for residents’ assistance needs with activities of daily living such as bed mobility, transfers, bathing, eating, and toileting, despite stating that staffing assignments were based on census, acuity, and resident preferences. Observations showed residents with unmet hygiene needs: one resident was seen in the dining room with oily, stringy hair and long, jagged fingernails and reported not having received a shower that week, attributing this to not enough staff and requesting nail care. Another resident, incontinent of urine and dependent on staff for showers, was observed in stained clothing with frizzy, messy hair and reported being scheduled for showers twice weekly but wanting more frequent showers due to odor and visitors; documentation showed only three showers in January and no shower records for December. Further observations showed another resident in bed on two separate days with toenails approximately 1/8 inch long and jagged and a whitish-yellow substance caked on the front teeth. This resident reported asking staff for nail trimming without assistance and stated that children had to come in to help with toothbrushing because staff were too busy. A CNA confirmed that nail care should be provided after showers and attributed the lack of oral hygiene assistance to staffing shortages, noting the resident required staff help with showers and personal hygiene. In addition to nursing care issues, review of therapy minutes from early September through late January showed no speech therapy evaluations, minutes, or services offered, and the Director of Rehab reported there was no speech therapy in place, only a recently hired PRN speech therapist, and that there had been no restorative program since their start at the facility. The DON acknowledged awareness of the lack of therapy and the absence of a restorative therapy program. Interviews with nursing staff and administration revealed systemic staffing and orientation problems. One LPN, initially an agency nurse who became a direct hire, stated being a brand-new nurse who received no orientation and was unaware of how poor staffing levels were. Another LPN reported it was their first day in the building, had never worked there as agency staff, and was working solo since early morning without training, relying on resident charts and other LPNs for questions. A third LPN described ongoing short staffing since new management took over, with only one night nurse until very recently, heavy reliance on agency staff, and critical care needs on the units such as IV medications and wound vacs. This LPN also reported that the admissions nurse did not help on the floor when short-staffed, the wound nurse had quit, the DON was working the floor extensively, and staff turnover was high. The Administrator confirmed frequent leadership changes, heavy use of agency staff, issues with RN coverage, and that regulatory duties were not handed off between administrators, while stating that agency staffing was used to meet minimum staffing requirements and that the DON was working on a system to ensure continuity of care amid frequent staff turnover.
Widespread Failure to Obtain and Administer Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician-ordered medications were obtained from the pharmacy and administered as ordered, resulting in numerous missed doses and “drug not available” occurrences for multiple residents. Facility policies required timely faxing and reordering of medications, use of the emergency kit or automatic dispensing unit for first doses, and prompt transcription and implementation of physician orders, including ensuring prompt delivery from the pharmacy. Despite these policies, staff frequently documented medications as unavailable, left blanks or holes on the MARs where doses should have been recorded, and did not consistently ensure that orders were correctly entered when the facility changed electronic medical record (EMR) systems. One resident with multiple sclerosis, repeated falls, and obstructive sleep apnea had an order for modafinil 100 mg, three tablets once daily, and Glatopa 40 mg SQ every other day. Modafinil was documented as drug not available for 20 of 22 opportunities, and Glatopa was documented as drug not available for 5 of 10 opportunities in one EMR system. After the facility switched to a second EMR, Glatopa was documented as not administered 8 of 9 opportunities, and the modafinil order was incorrectly entered as 100 mg, one tablet, instead of three tablets. A nurse’s note indicated the resident had not received modafinil since admission, and the DON later confirmed the EMR 2 order was incorrect. The pharmacist stated that only two doses of Glatopa (a one-week supply) had been dispensed and that failure to dispense or give modafinil correctly could potentially increase fall risk. Another resident with muscle weakness and diabetes had an order for tramadol 50 mg twice daily for pain, but the eMAR showed multiple missed doses over nearly two weeks, with staff documenting that tramadol was not administered because it was unavailable. The resident reported not receiving pain medication routinely. A different resident with acute kidney failure, acute respiratory failure, and muscle weakness had orders for tramadol, Bion Tears eye drops, and olopatadine eye drops; the eMAR showed repeated missed doses of all three medications over several days to weeks, with progress notes consistently stating the medications were unavailable. This resident reported not receiving eye drops and stated nurses told them the drops were not