Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grove At Kirkwood, The during CMS and state inspections, most recent first.
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 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.
A resident with dementia, traumatic brain injury, and fractures lacked a signed admission agreement and had no documented legal representative despite hospital notes requesting APS and state guardianship for an unrepresented patient. Another resident’s DNR paperwork was not signed, leading to a full code order in the chart, and a third resident with dementia, hearing loss, and missing dentures/hearing aids had no quarterly care plan meetings documented and no updated care plan reflecting current needs.
Failure to timely report and manage a new pressure injury. A resident with severe cognitive impairment, dementia, and full dependence for hygiene and bed mobility developed a dark purple area on the left outer foot that a CNA reported, but an LPN and the Wound Nurse were not timely notified. The resident was observed on a standard mattress without heel protectors or positioning devices, and the Wound Nurse identified the area as a DTI and stated pressure-relieving measures such as a low air loss mattress, heel protectors, and a turn-and-reposition program should have been in place.
A resident with Alzheimer’s disease, anxiety, severe protein-calorie malnutrition, and diabetes did not receive ordered Med Pass 90 mL TID consistently, and monthly weights were not documented after the last recorded weight. The MAR showed the supplement was unavailable many times, the care plan did not address the malnutrition or supplement rationale, and the resident’s weight later measured lower than the last charted weight.
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.
The facility failed to ensure its QAA/QAPI committee developed and implemented an appropriate plan to correct identified quality deficiencies. Surveyors found insufficient nursing staff, missed treatments and ADL care, incomplete facility assessment documentation, no restorative program or speech therapy, residents on EBP without signage or PPE, missing weight documentation, and dignity concerns with meals served on Styrofoam plates. The DON/Administrator stated the facility assessment should be complete, that he/she was responsible for it, and that QAPI review was uncertain because of a recent meeting and lost information during an ownership transition.
The facility failed to track required CNA annual in-service education and did not ensure all CNAs received training on dementia care and abuse/neglect prevention. Survey review of 10 CNAs found three with no documented training hours and seven without the required hours, and several records lacked annual competency documentation for dementia care and abuse prevention. The DON stated staff had recently been educated on the abuse and neglect policy, but no CNAs had documented education after September 2025.
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.
A resident and the resident council reported that fresh fruit listed on the breakfast menu was no longer being served, with only canned fruit offered instead. Staff observations and interviews showed no fresh fruit in the cooler, and dietary staff said ordering was limited by corporate pushback and budget cutbacks. The RD stated that if fresh fruit was on the menu, it should have been ordered and served, while the Administrator said he/she was not aware of the residents' requests.
Resident council grievances were not acted upon in a timely manner and no rationale was given when concerns were not addressed. Meeting minutes showed unresolved issues such as late med pass, showers not being done on day shift, and staff wearing headphones, with no documentation showing how the concerns were resolved. In a group interview, alert and oriented residents said staff rarely followed up after grievances were filed and often did not explain why concerns were not acted upon. The ADM acknowledged the lack of timely response and follow-up.
Failure to Post Survey Results for Resident and Visitor Access: The facility did not post the federal survey results where residents and visitors could easily view them. Observation at the front desk showed no sign directing people to the survey binder, no survey results documentation was visible, and five alert and oriented residents said they did not know where the survey results were located. The DON and Administrator both stated the survey results were expected to be readily available to residents and family members.
Failure to Complete Required Pre-Hire Background Checks: The facility failed to complete required pre-hire background checks for 10 of 10 sampled employees. Records showed missing NA Registry checks for 7 employees and missing CBC or FCSR checks for 8 employees, including a driver, admissions coordinator, dietary aide, activity director, director of rehab, social worker, LPN, and CNAs. The Administrator stated HR was responsible for background checks and expected them to be completed before staff began working.
A resident with heart disease, kidney disease, and HTN had orders for monthly then weekly weights, but no weights were documented for months, despite staff saying weights were taken and written on paper during an EMR transition. Another cognitively intact resident with diabetes, MDD, and CKD had an order for daily Vitamin D3, but the MAR showed multiple missed doses or blanks because the medication was unavailable, and progress notes confirmed it was not given.
Medication administration errors exceeded the allowed rate, with 4 errors in 30 observed opportunities. A CMT failed to give a resident’s ordered aspirin because the medication was not available, gave metoprolol without checking BP despite a BP parameter order, and administered two insulin injections without priming the pens or expelling air first. The residents involved had diagnoses including severe cognitive impairment, dementia, atrial fibrillation, high BP, and diabetes with CKD.
Incomplete Access to Prior EMR Records: The facility failed to fully integrate prior EMR records into the current system, and Admin did not have direct access to historical clinical information. For one resident with dementia, CKD, bipolar disorder, and other diagnoses, prior notes in the old EMR included documentation about missing hearing aids, but those records were not available in the current chart. For another resident with ileus, constipation, CKD, dysphagia, and a hx of epilepsy, prior progress notes and a hospital referral were also only obtained later from the old EMR.
Arbitration Agreement Did Not Allow Required Revocation Period: The facility’s admission packet included an arbitration agreement stating disputes would be resolved by binding arbitration, but the revocation language allowed only five business days after signature instead of the required 30-day period. The RNC said the agreement was part of admission and not required to be signed, while the Administrator said the form had not been reviewed since starting at the facility and was not aware it failed to allow 30 days for rescission.
