Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holden Manor Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with anxiety, legal blindness, muscle weakness, and severe cognitive impairment, who required maximal assistance with toileting, reported that when they requested help to use the restroom while sitting on the edge of the bed, a CNA replied that they had better things to do and pushed the resident back by the shoulders, causing fear and anger. An LPN and an RN later interviewed the resident in the presence of family, and the resident again alleged being pushed, pointing to the upper chest, though assessment showed no bruising or other physical findings. Another CNA and another resident reported that this CNA often seemed rushed, that residents felt ignored, and that the CNA used a gruff tone and yelled, while the CNA acknowledged being quick with care, having been counseled on tone of voice, and denied pushing the resident, stating they only tapped the resident’s shoulder to get their attention.
The facility exhibited multiple food safety and hygiene deficiencies, including improper handwashing, unlabeled food items, and inadequate cleaning practices. A dietary staff member handled food with bare hands and failed to check food temperatures, while margarine containers were improperly stored. Dust and debris were found in kitchen areas, indicating a lack of adherence to food safety protocols.
The facility failed to maintain proper hand hygiene during medication administration for three residents, with staff not sanitizing hands between tasks or changing gloves when soiled. Additionally, the facility did not complete required two-step Mantoux skin tests for two residents, indicating a lack of adherence to TB screening protocols.
The facility failed to maintain proper documentation for resident trust fund transactions and petty cash records, affecting two residents and potentially impacting 22 others. Transactions were recorded without receipts or signatures, and the previous BOM's practice of combining multiple transactions on one receipt complicated tracking. Additionally, there was no formal process for calculating petty cash, leading to a lack of proper accounting.
The facility failed to maintain room temperatures within the CMS-required range, with one resident's room reaching 85°F. Staff were unaware of thermometer locations, and two thermometers were malfunctioning. Additionally, there were cleanliness issues, including a pungent urine odor, dust buildup, and stained shower curtains, affecting at least 31 residents.
A facility failed to ensure proper labeling and storage of medications brought in by a resident's family, including expired and unlabeled items. Additionally, other medications in the CMT cart were improperly stored, and expired medical supplies were found in the medication room. Staff interviews confirmed the need for proper labeling and disposal of expired items.
The facility failed to provide adequate recipes for pureed foods, leading to dietary staff preparing meals without proper guidance. Observations showed that a dietary staff member made pureed foods without consulting a recipe book, and the recipes lacked specific instructions on liquid and thickener amounts. The dietary director and consultant RD acknowledged the inadequacy of the recipes, affecting five residents on pureed diets.
The facility failed to ensure food was palatable and properly prepared, as pureed French fries were bland and chunky due to lack of a recipe, and dinner rolls were undercooked. Cognitively intact residents expressed dissatisfaction with the food quality, and dietary staff acknowledged the issues.
The facility failed to ensure pureed chicken tenders and french fries were prepared to a smooth consistency for residents on pureed diets. The dietary staff did not follow recipes or measure ingredients, resulting in grainy and chunky textures. Interviews revealed a lack of standardized recipes and consultation with the RD.
The facility did not follow its policy for storing food brought by family and visitors, as observed in the resident use refrigerator. Unlabeled and expired food items, including French Onion Dip, cottage cheese, and hot dogs, were found without resident names or dates. Additionally, staff food was improperly stored in the resident refrigerator. Interviews with the DON and Dietary Director confirmed these practices were against facility policy.
The facility failed to ensure pneumococcal vaccines were offered, administered, or documented for three residents. Despite facility policy requiring vaccination assessments within five days of admission, documentation was lacking for a resident with chronic renal disease and another with chronic hepatitis C. A third resident received a PPSV23 vaccine but lacked documentation for the recommended PCV20 or PCV15. Interviews with the IP and DON confirmed the oversight in offering and documenting vaccines.
The facility failed to keep the kitchen and certain resident rooms free of ants, affecting four residents. Ants were observed in the kitchen and two resident rooms, with snacks left out of containers in one room. The Maintenance Director was unaware of the issue until it was reported, despite a housekeeper having informed them a week earlier.
A facility failed to obtain a resident's authorization signature to open and maintain a trust account. The resident's account was opened without the necessary signed form, as confirmed by interviews with the Regional BOM and the previous BOM, who transitioned to Activity Director.