available. A resident with chronic kidney disease, major depressive disorder, and anxiety had an order for midodrine 2.5 mg twice daily and for sodium chloride 0.9% IV infusions twice weekly. After the facility switched EMR systems, there was no physician order or administration documentation for midodrine in the new EMR, and two bags of sodium chloride labeled for the resident were observed sitting on top of the medication room refrigerator, with blank documentation for certain infusion dates. A hospital nurse reported that when this resident arrived at the hospital, their blood pressure was very low and remained low overnight. The DON later stated the midodrine order had not been transferred correctly into the new EMR and that the resident should have received the sodium chloride infusions. Another resident with chronic pain, diabetes, anxiety, high blood pressure, and a history of healed physical injury had an order for atenolol 50 mg daily, which was documented as not administered for all available opportunities. The same resident had an order for Augmentin three times daily for a urinary tract infection, with multiple doses over several days documented as not administered. The resident stated they had never received atenolol since it was ordered and had not received the antibiotic, and staff told them the antibiotic was on order. A further resident with coronary artery disease, heart failure, diabetes, high cholesterol, anemia, peripheral vascular disease, hypothyroidism, major depressive disorder, and chronic kidney disease had multiple cardiac, anticoagulant, thyroid, and blood pressure medications ordered, including atorvastatin, levothyroxine, metoprolol, midodrine, spironolactone, Eliquis, clopidogrel, and amiodarone. The eMAR showed extensive missed doses for each of these medications, with some documented as medication not available and others simply not given, and only one progress note indicating a call to the pharmacy about spironolactone. Staff interviews revealed systemic issues contributing to the missed medications. A certified medication technician stated that the facility had recently changed to a new medication ordering system, that the system was “messed up,” and that medications were frequently not given because they had not been ordered properly; the technician also reported not receiving proper training on the new system. An LPN stated that medications should be administered per physician order and that if a medication was unavailable, the nurse should document this and call the physician or pharmacy. The DON stated that holes and blank spots on the MAR meant medications were not given, that staff should check the Pyxis and request STAT delivery if medications were out, and that if a medication was on backorder, the physician should be contacted for a substitute order. The DON also stated that staff were expected to reorder medications timely and notify pharmacy and the physician after one missed dose, rather than after multiple missed doses, which contrasted with the repeated documentation of unavailable medications and numerous missed administrations found in the records.
Failure to Ensure Accessible Call Lights and Timely Repair of Shower
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were accessible and by not repairing a shower in a timely manner. One resident with severe cognitive impairment, Alzheimer’s disease, osteoarthritis, and insomnia was care planned as being at risk for falls and encouraged to use the call light for assistance with transfers. Multiple observations over several days showed this resident seated in a recliner while the call light was wrapped around the bed rail at the top of the bed or under the pillow, consistently out of reach. The resident stated a desire to go to bed but reported the call button was not within reach. A CNA and an LPN both confirmed the resident was able to use the call button and that it should have been within reach. Another resident with severe cognitive impairment, dementia, heart disease, and heart failure was dependent on staff for personal and toilet hygiene and was care planned to have the call light kept within reach at all times due to fall risk related to impaired mobility and altered mental status. On two separate observations, this resident was lying in bed while the call light was positioned on the floor behind the headboard, not accessible to the resident. A CNA and the DON both stated that call lights were to be positioned within residents’ reach at all times, regardless of cognitive status, which was inconsistent with the observed placement of the call lights for these residents. The facility also failed to provide reasonable accommodation by not repairing a shower in the 200 hall shower room for approximately a month. A cognitively intact resident with arthritis and spinal stenosis, who did not have a bathroom in the room, reported self-propelling in a wheelchair to the 200 hall shower room to use the bathroom but was unable to shower there because it was broken. The resident stated the shower had been broken for over a month, requiring use of another shower room located further down the hall and often needing staff assistance to reach it. Observations on multiple days showed a sign posted in the 200 hall shower room stating, "Please do not use shower." The maintenance associate and maintenance director both acknowledged the shower had been broken for about a month, with the maintenance director stating he had not gotten around to fixing it, while the administrator reported being unaware of the issue.