Failure to offer and document flu and pneumococcal vaccines for 5 sampled residents. Records for residents with conditions including HF, CKD, asthma, DM, osteomyelitis, stroke, and dysphagia showed no evidence the vaccines were offered, no vaccine education, and no documentation of receipt or refusal, despite facility policies requiring annual flu vaccination, pneumococcal vaccination on admission if eligible, and related consent and recordkeeping.
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.
Resident trust funds were not properly maintained for multiple residents. The facility had missing account statements, no signed authorization to hold resident funds, no interest applied to resident accounts, and one resident’s account showed repeated withdrawals that resulted in a negative balance before a later deposit. The BOM and Regional Nurse Consultant were unable to explain the earlier bank statement issues or why interest had not been applied.
The facility failed to ensure four sampled residents had signed advance directive documentation or documentation that they were given information about their right to formulate one. The EMR showed no signed advance directive documents for the residents, and the wing code status binder also lacked their code status sheets. Staff interviews confirmed the documents could not be located in either the EMR or the binder, despite expectations that each resident would have a signed code status sheet.
A resident with bilateral nephrostomy tubes, CKD, neurogenic bladder, CAD, and major depressive disorder was observed receiving dressing changes while seated in a wheelchair in the room. An employee performed the nephrostomy site care without closing the door, leaving the resident exposed to the hallway during treatment. An LPN and the DON stated the door should have been closed for privacy and dignity.
Failure to Report Alleged Abuse: A cognitively intact resident with anxiety, muscle weakness, and diabetes reported that a CNA intentionally threw the resident’s bed remote toward the resident after a disagreement about lowering the bed. An LPN documented the allegation and tried to reach the DON, but the allegation was not reported to the Administrator or DHSS, and the Administrator stated he/she was never informed.
The facility failed to promptly investigate abuse allegations involving two cognitively intact residents. One resident reported that an unknown staff member ripped the call light from the resident’s hand, but the investigation was started before all relevant staff were interviewed and the NOK was not informed right away. Another resident reported that an LPN documented a CNA throwing a bed remote toward the resident, yet the allegation was not investigated at the time, the resident was not interviewed by leadership, and the CNA was not suspended pending investigation.
A resident admitted with CHF, pneumonia, glaucoma, and diabetes had an order for an 1800 mL fluid restriction and daily weights, but the facility did not complete a baseline care plan within 48 hours. Staff reported no fluid restriction sign was posted, and the record lacked care plan documentation for the resident’s fluid restriction, wound care needs, and enhanced barrier precautions. The DON confirmed the facility had no care plan for the resident and that care plans were expected upon arrival.
Incomplete Comprehensive Care Plans for Multiple Residents: The facility failed to complete comprehensive person-centered care plans for four residents after admission assessments. One resident had only a DNR-focused care plan, while three others had no comprehensive care plan at all despite triggered care areas related to cognition, ADLs, incontinence, nutrition, pressure ulcers, pain, and psychotropic use. The DON stated care plans were expected to be completed upon arrival, and an LPN said care plans were needed to know how to care for residents.
Failure to provide appropriate catheter care affected two residents with indwelling catheters. One resident with bladder cancer and other serious conditions had no clear catheter care orders, and the drainage bag was placed on a fall mattress next to the bed rather than below the bladder. Another resident admitted with a UTI and indwelling catheter also had no catheter care orders, and the drainage bag was observed touching the floor and visible from the hallway. Staff interviews confirmed missing catheter care orders and uncertainty about who was providing catheter care.
A resident with a g-tube, stroke, dysphagia, diabetes, and kidney disease did not receive appropriate tube feeding care. Staff observed the resident with the HOB almost flat during continuous tube feeding, and later in a Broda chair with the back flat. The tube feeding bag was also left unlabeled, with no formula, rate, or hang time documented, and the resident’s care plan did not address tube feeding care.
Failure to document consent, alternatives, and assessments for bed rail use. The facility used side rails for three cognitively intact residents with diagnoses including DM, HTN, AKI, acute respiratory failure, muscle weakness, MDD, and CKD, but the EMR lacked documentation of a side rail assessment, attempted alternatives, and informed consent in each case. Observations showed quarter-length, U-shaped, and half-length side rails in use, while the DON and Administrator said they expected side rail assessments before placement and annual review.
A resident with diabetes, HTN, hyperlipidemia, and a urinary catheter had dark urine with a reddish tint and a strong odor, and the MD ordered a UA and BMP/CMP. Staff documented the abnormal urine, but the UA was not collected right away; an empty specimen container was seen at the nurse’s station on multiple days before the sample was later found in the refrigerator. An LPN said staff were busy, and the DON stated the UA should have been obtained and sent to the lab immediately.
Failure to complete routine bed rail inspections for three residents with side rails. Residents with DM, HTN, AKF, ARF, muscle weakness, MDD, and CKD were observed with quarter-length or U-shaped side rails in place, but there was no documentation of routine side rail checks. The Plant Ops Mgr said he had not been completing the safety assessments since the ownership change, and the Admin expected monthly assessments to prevent entrapment and other risks.
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.