The facility failed to transfer funds for a discharged resident and did not complete TPL forms for two deceased residents. A resident's funds were not forwarded to their new facility due to a lack of training for the BOM, resulting in a 176-day delay. Additionally, TPL forms for two residents who passed away were not completed, as confirmed by the Regional BOM.
A resident's request for a Do Not Resuscitate (DNR) order was not timely enacted, leaving them listed as a full code despite their wishes. The facility's staff, including an RN, MDS Coordinator, and DON, acknowledged the delay in processing the DNR, which should have been verified and enacted within 24 to 72 hours.
The facility failed to complete MDS assessments within the required timeframe for two residents and inaccurately completed an MDS assessment for a resident with depression. The MDS Coordinator was behind on assessments, and the Director of Nursing acknowledged the backlog and the need for accurate completion, especially given the resident's diagnosis.
The facility failed to develop comprehensive care plans for two residents within the required timeframe. One resident's care plan lacked goals and interventions for ADLs and mobility, and omitted information on depression, kidney disease, and surgical care. Another resident's plan did not address mobility and ADL assistance. Staff interviews revealed a lack of awareness and adherence to care planning regulations.
A resident did not receive scheduled bathing services for 11 days due to staffing shortages. The facility's shower aide was frequently reassigned to floor duties, leading to missed showers. Despite being cross-trained, nursing staff could not complete all showers, and the DON acknowledged the issue, citing staff shortages as a contributing factor.
A resident with a history of adjustment disorder, anxiety, and depression exhibited aggressive behaviors towards their roommate, but the facility failed to monitor or document these behaviors adequately. The resident's care plan was incomplete, lacking necessary interventions, and there were no referrals for counseling or behavioral management. Staff interviews revealed a lack of awareness and documentation of the incidents, and management did not take sufficient action to address the conflicts.
A facility failed to ensure monthly Medication Regimen Reviews (MRRs) were conducted and documented for a resident, as required by policy. The resident's EMR lacked documentation for several months, indicating a lapse in the review process. Interviews revealed unclear responsibilities among staff, with the DON expecting better documentation and record-keeping, which was not achieved.
The facility failed to complete recommended GDR and MRR for psychotropic medications for three residents. A resident with depression did not have a GDR completed for Venlafaxine, despite a recommendation. Another resident with depression, autism, and mood disorder lacked a completed MRR, and the physician did not respond to recommendations regarding Risperdal and Divalproex. A third resident with dementia and anxiety had no documentation for an MRR, and a recommendation regarding Zyprexa was not acted upon. The DON was unaware of these unaddressed recommendations.
Alleged Rough Handling and Disrespectful Interaction During Toileting Request
Penalty
Summary
The deficiency involves a failure to ensure that a resident was treated with dignity and respect, consistent with the facility’s dignity and abuse-prevention policies. A resident with anxiety disorder, legal blindness, muscle weakness, and severe cognitive impairment, who required maximal assistance with toileting, reported that while sitting on the side of the bed with legs dangling, a CNA entered the room. The resident stated that after requesting to use the restroom, the CNA responded, “I have better things to do,” and pushed the resident on the shoulders, causing the resident to lean back on the bed. The resident reported feeling scared at first and then angry, and another aide later came to assist with toileting. Following this alleged incident, an LPN overheard the resident telling a family member that the CNA had pushed them the previous night. The LPN notified an RN, and together they interviewed the resident in the presence of the family member. The resident again reported that the CNA had pushed them, and pointed to the upper chest as the area of contact. An assessment was completed, which revealed no marks, bruising, edema, or inflammation. The resident did not report falling off or out of the bed. The facility’s policies required that residents be treated with dignity and respect at all times, prohibited demeaning practices, and affirmed residents’ rights to be free from physical abuse. Other staff and residents provided additional context about the CNA’s interactions with residents. One CNA reported that the resident had complained about the CNA involved in the allegation, and that another resident had also