Failure to Track and Refund Resident Security Deposit After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to implement a process to identify and return refundable resident deposits upon discharge, as required under a prior admission agreement. The previous management’s admission contract, revised on 3/22/23, required a $6,000 interest‑free security deposit to reserve a room, with the deposit to be refunded within 45 days after discharge, less applicable balances. Review of records for one resident showed an application dated 4/2/25 with a documented $6,000 deposit and additional room and board charges due at signing. However, later invoice review showed no documentation of the $6,000 deposit. The current admission agreement under new management did not address the prior $6,000 deposit requirement or how deposits made under the previous management’s contract would be handled. The resident associated with the missing deposit had severe cognitive impairment and diagnoses including HTN, non‑Alzheimer’s dementia, and asthma, and was discharged to another facility, as documented in progress notes describing coordination with the resident’s daughter and transfer by transportation with a Broda chair and Hoyer pad. Interviews revealed that the Regional Nurse Consultant was unaware of the prior contract’s $6,000 deposit and refund requirement and stated that the new management did not require such deposits, though they were still under the previous management until the change of ownership was completed and were honoring the original contract. The Administrator reported that funds were not turned over during acquisition and that all information had been requested from the previous ownership, but also stated unawareness of the specific deposit while acknowledging that the corporate Business Office Manager knew of it. These findings show that the facility lacked an effective process to track and return refundable deposits owed to discharged residents under the prior agreement.
Failure to Ensure Safe and Coordinated Discharge Planning for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and properly planned discharges in accordance with its own discharge planning policy. The policy required an IDT-driven discharge process, including a physician’s order, coordinated discharge planning by social work, therapy home assessments as needed, referrals to home health or other services, nursing education on medications and treatments, and completion and distribution of a discharge summary with documentation in the medical record. Surveyors found that these steps were not followed or documented for two residents who were discharged. For one resident with anxiety, diabetes, and open-angle glaucoma, there was no baseline care plan in the record and the resident reported being “kicked out.” The social worker reportedly told the resident it was not in her job description to find a new placement and stated she could not help residents file appeals. The resident received a NOMNC with a set discharge date and reported being unable to fully participate in therapy due to COVID and a strained neck. Therapy staff, including the OT and the Director of PT/OT, described the resident as non-ambulatory, needing moderate assistance with showering, assistance with toileting and dressing, and having very weak legs. The Director of PT/OT stated she did not feel it was safe for the resident to return home due to the number of stairs and the resident’s limited ability to manage steps, yet the resident was discharged home after arranging their own transportation, with no indication of a coordinated safe discharge plan. For another resident who was cognitively intact and had multiple diagnoses including hypertension, peripheral vascular disease, diabetes, hyperlipidemia, depression, and asthma, the record contained no physician order for discharge. The only documentation was a progress note stating the resident was discharged home with medications and that nurse management was aware. There was no documentation of discharge planning, referrals, outside resources, or a discharge summary in the medical record. In an interview, the DON stated that the expectation was for the social worker to assist with discharge planning and for all services to be documented, including a discharge summary, but this was not done for the residents reviewed.