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 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 complete social services, code status, and care planning documentation
Penalty
Summary
The facility failed to provide medically related social services for a resident with impaired decision-making capacity who needed help obtaining a legal representative. Resident #507’s hospital records documented moderate dementia, lack of capacity, and a social work consult requesting contact with APS and a state-appointed guardian for an unrepresented patient. The resident’s records also showed severe cognitive impairment, aphasia, multiple fractures, and traumatic brain injury. Facility staff later acknowledged the resident was not able to make decisions, but the social worker had only one interaction with the resident and was not aware the resident needed a POA until it was brought to attention during the survey period. The resident’s record did not contain a signed admission agreement. The care plan also lacked documentation of the resident’s brain injury, compression fractures, and inability to make medical decisions. During a later neurosurgery visit, the resident was described as only able to answer yes/no questions, and the surgeon attempted to contact the facility social worker and the resident’s decision maker/healthcare POA to discuss a possible procedure because the resident’s subdural hematoma had increased in size. Facility staff stated family members were persistently unresponsive, the friend would not consent to the procedure, and guardianship through the state had been discussed but not established. The facility also failed to ensure code status documentation was completed for another resident and failed to conduct and update care plan meetings for a third resident. Resident #505 had a DNR order listed on the face sheet and in the care plan, but the physician order sheet later showed a full code order because the DNR form was not signed and was reportedly missing. Resident #94 had diagnoses including vascular dementia, hearing impairment, and missing dentures and hearing aids, yet there was no documentation of quarterly care plan meetings in the current record, and staff stated there had been no care plan meeting since admission. The resident was observed wearing headphones connected to a charger pack, without dentures, and reported that proper hearing aids and dentures were missing shortly after admission.
Failure to Timely Report and Off-Load a New Pressure Injury
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing. The facility failed to ensure care was consistent with professional standards of practice to prevent pressure injury when staff did not timely report a new skin issue to the Wound Nurse and did not timely implement pressure-reducing interventions after the skin issue was identified for one resident. The resident had severe cognitive impairment, required full staff assistance for hygiene, bathing, and bed mobility, and had diagnoses including epilepsy, difficulty swallowing, kidney disease, and dementia. The resident’s care plan identified the resident as at risk for self-care deficit related to dementia and noted the resident required assistance with hygiene. The physician order sheet did not include orders for a specialty mattress or heel protectors. On observation, the resident was seen reclined in bed on a standard mattress on the left side, appearing thin and frail, with no heel protectors or pillows in use with the feet. A CNA stated the resident had become weaker, was incontinent, needed staff assistance for bed mobility, and that a dark area on the left outer foot was observed and reported to a nurse. An LPN stated he/she had not been notified of changes in the resident’s skin condition and was unaware of the facility’s skin care or reporting policy. The Wound Care Nurse stated she had not been notified of the change in skin condition and, when she assessed the area, found an intact dark purple area on the left outer foot measuring 1.5 cm by 0.6 cm with no depth, which she identified as a DTI. She stated the area should have been reported and pressure-relieving measures should have been in place, including a low air loss mattress, heel protectors, a turn and reposition program, and increased monitoring. Subsequent documentation identified the wound as a DTI to the left lateral foot, and later physician documentation described pressure-related DTIs involving the left lateral foot and left fifth toe, with recommendations for off-loading, floating heels, repositioning, and use of pressure off-loading boots and a low air loss mattress.
Failure to Follow Ordered Nutrition Supplement and Monthly Weight Monitoring
Penalty
Summary
The facility failed to follow physician orders for one resident with Alzheimer’s disease, anxiety, severe protein-calorie malnutrition, and diabetes by not providing the ordered nutritional supplement consistently and by not obtaining monthly weights as ordered. The resident had an order for Med Pass 90 mL three times daily and an order for monthly weight monitoring, but the weight record showed weights only through September 2025, with no further weights documented in the chart. The resident’s December 2025 MAR showed Med Pass 90 mL TID documented as not available 57 out of 93 opportunities. The resident’s recorded weights showed 107 lbs., then 109 lbs., then 113.2 lbs., and later the resident was weighed at 106.8 lbs. during the survey. The quarterly MDSs listed the resident at 113 lbs., and the nutrition progress note stated supplements included Med Pass 90 mL TID and that the current diet supported needs. The care plan did not address severe protein-calorie malnutrition or the reasons for the ordered nutrition supplements. Staff interviews indicated residents were weighed at the beginning of each month, but the nurses had to enter the weights into the computer, and the RD stated the available weights in the medical record were all the weights available after the facility’s electronic record transition.
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.
QAPI Committee Failed to Address Multiple Quality Deficiencies
Penalty
Summary
The facility failed to ensure its QAA/QAPI committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. The facility’s QAPI policy, dated 7/1/25, stated that the QAPI plan would describe how the facility would ensure care and services met accepted standards of quality, identify problems and opportunities for improvement, and ensure progress toward improvement was achieved and sustained. The policy also stated the QAA committee would meet monthly, review prior audits, identify action items, provide staff training as needed, conduct root cause analysis, and develop performance improvement plans for systems or processes needing further action. During the survey, multiple problems were identified, including insufficient nursing staff to meet resident needs, missed treatments, missed ADL care, incomplete facility assessment documentation regarding the monthly average number of residents needing ADL assistance, no restorative program or speech therapy, residents on Enhanced Barrier Precautions without signage or PPE supplies, residents without ongoing documentation of daily, weekly, or monthly weights, and dignity concerns related to meals served on Styrofoam plates. The Administrator stated the facility assessment should be fully complete, was responsible for ensuring it was completed, and said there had been a recent QAPI meeting but he/she would need to check whether it was reviewed then. The Administrator also stated they attempted to have a QAPI meeting on the first day of survey and that information was lost during the ownership transition when the prior management email was shut down.