complained that this CNA always seemed to be in a hurry. Another resident stated that this CNA was “not the best aide,” seemed to be in a hurry, and made the resident feel ignored; this resident also reported hearing the CNA yelling at the resident involved in the allegation, describing the CNA’s tone as gruff, though they could not understand the words. The CNA in question acknowledged that residents had asked them to slow down, that they sometimes did not have time to spend extra time with residents, and that they had previously discussed their tone of voice with the Administrator. The CNA denied pushing the resident, stating that the resident sometimes became verbally aggressive and that, due to the resident’s hearing impairment, they would tap the resident on the shoulder to signal their presence.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility was observed to have several deficiencies related to food safety and hygiene practices. During breakfast meal preparation, there was a buildup of dust and food debris under the reach-in refrigerator, and an old container of yogurt was found. A dietary staff member, referred to as DC A, handled their phone and did not wash their hands before returning to serve food. Additionally, grime and dust were present in the air conditioning unit, and a shaker with a white granulated substance was not labeled. DC A also broke a waffle apart with bare hands and did not follow the proper three-step cleaning process for the food processor. Furthermore, DC A handled waffles with bare hands from the toaster. During lunch meal preparation, similar issues were noted. There was debris and dust in the window air conditioner unit, and a box of margarine containers was not refrigerated, with many containers missing covers. DC A placed French fries on the steam table without checking the temperature and used a damaged potholder to handle a pan of pureed chicken, again without checking the temperature. DC A also improperly handled dessert cups by placing fingers inside them while serving applesauce and did not properly clean the food processor cover between uses. Interviews with staff revealed a lack of awareness and adherence to proper food safety protocols, contributing to these deficiencies.
Inadequate Hand Hygiene and TB Screening in LTC Facility
Penalty
Summary
The facility failed to perform adequate hand hygiene during medication administration for three residents, leading to potential infection control issues. Certified Medication Technician (CMT) A did not change gloves or sanitize hands between different routes of medication administration for Resident #11, even after the gloves were soiled with yogurt. Similarly, CMT A did not sanitize hands before entering or after exiting Resident #10's room, nor did they sanitize hands between glove changes during medication administration. Licensed Practical Nurse (LPN) B also failed to perform proper hand hygiene during an Accu-Chek procedure for Resident #27. LPN B did not sanitize hands upon entering or exiting the shower room, nor before and after donning gloves. This lack of hand hygiene was acknowledged by LPN B during an interview, where they admitted to not sanitizing hands as frequently as required. Additionally, the facility did not implement a proper Tuberculosis (TB) screening program, as evidenced by the failure to complete two-step Mantoux skin tests for Residents #141 and #241. The facility's policy lacked specific instructions for administering the two-step TB skin test, and there was no documentation of the second step being completed for these residents. The Director of Nursing and the Minimum Data Set Coordinator acknowledged these deficiencies, indicating a lack of adherence to state and federal regulations for TB screening.
Deficiency in Resident Trust Fund and Petty Cash Management
Penalty
Summary
The facility failed to maintain proper documentation and accounting for resident trust fund transactions and petty cash records, affecting two out of four sampled residents and potentially impacting 22 residents with resident trust accounts. Specifically, for one resident, there were transactions recorded without corresponding receipts or signatures, including a transaction for $40.41 and another for $18.97. Another resident's transaction for $28.56 also lacked a receipt and signature. The Regional Business Office Manager (BOM) indicated that the previous BOM combined multiple transactions on one receipt, complicating the tracking of individual transactions, and did not keep specific receipts for grocery store transactions. Additionally, the facility did not maintain petty cash records from July 2023 through April 2024. The Regional BOM acknowledged the absence of a formal process for calculating petty cash, which contributed to the lack of proper accounting. This deficiency in managing and documenting financial transactions for resident trust funds and petty cash was identified during interviews and record reviews.