Failure to Provide Ordered Ostomy Care and Staff Awareness for Resident With Ileostomy
Penalty
Summary
The deficiency involves the facility’s failure to provide ostomy care and obtain physician orders for a resident with an ileostomy, contrary to its own policy requiring licensed nurses to provide ostomy care under physician orders specifying type of ostomy, frequency of pouch changes, and equipment. The resident’s admission MDS documented moderately impaired cognition, diagnoses including Crohn’s disease, ileostomy status, chronic kidney disease, major depressive disorder, and anxiety, and the presence of an ostomy appliance. However, review of the physician order summary showed no orders for ostomy care, and the medical record contained no baseline or comprehensive care plan addressing ostomy care needs. During interview, the resident reported feeling shaky and unwell and was unable to answer specific questions about medical needs. A family member reported that family had been coming in to assist with ostomy care because staff were not helping the resident empty the ostomy bag, resulting in the resident waiting for family assistance, and stated that concerns had been reported to a DON without any response. Staff interviews further demonstrated lack of awareness and direction regarding the resident’s ostomy. One LPN described responding to a loud noise from the resident’s room and finding the resident on the floor after an unwitnessed fall, with feces covering the floor and the resident holding the ostomy bag to prevent further leakage; the resident stated they had been trying to walk to the bathroom to empty the bag. The resident was sent to the hospital for shoulder pain and altered cognitive status. That LPN, as well as another LPN, both stated they were unaware the resident had an ostomy bag and confirmed there were no physician orders for ostomy care or information on whether the resident could manage the ostomy independently. The DON later stated an expectation that staff assist with ostomy care, be informed of the ostomy’s presence, have a care plan with ostomy interventions, have physician orders for ostomy care, and that concerns reported by family be addressed, underscoring that these expectations were not met in this case.
Improper Medication Storage, Labeling, and Temperature Control on Multiple Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and biologicals were stored securely, properly labeled, and maintained at appropriate temperatures in accordance with facility policy and professional standards. On one medication cart, surveyors observed personal items including two individually wrapped cupcakes, an earring, and a personal fan stored on the cart. In the same area’s medication room, a mini refrigerator containing a variety of medications for multiple residents was found unplugged, with the temperature gauge reading 65°F and a high temperature alarm displayed. Temperature readings taken over several minutes showed the refrigerator temperature remained outside the facility’s required 36°F to 46°F range, and the temperature log showed no documented checks for several consecutive days. On another hall’s nurse cart, surveyors observed non-medication items such as dry erase markers in the top drawer and multiple medications that were not properly labeled. These included insulin pens without open dates and with resident names handwritten only on the caps, and topical creams (Boudreaux’s Butt Paste and Desitin) without open dates or resident names. On the corresponding CMT cart, a half white circular pill identified as trazodone 50 mg remained in a pill cutter, indicating a loose, unidentified dose not stored in its original packaging. Staff interviews revealed that night shift staff were responsible for checking refrigerator temperatures, but the LPN on duty did not confirm that the refrigerator had been checked and was unfamiliar with the facility’s policy. On the Med A Hall nurse cart, surveyors found 13 insulin pens with only handwritten names and no patient labels, as well as topical medications such as betamethasone valerate ointment and Aspercreme without open dates. A biohazard bag on the cart contained 24 expired urine tubes and urine culture tubes, and a plastic bag labeled for refrigeration contained two prefilled syringes of glatopa 40 mg/mL that were not in a refrigerator. On the Med A Hall CMT cart, a blister pack of loperamide 2 mg and a blister pack of cetirizine with four remaining pills were present without patient labels or open dates, and a loose oval white pill was also observed. During interview, the DON confirmed that insulin pens should have proper patient labels and that resident names should not be handwritten on caps, and stated that when a resident is discharged, the nurse is primarily responsible for removing and destroying medications no longer in use.