Missing CNA Annual Training and Dementia/Abuse Education
Penalty
Summary
The facility failed to ensure it had a system in place to track the required CNA 12 hours of annual education. Survey review identified 10 CNAs who had worked for the facility for at least one year, and all 10 were sampled. Three of the 10 CNAs had no documented training hours, and seven of the 10 CNAs did not have the required training hours. The census was 91. Review of the facility assessment showed staff training and education requirements for abuse, neglect, exploitation, resident property misappropriation, reporting procedures, care and management for persons with dementia, and resident abuse prevention, including annual and as-needed in-services. Record review showed no CNAs received education after September 2025. Several CNA records lacked documentation of annual competency in-service on abuse and neglect prevention and dementia care, while others showed only partial in-service hours or limited dementia-related content. During interview, the Administrator and DON stated they had recently educated staff on the abuse and neglect policy and that the DON was responsible for ensuring aides received their required minimum training.
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.
Failure to Honor Resident Requests for Fresh Fruit
Penalty
Summary
The facility failed to promote and facilitate resident self-determination when it did not honor reasonable requests for fresh fruit, even though fresh fruit was listed on the weekly breakfast menu. Resident #13 stated that fresh fruit or salads were no longer offered on meal trays and that only canned fruit was being served, which the resident did not like. An observation of the walk-in cooler showed no fresh fruit available, while the cooler contained lettuce, tomatoes, and potatoes. Dietary staff said food delivery occurred weekly and they were not always told what would be delivered. During the resident council meeting, 5 of 5 residents said they wanted more fresh fruit and reported that they seldom received fresh fruit during meals or snacks. The Dietary Manager said food was ordered through corporate and that corporate pushed back on food ordering, including requests for produce such as bananas and grapes, with budget concerns limiting what could be ordered. The RD stated that if fresh fruit was on the menu, it should have been ordered and served. Staff also reported that residents no longer received fresh fruit, and the Administrator said he/she was not aware of the residents' requests for fresh fruit and that there were budget cutbacks.
Resident Council Grievances Not Timely Addressed
Penalty
Summary
The facility failed to ensure grievances raised by resident council members were acted upon in a timely manner and failed to provide a rationale when the grievances were not acted upon. Review of the grievance policy showed residents and resident representatives had the right to voice concerns or grievances, and that staff were to follow the grievance procedure when issues could not be resolved immediately. The policy also stated the Social Service/Grievance Official was responsible for notifying the resident representative and ombudsman, as appropriate, of the resolution, and that the IDT members were responsible for notifying the resident of the resolution and documenting it on the grievance form. Resident council meeting minutes showed concerns including late medication pass, showers not being done on day shift, and staff wearing headphones. The later meeting minutes referenced the prior outstanding issues but contained no documentation showing how those concerns were addressed or resolved. During a group interview, five alert and oriented residents stated staff very seldom contacted them after grievances were filed, that it often took months to hear back, and that most grievances were not acted upon or explained. The Administrator acknowledged that resident council grievances had not been acted upon in a timely manner, or in some cases at all, and expected residents to be informed of the outcome and given a rationale if a grievance was not acted upon.
Failure to Post Survey Results for Resident and Visitor Access
Penalty
Summary
The facility failed to post the federal survey results for residents and visitors to view. During observation of the front desk area, there was no sign indicating the location of the facility's survey results, and no survey results documentation was visible. During a group interview, five out of five alert and oriented residents said they did not know where the survey results were located. The DON stated the survey results were expected to be readily available to residents and family members, and the Administrator stated the survey result binder had been updated and was located at the front desk, but there was no sign posted indicating where residents and family members could find it.
Failure to Complete Required Pre-Hire Background Checks
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after the facility failed to complete required background checks for newly hired employees before they began working. Based on interview and record review, the facility did not complete all required background checks for 10 of 10 employees sampled. The facility failed to check the Nurse Aide Registry for 7 of 10 employees and failed to check either a criminal background check or the Family Care Safety Registry for 8 of 10 employees. Review of the facility’s Employee Background Checks policy showed the facility was committed to protecting residents from abuse, neglect, and exploitation and required a thorough pre-hire background check to confirm individuals had not been found guilty of abuse, neglect, exploitation, mistreatment, or misappropriation of property, did not have a finding in the state NA registry, and did not have a disciplinary action against their professional license. Record review showed multiple employees, including a driver, admissions coordinator, dietary aide, activity director, director of rehab, social worker, LPN, and CNAs, had hire dates documented with no CBC check completed and no NA registry check in their files, while several had FCSR checks completed after the hire date. During interview, the Administrator stated Human Resources was responsible for conducting background checks and that the background check was expected to be completed before staff started working; the Administrator also stated the NA registry was expected to be checked for all staff.