Temperature and Cleanliness Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain the ambient temperature in several resident rooms, including Resident #291's room, within the required CMS regulatory range of 71-81 degrees Fahrenheit. Observations revealed that Resident #291's room temperature reached as high as 85 degrees Fahrenheit, causing discomfort to the resident. The facility did not monitor the temperatures effectively, as staff were unaware of the locations of thermometers, and two facility thermometers were found to be malfunctioning. The Maintenance Director admitted to not regularly checking the thermometers for accuracy, and the Director of Nursing and other staff did not perform temperature monitoring or know where the thermometers were located. Additionally, the facility failed to maintain cleanliness and hygiene in various areas. A pungent urine odor was detected in the restroom of one resident room, and there was a buildup of dust and debris in multiple rooms, including on fans and climate control units. The Maintenance Director acknowledged the presence of dirt and debris affecting the climate control units' performance, and the housekeepers were reportedly responsible for cleaning the fans, which had not been done adequately. The facility also neglected to maintain the shower rooms and therapy room in a clean state. Observations noted red stains on a shower curtain, debris under a tub, and a heavy buildup of dust in ceiling vents and fans. The Certified Occupational Therapist Assistant admitted that the therapy staff had not been diligent in cleaning the fans. These deficiencies potentially affected the comfort and safety of at least 31 residents in the facility.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications brought in by a resident's family member were labeled and stored correctly. Specifically, medications for a resident with neurocognitive disorder and Parkinson's disease were found in the Certified Medication Technician (CMT) cart without proper labeling or with illegible expiration dates. These included Causticum, SeaBD, Nuadapt, Hyoscyamus, Nux Vomica, and Magnesium solution. The Magnesium solution was expired, and the CMT acknowledged that the family had just brought it in without checking the expiration date. Additionally, other medications in the CMT cart were not stored or labeled appropriately. Observations revealed that a budesonide and formoterol fumarate inhaler was unlabeled and not stored in any container, while a fluticasone propionate nasal spray was outside its original container without a visible expiration date. Dietary supplements were also found without resident labels or expiration dates. The facility also failed to dispose of expired medical supplies in the medication room, which included intravenous start kits and safety blood collection sets that had expired. Interviews with staff, including CMTs, LPNs, the MDS Coordinator, and the Director of Nursing, confirmed that medications should remain in their original containers, be properly labeled, and that expired medications and supplies should not be stored or accepted.
Inadequate Pureed Food Recipes and Preparation
Penalty
Summary
The facility failed to ensure that recipes for pureed foods, such as waffles, chicken tenders, and mixed vegetables, were available and detailed enough for dietary staff to use. Observations revealed that the dietary staff member, referred to as DC A, prepared pureed foods without consulting a recipe book. The recipes lacked specific instructions on the amounts of liquids and thickeners needed, which led to inconsistencies in food preparation. The dietary director acknowledged the inadequacy of the recipes and the absence of printed recipes due to a computer issue. Interviews with the dietary director and the consultant registered dietitian (CRD) highlighted the expectation for staff to use recipe books, although it was noted that gathering staff for in-service training was challenging. The CRD confirmed that the recipes were not specific enough and could be improved. This deficiency potentially affected five residents on pureed diets, with the facility census at 46 residents.
Deficiencies in Food Preparation and Palatability
Penalty
Summary
The facility failed to ensure that the food served to residents was palatable and properly prepared, as evidenced by the issues with pureed French fries and dinner rolls. Observations and interviews revealed that the pureed French fries were prepared without a recipe, resulting in a bland taste and chunky texture. The Dietary Director confirmed the absence of printed recipes for pureed fries, and the dietary staff did not taste the fries after preparation. Resident feedback indicated dissatisfaction with the taste and texture of the fries, describing them as mushy and undercooked. Additionally, the facility did not properly cook the dinner rolls served during a lunch meal. Observations showed that the rolls were cooked on the outside but remained doughy and undercooked on the inside. A resident was able to stretch the dough, confirming the undercooked state. The dietary staff acknowledged the rolls were not completely cooked, and the Dietary Director noted the issue was not identified earlier because they were not present in the kitchen that day. These deficiencies were reported by cognitively intact residents who expressed dissatisfaction with the quality of the food.
Failure to Ensure Proper Consistency of Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed chicken tenders and french fries were prepared to a smooth consistency, as required for residents on pureed diets. During an observation, it was noted that the dietary staff member, referred to as DC A, did not follow a recipe or measure the ingredients while preparing the pureed chicken tenders. Instead, an unmeasured amount of chicken base and water was added to the chicken before pureeing. The staff member did not taste the final product, which was later found to have a grainy texture during a taste test. Similarly, the pureed french fries were prepared without a recipe, using cold milk, and were not tasted by the staff member, resulting in a chunky texture. Interviews with the dietary staff and the Dietary Director revealed a lack of standardized recipes for pureed foods, specifically for the fries, and an absence of consultation with the Registered Dietitian. The Dietary Director acknowledged the presence of chunks in the pureed fries and expressed an expectation for staff to use available recipes, although it was unclear why a recipe for the fries was not available. The dietary staff member admitted to not using the recipe book and recognized the need for further pureeing to achieve the desired smooth consistency.