Failure to Provide Ordered Therapy, Offer ST, and Maintain a Restorative Program
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services as ordered, failure to offer speech therapy (ST) over several months, and failure to maintain an active restorative program in accordance with resident needs. Facility policy required that therapy services be provided under physician orders, coordinated with the interdisciplinary team, and accurately documented in the medical record, with periodic evaluation of effectiveness. Review of therapy minutes showed no ST evaluations or services offered during the review period, and interviews confirmed there was no restorative nursing program in place following a change in ownership and therapy staffing transitions. One resident, identified as having moderate cognitive impairment and multiple diagnoses including heart failure, coronary artery disease, hypertension, MDRO, anxiety, and depression, required extensive assistance with mobility and transfers and used a wheelchair/scooter. The resident’s MDS dated 10/24/25 showed no therapy minutes and no days in a restorative nursing program, despite physician orders for PT/OT/ST to evaluate and treat for transfer status, functional decline, and confusion. Orders for PT/OT/ST were initiated and then discontinued on two separate occasions, and the resident’s care plan did not document the outside therapy services the resident was receiving. Progress notes documented that the resident left the facility for outside therapy appointments and that the physician noted the resident was receiving outside PT five times per week, but this outside therapy was not reflected in the care plan or therapy documentation as required by facility policy. Interviews with the resident and family member revealed that the resident did not receive consistent PT or ST in the facility and had a three‑month period without therapy after an ownership change and staff turnover. The family arranged for the resident to attend an outside day program providing PT five days per week, with the family providing transportation after the facility stated it could not provide daily transport. The Director of Rehab stated the resident had not received in‑house therapy since the director’s start date, that there was no ST available during the period in question, and that there was no restorative program in place. The DON acknowledged awareness that the resident received outside therapy and stated expectations that such services should be scheduled, coordinated, documented, and care planned, but confirmed there was no restorative therapy program operating at the facility during this time. Additional staff interviews corroborated that there was a gap in PT/OT services during the transition to new ownership and that the restorative aides were removed without replacement, leaving the facility without a restorative program. The Plant Operations Manager reported that therapy under the prior contract became “light” during the transition and that nursing management handled therapy after the therapy company left. The Dietary Manager and Director of Rehab confirmed that ST had not been provided during the review period, with only a plan for telehealth ST and a new ST hire pending. Collectively, these findings show that the facility did not provide therapy services as ordered, did not offer ST for an extended period, and did not maintain an active restorative program, and failed to update the medical record and care plan to reflect and coordinate the resident’s outside therapy services.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
A resident with a history of severe pain due to neuropathy, recent orthopedic and heel surgery, and multiple pressure ulcers did not receive pain medication as ordered by the physician. Upon admission, the resident was assessed as having frequent, severe pain, and had orders for both acetaminophen and oxycodone to be administered as needed for pain management. Despite these orders, documentation shows that the resident did not receive acetaminophen from the time of arrival through several days, and there were inconsistencies in the administration of oxycodone, with gaps in documentation and missed doses. On one occasion, the resident reported pain at a level of 10/10, which was described as their baseline, and repeatedly requested pain medication throughout the night. Certified Nurse Aides (CNAs) observed and reported the resident crying, yelling, and expressing severe pain multiple times to the agency charge nurse. The agency nurse did not administer the ordered pain medication, citing lack of access to the automated drug dispensing machine (Pixus), and did not notify facility leadership or the physician about the inability to provide the medication. The nurse also refused to provide care, stating their shift had ended, and left the facility before the replacement nurse arrived, leaving the resident without pain relief for an extended period. Interviews with staff confirmed that agency nurses did not have access to the Pixus and were expected to request assistance from facility nurses to obtain medications. However, this process failed, resulting in the resident not receiving pain medication as ordered. The DON and Administrator were not made aware of the resident's pain or the medication access issue until the following morning, and the resident's physician was not notified of the problem. The facility's pain management policy required systematic recognition, evaluation, and treatment of pain, but these procedures were not followed, leading to the resident experiencing unmanaged severe pain.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions, inactions, or events that led to this deficiency. No further information about the residents involved or their conditions at the time of the deficiency is included in the report.