Failure to Obtain Ordered Weights and Administer Prescribed Vitamin D
Penalty
Summary
The facility failed to ensure Resident #13 received weights as ordered. The resident’s quarterly MDS dated 10/17/25 showed admission on 8/29/25 with diagnoses including heart disease, kidney disease, and high blood pressure. The medical record included an order dated 10/21/25 for monthly weights and another dated 12/17/25 for weekly weights, but no weights were documented from August 2025 through January 2026. During interviews, a CMT said he/she helped obtain resident weights in January 2026, wrote the weights on paper, and gave them to a nurse to enter into the EMR because he/she did not know how to do that. The CMT also said all residents were weighed in the beginning of the month, between the 1st and 5th. The Dietician said the facility had asked for the resident’s weights during the transition from EMR 1 to EMR 2, but the weight report could not be pulled over. The DON stated staff were expected to follow physician orders and obtain and document weights as ordered. The facility also failed to administer Vitamin D3 as ordered for Resident #78. The resident’s annual MDS showed diagnoses including diabetes, major depressive disorder, and chronic kidney disease, and the resident was cognitively intact. The POS dated 1/2026 included an order dated 12/20/25 for Vitamin D3 oral tablet 25 mcg, two tablets by mouth daily for vitamin D deficiency. The MAR showed multiple scheduled doses in January 2026 coded 9 or left blank, and the progress notes stated the Vitamin D3 was not administered because it was unavailable. An LPN stated medications should be administered per physician orders, and if a medication was unavailable, the nurse should call the physician or pharmacy; the LPN expected the resident to receive the Vitamin D as prescribed.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with 4 errors identified in 30 observed medication administration opportunities for a 13.33% error rate. The facility’s Medication Administration Procedure required staff to review the MAR, read each order entirely, verify discrepancies against the physician’s order, obtain required vital signs before administration when needed, and follow specific instructions for medications with blood pressure parameters and for medications not present in stock. For a resident with severe cognitive impairment, Alzheimer’s disease, and atherosclerotic heart disease, aspirin 325 mg daily was ordered, but the CMT did not administer the dose because the blister pack was empty. The CMT stated the medication would need to be checked in the Pyxis machine and later said the facility did not have the medication in stock and it would need to be reordered. For another resident with severe cognitive impairment, dementia, high blood pressure, atrial fibrillation, and chronic kidney disease, metoprolol 50 mg twice daily with instructions to hold if systolic BP was below 110 was administered without first taking the resident’s BP. The CMT acknowledged the BP was not taken and stated there was no physician order to do so. Two additional errors involved insulin administration. For one resident with diabetes and chronic kidney disease, Novolog FlexPen was ordered three times daily, but the CMT placed the needle on the pen, dialed the dose, and injected 5 units without performing an air shot or expelling air from the needle. For another resident with diabetes and chronic kidney disease, Lantus SoloStar 8 units daily was ordered, but the CMT placed a needle on the pen, dialed to 8 units, and injected without expelling air from the needle. During interview, the DON stated staff were expected to prime the pen and then set the dial to the appropriate dose for administration.
Incomplete Access to Prior EMR Records
Penalty
Summary
The facility failed to ensure resident medical records were complete, accurate, and readily accessible after transitioning from EMR Program A to EMR Program B. Based on interview and record review, records from the prior system were not fully integrated into the current system, and Administration did not have direct access to historical clinical information. The facility’s ePOS and progress notes in EMR Program B showed only entries dated after 12/11/25 for one resident and after 12/16/25 for another, with no earlier progress notes available in the current system. For one resident with essential tremor, BPH, bipolar disorder, vascular dementia, CKD, and pneumonia, the resident stated during interview that hearing aids and dentures were missing shortly after admission. When asked for prior progress notes, the Administrator stated access to EMR Program A was unavailable and corporate would need to be contacted; later records from EMR Program A showed progress notes from 5/6/25 through 12/26/25, including documentation that the spouse brought in a hearing aid and that the left hearing aid had been lost at the hospital. For another resident with ileus, constipation, CKD, and dysphagia, the Administrator again stated prior records were inaccessible in EMR Program A; later records from EMR Program A showed progress notes from 10/23/25 through 1/28/26 and a hospital referral noting a history of well controlled epilepsy.
Arbitration Agreement Did Not Allow Required Revocation Period
Penalty
Summary
The facility failed to ensure its arbitration agreement, which was included in the admission agreement provided to residents on admission, allowed the resident or representative to revoke the agreement within 30 days of signature. The agreement stated that disputes would be resolved by binding arbitration and that the provision could be revoked only by written notice delivered to the facility within five business days of signature. The report identified that this language did not provide the 30-day revocation period required by the facility’s process. During interviews, the Regional Nurse Consultant stated the arbitration agreement was part of the admission agreement and was not required for residents to sign. The Administrator stated the admission agreement had been completed by five people, including corporate social workers, and had not been reviewed since he/she started at the facility. The Administrator also stated he/she was not aware the arbitration agreement did not allow 30 days for residents to rescind and that the company would have to re-evaluate and ensure it was up to date.
Failure to Offer and Document Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to offer eligible residents the influenza vaccine and pneumococcal pneumonia vaccine for 5 of 5 residents sampled for immunizations. Review of the records for Residents #12, #13, #8, #9, and #6 showed no documentation that they received either vaccine, and no documentation that staff offered the vaccines or provided vaccine education. The sampled residents had diagnoses including heart failure, kidney disease, asthma, diabetes, osteomyelitis of the foot, stroke, and dysphagia. The facility’s written Pneumococcal Vaccine policy stated that all residents would be offered the pneumococcal vaccine upon admission, with education, consent, physician order, and documentation in the medical record. The Influenza Vaccine policy stated that all residents would be offered the influenza vaccine annually between October 1 and March 31, with education, consent, physician order, and documentation in the medical record. During interview, the Regional Nurse Consultant, who also served as the facility’s Infection Preventionist, stated that all residents are expected to be offered influenza vaccine yearly and pneumococcal vaccine on admission if eligible, and that refusals, education, and administered vaccines should be documented in the resident’s medical record.