Improper Storage of Resident Food in Facility Refrigerator
Penalty
Summary
The facility failed to adhere to its policy regarding the proper storage of food brought by family and visitors for residents. During an observation, it was noted that the resident use refrigerator contained several food items that were not labeled with a resident's name or a date, as required by the facility's policy. These items included French Onion Dip, cottage cheese, hot dogs, creamy mayo, hummus, boiled eggs, peanut butter, and food in various containers. Additionally, a container of food belonging to a staff member was found in the resident use refrigerator, which is against the facility's policy that staff food should be stored in a separate refrigerator. Interviews with the Director of Nursing (DON) and the Dietary Director revealed that the facility's expectations were not being met. The DON stated that the refrigerator should be cleaned weekly and that all items should be labeled with the date received and the resident's name. The Dietary Director confirmed that staff food should be stored in a different area. The presence of unlabeled and expired food items in the resident use refrigerator indicates a failure to follow the established policy, potentially affecting at least four residents who had food stored there.
Failure to Document and Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that pneumococcal pneumonia vaccines were offered, administered, or documented for three residents out of five sampled for vaccination provision. The facility's policy required that all residents be offered pneumococcal vaccines to prevent infections, with assessments of vaccination status occurring within five days of admission. However, for Resident #10, who was older than the recommended age and had chronic renal disease, there was no documentation of vaccine administration, education, consent, or refusal. Similarly, Resident #141, who had chronic hepatitis C, lacked documentation of pneumococcal vaccination, education, consent, or refusal. Resident #241, who was older and had chronic renal disease, had received a PPSV23 vaccine but lacked documentation of receiving the recommended PCV20 or PCV15 vaccine. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed that residents should have been screened for pneumococcal immunizations upon admission, and all administered immunizations or refusals should have been documented in the medical record. The IP and DON acknowledged that residents recommended for pneumococcal vaccines should have been offered the vaccine by the facility. The failure to document and offer the vaccines as per the CDC recommendations and facility policy led to the deficiency identified in the report.
Ant Infestation in Kitchen and Resident Rooms
Penalty
Summary
The facility failed to maintain the kitchen area and certain resident rooms free of ants, affecting the kitchen and four residents. Observations on July 29, 2024, revealed ants at the 3-compartment sink in the kitchen. The Maintenance Director was unaware of the ant issue prior to this observation. Further observations on July 30, 2024, showed ants in two resident rooms, with snacks left out of containers in one room. The Social Service Designee acknowledged the need to address the storage of snacks with the resident. Despite the Maintenance Director's claim that ants were not an ongoing issue, a housekeeper reported seeing ants in a resident room a week earlier and had informed the Maintenance Director, who provided ant spray.
Failure to Obtain Authorization for Resident Trust Account
Penalty
Summary
The facility failed to obtain an authorization signature from a resident to open and maintain a resident trust account. The resident was admitted to the facility and had a balance of $0.0 in their account. However, there was no signed authorization form on file. During an interview, the Regional Business Office Manager (BOM) stated that the form was given to the new facility BOM, but the resident did not sign it. The previous BOM, who worked until mid-July and then became the Activity Director, confirmed that the resident's account was opened in late July without the necessary authorization signature.
Failure to Transfer Resident Funds and Complete TPL Forms
Penalty
Summary
The facility failed to ensure the timely transfer of funds for a discharged resident and did not complete necessary forms for two deceased residents. Resident #93 was discharged from the facility to a hospital and subsequently moved to another facility. At the time of discharge, the resident had $80.24 in their trust account, but there was no documentation indicating that these funds were forwarded to the resident at the new facility. The Regional Business Office Manager (BOM) noted that the facility BOM was new and untrained, leading to delays in closing the account, which was only done 176 days after the resident's transfer. Additionally, the facility did not complete Third Party Liability (TPL) forms for two residents who had passed away. Resident #91, who died with $121.79 in their trust fund, and Resident #92, who passed away with $50.00 in their account, both had incomplete TPL forms. The Regional BOM confirmed that the former BOM did not complete these forms, which are required to be sent to Missouri Healthnet within 30 days of a resident's death.