Deficient Care Plans for Residents on Anticoagulants
Penalty
Summary
The facility failed to ensure that residents receiving anticoagulant treatment had complete, accurate, and individualized care plans to address their increased risk of bruising and bleeding. This deficiency was identified for three residents who were on high-risk drug classes, including anticoagulants and antiplatelets. Despite the residents' medical conditions, such as atrial fibrillation, coronary artery disease, and history of pulmonary embolus, their care plans lacked specific interventions to mitigate the risk of bleeding and bruising. Observations during the survey showed no visible bruises on the residents, but the care plans did not reflect necessary preventive measures. Interviews with facility staff, including an LPN and the Director of Nursing, revealed that there was an expectation for all residents to have care plans that reflect their needs. However, the LPN admitted to not always creating care plan interventions for residents on medications that increase the risk of bruising or bleeding. The Director of Nursing and the Administrator both expressed that they expected the nursing department to adhere to the facility's care plan policy, which was not followed in these cases.
Food Storage and Infection Control Deficiencies
Penalty
Summary
The facility failed to discard outdated food and properly label, date, and cover food items in their storage areas. Observations revealed multiple instances of expired food items, including cans of potato salad, soup, V8 drink mix, and cherry pie filling. Additionally, several containers in the cooler and freezer were found without dates, and some food items were exposed to air due to improper storage. The Dietary Manager acknowledged that all staff were responsible for ensuring food was properly labeled, dated, and expired items were discarded, but these practices were not followed consistently, leading to potential risks for residents consuming food from the facility kitchen. Furthermore, improper infection control practices were observed during food preparation. A cook was seen using gloves to handle pureed vegetables and then scraping the mixture into plates with their hands, followed by rinsing the gloves instead of changing them. The cook also handled fish with the same gloves before discarding them. The Dietary Manager confirmed that proper infection control practices, including glove changes and handwashing, were expected but not adhered to. Additionally, the kitchen equipment, including the stove and ovens, was found to be heavily soiled with caked-on stains and blackened matter, indicating a lack of regular cleaning and sanitization. The Dietary Manager admitted that the equipment was not cleaned as required, which was her and her assistant's responsibility.
Failure to Reconcile Petty Cash and Maintain Sufficient Resident Trust Funds
Penalty
Summary
The facility failed to reconcile the petty cash on a monthly basis and did not maintain sufficient funds in the resident trust account to cover all residents with a trust account for three months. The facility held funds for five residents, and the census was 81 with 38 residents in certified beds. The monthly accounts from April 2023 through March 2024 lacked documentation of the ending balances for petty cash. The Accounting Coordinator confirmed that the petty cash was not included in the reconciliation sheet because it was considered separate from the bank funds. Additionally, the monthly balance reports showed discrepancies between the reported ending balances and the actual bank statement balances, with amounts transferred from the resident trust account to the facility's corporate account, resulting in insufficient funds to cover the residents' balances if they wanted to close their accounts. During interviews, the Accounting Coordinator and the Administrator provided conflicting information about the source of the petty cash funds and the reconciliation process. The Administrator expected the resident trust to be accurately reconciled every month and believed the petty cash was company-funded, but would need to verify. The Accounting Coordinator stated that if there was not enough money in the account, they would provide the resident with cash. The facility's failure to accurately reconcile the resident trust account and maintain sufficient funds led to the deficiency identified in the report.
Failure to Check NA Registry for All New Hires
Penalty
Summary
The facility failed to check the federal indicator for abuse, neglect, or misappropriation of resident property through the state Nurse Aide (NA) registry prior to hiring new employees. Specifically, the facility's policy did not direct staff to check the NA registry for all employees, only for Certified Nursing Assistants (CNAs). This oversight was identified in the employee files of a Dietary Aide, a Registered Nurse (RN), and a Licensed Practical Nurse (LPN), none of which contained documentation of the NA registry federal indicator check. The facility's Background Screening Investigation policy mandates employment background checks, reference checks, and criminal conviction checks, but it did not include a requirement to check the NA registry for all staff members, leading to this deficiency. The Administrator confirmed that the NA registry was only checked for CNAs, contrary to what is expected for all new hires. The deficiency was identified during a review of employee files and an interview with the Administrator. The employee files reviewed included those of a Dietary Aide hired on 8/18/23, an RN hired on 5/2/23, and an LPN hired on 1/30/24. None of these files had documentation of the NA registry federal indicator check. The Administrator acknowledged this gap in the hiring process, confirming that the NA registry was only checked for CNAs, which is not in compliance with the expected procedure for all new hires. The facility's policy failed to ensure comprehensive background checks, including the NA registry check for all staff, leading to this deficiency in their hiring practices.