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.
Resident Trust Funds Not Properly Maintained
Penalty
Summary
The facility failed to maintain resident trust records and accounting for resident funds for eight residents. Review of the facility’s resident trust records showed no account statements available between January 2025 and August 2025. The facility also did not have signed authorization allowing it to hold funds for any of the reviewed residents, and the resident trust account statements reviewed showed no interest applied to resident accounts. For Resident #64, the trust statement showed direct deposits and credits posted months after the transactions, a life insurance debit, and a room and board debit, with a balance of $5,044.42 as of 1/22/26. For Resident #65, the statement showed multiple cash withdrawals and a negative balance of (-) $619.95 before a later deposit brought the balance to $5.05. For Residents #52, #7, #82, #92, #94, and #100, the statements showed credits, withdrawals, or direct deposits with no interest applied and no signed authorization for the facility to hold funds. The facility’s Personal Needs Allowance policy, revised 9/1/25, stated that residents must sign requests and receipts acknowledging receipt of funds and that requests made by other parties would not be honored without resident signature or other appropriate documents. During an interview on 1/28/26, the Regional Nurse Consultant said the corporate BOM would be able to answer questions about bank statements prior to September 2025 and why there were negative balances, and he was not aware interest was not applied to resident trust accounts, though he expected it to be applied.
Missing Advance Directive Documentation and Code Status Sheets
Penalty
Summary
The facility failed to ensure four of 21 sampled residents had a signed advance directive or received information about their right to formulate an advance directive. Review of the facility policy stated that residents who are medically deemed competent, or their representatives, and who do not have an existing advance directive, are to be provided written information and instructions regarding the right to make advance directives upon admission or at any requested time. For Residents #17, #52, #63, and #93, review of the EMR showed no signed advance directive document and no documentation that advance directive information had been provided to the resident or representative. Resident #17 was cognitively intact and had diagnoses including muscle weakness and diabetes; the POS included a do not resuscitate order. Resident #52 was cognitively intact with diagnoses including acute kidney failure, acute respiratory failure, and muscle weakness; the POS included a full code order. Resident #63 was cognitively intact with diagnoses including diabetes, high blood pressure, and hyperlipidemia; the POS included a full code order. Resident #93 had moderately impaired cognition and diagnoses including chronic kidney disease, major depressive disorder, and anxiety; the POS included a full code order. Observation of the wing code status binder showed no signed code status document for each of these residents, and staff interviews confirmed the documents could not be found in the EMR or binder.
Privacy Not Maintained During Nephrostomy Dressing Change
Penalty
Summary
The facility failed to protect a resident’s right to privacy during personal care and medical treatment when staff did not close the door while performing dressing changes to bilateral nephrostomy tubes. Resident #108 was cognitively intact and had diagnoses including CAD, neurogenic bladder, major depressive disorder, nephrostomy catheter, and CKD. The resident’s care plan called for daily dressing changes to the nephrostomy tubes, and the physician orders directed daily dressing changes to the right and left nephrostomy tube sites, along with topical gentamicin and PRN flushing of the tubes. During observation on 1/27/26 at 12:30 P.M., an employee entered the resident’s room and changed the nephrostomy tube dressings while the resident sat in a wheelchair watching television. The employee did not close the room door during the dressing change, leaving the resident exposed to the hallway during care. During interviews, an LPN stated the door should be closed for privacy and dignity during dressing changes on or near nephrostomy tubes, and the DON agreed the door should have been closed while the resident’s dressings were being changed.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported to the Administrator and to DHSS for one resident who was cognitively intact and had diagnoses including anxiety, muscle weakness, and diabetes. The facility’s Abuse Prevention policy required the Administrator and DON to be promptly notified of suspected abuse and required the Administrator or designee to report allegations of abuse, neglect, misappropriation, exploitation, or reasonable suspicion of crime to the Department of Health as required. According to the resident’s account and staff documentation, the resident reported that a CNA intentionally threw the resident’s bed remote toward the resident after the resident refused to have the bed lowered. An LPN documented that the resident said the remote almost hit the resident in the head, attempted to contact the DON multiple times without success, and later sent the CNA home. The LPN stated the allegation was never reported to DHSS. The resident said the incident was reported to the LPN, and the Administrator stated he/she was never informed of the allegation. The DON said he/she could not confirm or deny being alerted and did not report the allegation to the Administrator or to DHSS.
Delayed Investigation of Abuse Allegations
Penalty
Summary
The facility failed to ensure allegations of abuse were investigated in a timely manner for two residents. The facility’s Abuse Prevention policy stated that suspected abuse must be promptly reported to the Administrator and DON, that an investigation must be initiated at the time of any finding of potential abuse or neglect, and that allegations against an employee must result in immediate suspension. The census was 91, and the deficiency involved Residents #17 and #65, both of whom were cognitively intact. For Resident #17, the resident reported that on the evening of 1/25/26 an unknown female staff member entered the room, ripped the call light from the resident’s hand, and placed it where the resident could not reach it. The resident said the incident was reported to the hospice nurse the next day. The facility’s investigation showed the allegation occurred on 1/25/26 and the investigation started on 1/26/26, but only CNA K had been interviewed. CNA L and CMT XXX, both of whom were working on the resident’s hallway on the date of the allegation, had not been interviewed. The resident’s NOK said he/she had not been informed of the allegation, and staff interviews showed CNA K and CNA L had not yet been contacted for interviews. Administrator A said the allegation had already been unsubstantiated even though staff interviews were still pending. For Resident #65, an LPN documented that staff reported the resident said CNA WWW threw the resident’s bed remote at him/her after the resident refused to lower the bed, and the remote almost hit the resident in the head. The LPN attempted to contact DON D multiple times, but calls and messages were unanswered, and CNA WWW was told to clock out and leave the premises. The facility’s investigation showed it was not started until 1/23/26, even though the allegation was reported on 11/28/25. The resident stated the remote was thrown toward him/her and that Administrator A and DON D never reached out to interview him/her. Administrator A said he/she had not been informed of the allegation, while DON D said he/she could not confirm or deny being alerted and did not start an investigation. CNA WWW was not suspended pending investigation.