Failure to Timely Enact DNR Order
Penalty
Summary
The facility failed to obtain a timely advanced directive for a resident who elected to be a Do Not Resuscitate (DNR). Upon admission, the resident signed a DNR form, but it lacked additional required signatures. Despite the resident's clear wishes to not receive CPR in the event of cardiac arrest, the Physician Order Summary indicated the resident was a full code, meaning CPR would be administered. Interviews with staff revealed that the process to verify and enact the DNR was not completed in a timely manner, with the resident's DNR status remaining unverified for an extended period. Staff members, including a Registered Nurse (RN), the Minimum Data Set (MDS) Coordinator, and the Director of Nursing (DON), acknowledged the delay in processing the DNR order. The RN stated that CPR would have been performed due to the full code order in the medical record. The MDS Coordinator and DON both expressed expectations for the DNR to be enacted within a short timeframe, ideally within 24 to 72 hours, to ensure the resident's wishes were respected. However, the DNR remained unsigned by a physician or witnessed by staff, highlighting a lapse in the facility's protocol for handling advanced directives.
Failure to Complete and Accurately Submit MDS Assessments
Penalty
Summary
The facility failed to complete Minimum Data Set (MDS) assessments in a timely manner for two residents and failed to complete an accurate MDS assessment for another resident. Specifically, the MDS assessments for two residents were not completed within the federally mandated 14-day period following their admissions. The MDS Coordinator acknowledged being behind on completing these assessments, which were past due. The Director of Nursing confirmed the responsibility of the MDS Coordinator in ensuring timely completion of these assessments and acknowledged the facility's backlog. Additionally, the facility did not accurately complete the MDS assessment for a resident diagnosed with depression. The resident's Annual MDS lacked completed sections on cognitive patterns and mood, despite the resident's documented symptoms of depression. The MDS Coordinator, who was not in the role at the time of the previous submissions, confirmed that these sections should have been completed. The Director of Nursing expected these assessments to be completed accurately, given the resident's diagnosis.
Incomplete Comprehensive Care Plans for New Admissions
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for two residents within the required timeframe. Resident #291's care plan was incomplete, lacking goals and interventions for activities of daily living and limited physical mobility, and missing information on depression, chronic kidney disease, and surgical site care for a femur fracture. Similarly, Resident #292's care plan did not address reduced mobility and activities of daily living assistance, despite the resident's diagnoses of malnutrition, asthma, dysphagia, and reduced mobility. Interviews with facility staff revealed a lack of awareness regarding the regulatory requirements for completing comprehensive care plans. The MDS Coordinator, responsible for these care plans, admitted to being behind schedule and uncertain about the specific timeframe for completion. The Director of Nursing also acknowledged the delay in completing care plans and was unsure of the required timeline, indicating a systemic issue in adhering to care planning regulations.
Failure to Provide Scheduled Bathing Services Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that a resident received bathing services according to their preferences and care plan. The resident, who was cognitively intact and required partial to moderate assistance with bathing, had not received a shower for 11 days, despite their preference for twice-weekly showers. The resident expressed concerns about not receiving showers as scheduled, and the facility's records showed inconsistencies in documenting bathing services. The deficiency was attributed to staffing issues, as the designated shower aide was frequently reassigned to work on the floor due to staff shortages. This reassignment led to a lack of consistent bathing services for residents, including the affected resident. Interviews with CNAs and the LPN revealed that while all nursing staff were cross-trained to assist with bathing, they were unable to complete all scheduled showers due to the increased workload and insufficient staffing. The Director of Nursing acknowledged the issue, noting that the facility was aware of the failure to provide showers twice weekly as required. The DON cited staff call-ins and a general lack of staff as contributing factors to the deficiency. Despite efforts to hire and retain staff, the facility struggled to maintain adequate bathing schedules, resulting in the resident going without a shower for an extended period.