Failure to Track CNA Training Hours
Penalty
Summary
The facility failed to have a tracking system to ensure that 10 of 10 randomly selected Certified Nurse Aides (CNAs) received the required annual 12-hour resident care training, tracked and calculated by hire date. The census was 81 with 38 residents in certified beds. The facility assessment indicated various training and competencies that staff should receive, including abuse prevention, dementia care, and medication administration. However, a review of individual in-service records showed that none of the CNAs met the required 12 hours of training, with some receiving as little as 34 minutes to 8 hours of in-service education. The facility's in-service sign-in sheets lacked documentation of the amount of time for each in-service or education event, and there was no tracking of which CNAs attended these sessions or the dates of the education events. During an interview, the Administrator revealed that the previous Minimum Data Set (MDS) coordinator, who was responsible for education, had left two weeks prior, and the facility was currently looking for a new educator. The Administrator acknowledged the lack of a tracking system and stated that three nurse managers were now responsible for tracking in-service education. Moving forward, the education would be tracked through payroll, with the Administrator initiating it and nurse managers tracking the clinical information. Despite these plans, the facility had no current system in place to ensure CNAs received the required training hours, leading to the deficiency identified by the surveyors.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow acceptable standards of practice for infection prevention and control for three residents. Specifically, the facility did not ensure that the tubing for an indwelling urinary catheter did not drag on the floor for one resident. The resident, who had diagnoses including kidney disease stage three and chronic kidney disease, was observed multiple times with the urinary catheter tubing and drainage bag dragging on the floor while self-propelling in a wheelchair. Despite passing by several staff members, no one assisted the resident in repositioning the catheter tubing to prevent it from dragging on the floor. The facility's policy did not provide specific instructions on the proper positioning of the catheter tubing, contributing to this oversight. Additionally, the facility failed to clean shared medical equipment between resident use. Two residents were observed being transferred with a mechanical lift that was not disinfected between uses. The staff retrieved the Hoyer lift from the hall, used it to transfer one resident, and then immediately used the same lift to transfer another resident without sanitizing it in between. This action was contrary to the facility's policy, which required cleaning shared equipment with an antiseptic wipe between uses to prevent the transmission of pathogens. During an interview, the Director of Nursing (DON) confirmed that the facility's policy mandates proper infection control practices, including keeping urinary catheter tubing off the floor and cleaning shared medical equipment between uses. However, these practices were not followed, leading to deficiencies in infection prevention and control for the residents involved.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, resulting in a 7.14% error rate. Out of 28 medication administration opportunities observed, 2 errors occurred involving a resident with diagnoses including epilepsy, type 2 diabetes with polyneuropathy, and chronic kidney disease. The errors were related to the improper priming of an insulin pen before administering the prescribed dose of Lantus insulin. Specifically, the Licensed Practical Nurses (LPNs) involved did not follow the manufacturer's recommendation to prime the pen with 2 units of insulin before administering the resident's dose. On two separate occasions, LPNs failed to prime the insulin pen correctly. One LPN primed the pen with only 1 unit instead of the recommended 2 units, while another LPN did not prime the pen at all before administering the insulin. The Director of Nursing (DON) confirmed during an interview that the insulin pens should be primed with 2 units as per the manufacturer's guidelines. This failure to follow proper procedures led to the identified medication errors.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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