Baseline care plan not completed for resident with CHF and fluid restriction
Penalty
Summary
The facility failed to ensure Resident #123 had a baseline care plan completed within 48 hours of admission that included the instructions needed to provide effective and person-centered care. The resident was admitted on 1/16/26 with diagnoses including CHF, pneumonia, glaucoma, and diabetes. The record showed an order for an 1800 mL daily fluid restriction and daily weights, but there was no baseline care plan to direct staff on the resident’s care needs, no documentation for the medical conditions requiring fluid restriction with goals and interventions, and no documentation of the care needs or wound requiring enhanced barrier precautions. Observation on 1/26/26 showed no fluid restriction sign on the resident’s door. During interviews, an LPN stated he/she was not aware of any fluid restriction on the hall and did not receive information about anyone being on fluid restriction, though he/she said a resident fresh out of the hospital for CHF and pneumonia would be the one most likely to have such an order. Another LPN said residents should have a sign on the door and an order in the medical record for fluid restrictions, but did not believe anyone on the hall was on fluid restriction. The DON stated the facility had no care plan for the resident and expected care plans to be done and completed upon a resident’s arrival; the facility also did not have signs for fluid restrictions.
Incomplete Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that comprehensive care plans were completed within 7 days of completion of the resident assessment and no later than 21 days after admission for four sampled residents. The facility policy stated that each resident should have a person-centered plan of care developed within 7 days after completion of the admission MDS and reviewed or revised as needed. Review of the records for Residents #1, #63, and #93 showed no comprehensive care plan completed, despite admission MDS assessments identifying multiple care areas that were triggered for inclusion in the care plan. Resident #1 was cognitively intact and had diagnoses including heart failure, high blood pressure, kidney failure, anxiety, depression, and asthma, with dependence or extensive assistance needed for multiple ADLs, frequent bowel and bladder incontinence, a therapeutic diet, pressure-reducing devices, and several triggered CAAs including communication, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, pressure ulcer, psychotropic drug use, and pain. Resident #4 had moderately impaired cognition, diagnoses including anemia, high blood pressure, kidney failure, aphasia, and non-Alzheimer's dementia, required varying levels of assistance with eating, hygiene, transfers, and dressing, was always incontinent of bowel and bladder, had an indwelling catheter, and had a one-page care plan that addressed only DNR status and did not address the triggered care areas. Resident #63 had diagnoses including diabetes, high blood pressure, and high cholesterol, was cognitively intact, and had triggered care areas including ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, nutritional status, pressure ulcer, and pain, but no comprehensive care plan was completed. Resident #93 had chronic kidney disease, major depressive disorder, and anxiety, moderately impaired cognition, and triggered care areas including cognitive loss/dementia, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, pressure ulcer, psychotropic drug use, and pain, but no comprehensive care plan was completed.
Failure to Provide Ordered Catheter Care and Proper Drainage Bag Positioning
Penalty
Summary
The facility failed to ensure appropriate urinary catheter care for two residents with indwelling catheters and failed to obtain physician orders that clearly identified catheter type and care needs. The facility’s catheter care policy, reviewed 7/1/25, stated that residents with indwelling catheters should receive consistent and adequate hygiene to maintain function and prevent infection or complications. For one resident with a history of stroke, acute kidney injury, bladder cancer, UTI, wounds, and protein malnutrition, the hospital discharge record showed catheter use for urinary output and the facility ePOS included only an order to irrigate the catheter as needed; the POS did not clarify catheter type, size, or balloon size and did not include catheter care orders. The TAR had no catheter care orders, and the care plan referenced an indwelling catheter but left catheter details unspecified. Observations showed the resident’s drainage bag placed on top of a full-size mattress next to the bed while the bed was lowered to the floor, and the bag was not below the level of the bladder. CNA DD stated the resident arrived with a catheter, the fall mattress was placed next to the bed for safety, and the drainage bag was placed on the mattress; the CNA also said catheter care had not been provided by the aide and was assumed to be done by the nurse. For the second resident, the hospital discharge summary documented UTI, an indwelling catheter, IV antibiotics, and the need for continued catheter care, but the facility admission ePOS contained no physician catheter care orders. An observation showed the urinary drainage bag hanging from the bed frame and touching the floor, with no barrier underneath and the bag visible from the hallway. The resident stated staff had not cleaned the catheter since arrival. An LPN said no catheter care orders were present and was unsure which staff provided catheter care, and the DON stated catheter orders should include diagnosis, size, balloon size, type, changing schedule, and care orders.