Failure to Address Behavioral Health Needs Leads to Resident Conflict
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, leading to ongoing conflicts with their roommate. The resident, who had a history of adjustment disorder, anxiety, depression, and substance abuse, exhibited aggressive and disruptive behaviors towards their roommate. Despite these known issues, the facility did not adequately monitor or document the resident's behaviors, nor did they implement timely interventions to address the aggressive incidents. The resident's care plan was incomplete and did not reflect their psychiatric history or the specific behaviors they exhibited. The facility's staff failed to update the care plan with necessary interventions to manage the resident's adjustment disorder and aggressive behaviors. Additionally, there was no evidence of referrals for counseling or behavioral management services, despite the resident's ongoing conflicts and requests for room changes. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's behavioral incidents. The staff did not consistently monitor the resident's behaviors or implement a behavior plan to prevent further escalation. The facility's management was aware of the conflicts but did not take sufficient action to separate the residents or provide appropriate behavioral health services.
Failure to Conduct and Document Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly Medication Regimen Review (MRR) for a resident, which is essential for identifying and addressing medication irregularities. The facility's policy mandates that MRRs involve a thorough review of the resident's medical record to prevent, identify, report, and resolve medication-related problems. However, for one resident, there was no documentation of MRRs for January, March, and April 2024 in the resident's Electronic Medical Record (EMR), indicating a lapse in the review process. Interviews with facility staff revealed a lack of clarity and responsibility in the MRR process. An LPN stated that nurses were responsible for completing MRRs and faxing recommendations to physicians, but there was no verification process if documentation was missing. The Director of Nursing (DON) indicated that the Pharmacy Consultant was responsible for emailing MRRs to the facility, and the medical records staff were to scan recommendations into the EMRs. However, the facility was behind on MRRs, and there was an expectation for better documentation and record-keeping, which was not met, leading to the deficiency.
Failure to Complete GDR and MRR for Psychotropic Medications
Penalty
Summary
The facility failed to complete recommended Gradual Dose Reductions (GDR) and Medication Regimen Reviews (MRR) for psychotropic medications for three residents. Resident #1, who was diagnosed with depression, had been taking Venlafaxine since September 2023. A GDR was recommended by the pharmacy consultant in May 2024, but the facility did not respond to this recommendation. Interviews with the LPN and MDS Coordinator revealed that there was no documentation or verification of the GDR recommendation being completed or signed off by the physician. The Director of Nursing (DON) was responsible for ensuring the completion of all pharmacy recommendations, but no documentation was found to confirm the GDR completion for Resident #1. Resident #18, who had diagnoses including depression, autism, and affective mood disorder, also did not have a completed MRR for February 2024. The pharmacy consultant made recommendations regarding the use of Risperdal and Divalproex, noting the lack of allowable diagnoses to support their use. However, there was no written response from the physician to these recommendations. The resident's care plan indicated that psychotropic medication should be administered as ordered by the physician, and dosage reductions should be considered when clinically appropriate. Despite this, there was no documentation from the physician related to the pharmacy's requests. Resident #33, diagnosed with dementia with behavioral disturbance, Alzheimer's, depression, and anxiety, also lacked documentation for an MRR in February 2024. A recommendation was made regarding the use of Zyprexa, which lacked an appropriate diagnosis to support its use. Although the physician reviewed the recommendation, there was no documentation of any change in diagnosis. Interviews with the LPN and DON indicated that the MRRs were completed monthly, and the recommendations were to be reviewed by the DON and sent to the physician. However, the DON was not aware that the pharmacy MRR/GDR recommendations were not acted upon for Residents #18 and #33.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Holden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Johnson County Care Center | 14.4 mi | ★★★★★ | 17 | 0 |
| Ridge Crest Nursing Center | 14.9 mi | ★★★★★ | 16 | 0 |
| Aspire Senior Living Pleasant Hill | 15.3 mi | ★★★★★ | 2 | 0 |
| Country Club Rehab And Healthcare Center | 15.5 mi | ★★★★★ | 0 | 0 |
| Warrensburg Manor Care Center | 15.5 mi | ★★★★★ | 0 | 0 |
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