G-tube Care Not Properly Managed
Penalty
Summary
Facility staff failed to provide appropriate g-tube care for a resident with stroke, dysphagia, diabetes, and kidney disease. The resident’s admission MDS showed the resident was rarely or never understood and was dependent on staff for bed mobility and transfers. The resident had an order for Glucerna 1.2 tube feeding at 20 ml per hour with advancement by 10 ml every 24 hours to a goal rate of 50 ml per hour. The resident’s care plan did not address tube feeding care, despite the resident having a g-tube and receiving continuous tube feeding. During multiple observations, the resident was found in bed with the head of the bed almost flat while the tube feeding was running through the g-tube. The same condition was observed again in a Broda chair with the back of the chair flat and the resident’s feet elevated. On more than one occasion, the tube feeding bag was connected to the g-tube and running on a pump set at 50 ml, but the bag was not labeled with the formula, rate, or the date and time it was hung. Staff interviews stated that residents on tube feeding should have the head of the bed elevated at least 45 degrees and that the tube feeding bag should be labeled with the formula, rate, and hang time so it can be changed every 24 hours.
Failure to Document Consent, Alternatives, and Assessments for Bed Rail Use
Penalty
Summary
The facility failed to obtain and document informed consent for the use of side rails, failed to document attempted alternative approaches before side rail use, and failed to assess the use of side rails for three residents. The report states that the facility's Bed Rail policy required a person-centered approach, assessment of alternatives attempted before bed rail use, assessment of resident risk from bed rails, and ongoing monitoring. However, for Resident #63, whose admission MDS showed diabetes, high blood pressure, and intact cognition, the EMR contained a physician order for therapy to evaluate side rail usage but no documented side rail assessment, no documentation of alternatives attempted, no consent, and no care plan. Observations showed the resident in bed with quarter-length side rails raised at the head of the bed and later leaning against one of the raised rails. For Resident #52, whose admission MDS showed acute kidney failure, acute respiratory failure, muscle weakness, and intact cognition, the EMR showed a quarterly side rail assessment indicating side rails were used, but there was no physician order, no documentation of alternatives attempted, and no documentation of consent. The care plan identified the resident as using U-shaped side rails, and observations showed a U-shaped side rail on the right side of the bed and later the resident in bed with a U-shaped side rail raised on the right side. For Resident #78, whose annual MDS showed diabetes, major depressive disorder, chronic kidney disease, and intact cognition, the EMR included a quarterly side rail assessment and a physician order for half-length side rails on both sides of the bed for bed mobility, but there was no documentation of alternatives attempted and no documentation of consent. The care plan stated the resident used bilateral side rails for increased independence with bed mobility and boundary setting, and observations showed quarter-length side rails raised on both sides of the bed. The DON and Administrator stated they expected side rail assessments before installation and then annually, and that therapy should assess each resident for side rail safety before placement.
Delayed UA Collection for Resident with Abnormal Urine
Penalty
Summary
The facility failed to obtain a urinalysis in a timely manner for one resident with diabetes, high blood pressure, hyperlipidemia, and intact cognition. On 1/25/26, staff documented that the resident had a urinary catheter in place with 300 mL of output, and the urine was dark with a reddish tint and a strong odor. The physician was notified, and new orders were received for a urinalysis and BMP/CMP labs. The resident’s EMR showed no baseline or comprehensive care plan, and the ePOS showed no orders for catheter care. Observations showed the resident’s catheter bag on the bedframe on 1/26/26 with dark yellow urine and a reddish tint. A urine collection container labeled for the resident was observed empty at the nurse’s station on 1/26/26 and again on 1/27/26, and the urine sample container was later observed in the refrigerator on 1/28/26. An LPN stated the resident needed a UA because of blood in the urine and that the sample had not yet been collected because staff were busy. The DON stated the UA should have been collected right away and that the resident’s urine sample was not obtained in a timely manner and should have been sent to the lab on 1/25/26, not on 1/28/26.
Failure to Complete Routine Bed Rail Inspections
Penalty
Summary
The facility failed to ensure staff completed routine inspections of bed and side rails as part of a regular maintenance program for three residents with side rails, identified as Residents #63, #52, and #78. The report states that the facility did not document routine inspections of the side rails for any of these residents. The facility’s Bed Rail policy, dated 7/1/25, required the maintenance director or designee to follow a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails, and to ensure correct installation, use, and maintenance of the rails. Resident #63 had diagnoses of diabetes and high blood pressure and was observed in bed with quarter-length side rails raised at the head of the bed, including one observation where the resident was leaning against one of the raised rails. Resident #52 had diagnoses of acute kidney failure, acute respiratory failure, and muscle weakness and was observed with a U-shaped side rail on the right side of the bed. Resident #78 had diagnoses of diabetes, major depressive disorder, and chronic kidney disease and was observed in bed with quarter-length side rails raised on both sides of the bed. The Plant Operations Manager stated he had not been completing side rail safety assessments since the ownership change two months earlier and had received a new assessment document that day. The Administrator stated he/she expected monthly safety assessments of the side rails to avoid entrapment and other risks.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kirkwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aberdeen Heights | 1 mi | ★★★★★ | 0 | 0 |
| Bethesda Dilworth | 1.4 mi | ★★★★★ | 1 | 0 |
| Fountain Care At Sunset Hills | 3.3 mi | ★★★★★ | 3 | 0 |
| Friendship Village Sunset Hills | 3.4 mi | ★★★★★ | 0 | 0 |
| Quarters At Des Peres, The | 3.7 mi | ★★★★★ | 6 | 0 |
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