Ignite Medical Resort Blue Springs
Inspection history, citations, penalties and survey trends for this long-term care facility in Blue Springs, Missouri.
- Location
- 20511 E Trinity Place, Blue Springs, Missouri 64015
- CMS Provider Number
- 265880
- Inspections on file
- 15
- Latest survey
- April 24, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ignite Medical Resort Blue Springs during CMS and state inspections, most recent first.
A resident with dementia, muscle weakness, and impaired mobility was found on the floor outside the bathroom with the bathroom track door also dislodged. The resident sustained a head hematoma and a left femoral neck fracture. Staff and maintenance interviews revealed no prior reports of issues with the door, though it was noted that the door could come off the track if bumped with enough force. The deficiency involved the failure to maintain an environment free from accident hazards, as the door's dislodgement contributed to the resident's fall and injuries.
A nurse administered the wrong medications to a resident with complex medical needs after preparing medications for two residents simultaneously and becoming distracted by interruptions during the medication pass. The resident, who was cognitively intact and had multiple serious diagnoses, became lethargic after receiving the unprescribed medications and was sent to the hospital for evaluation, though no treatment was needed. Staff interviews indicated that distractions and the use of a pre-popping method contributed to the error.
The facility failed to ensure proper infection control during resident care, including inadequate hand hygiene and use of enhanced barrier precautions by staff. An LPN did not follow hand hygiene protocols during colostomy care, and staff failed to wear PPE when caring for a resident with a wound. Additionally, a dietary aide did not receive timely TB screening as per facility policy.
The facility failed to maintain a clean environment in several resident rooms, with observations revealing cobwebs and dust buildup behind beds, armoires, and in corners. Despite expectations for thorough cleaning, these deficiencies were noted during a walkthrough with the EVS Director, potentially affecting 23 residents.
A resident with moderately impaired cognition was found self-administering Miconazole Nitrate 2% powder without a physician order or proper assessment in a facility. The medication was not stored in a locked drawer as required by policy. Staff interviews revealed a lack of clarity and enforcement regarding the assessment and documentation process for self-administration.
A facility failed to assess and document a resident's wounds as per its policy. Despite having a left knee wound and a right hip surgical incision, the resident's records lacked measurements and descriptions. Interviews with staff revealed a lack of awareness and documentation, and observations confirmed the presence of wounds that were not properly recorded.
A facility failed to apply a physician-ordered splint device for a resident with limited mobility due to stroke and hemiplegia. Despite the care plan requiring a left hand splint during waking hours, observations showed the resident without the splint on two occasions. Staff interviews revealed a CNA did not apply the splint due to perceived discomfort, and an RN was unaware of the splint's status. The DON expected staff to apply such devices and not document their application if not done.
A resident with moderately impaired cognition and an ostomy was performing colostomy care independently without a physician's order or a full assessment of their ability to self-administer the care. The facility's policy required such an order and assessment, but these were not completed. Interviews revealed that the nursing staff were responsible for the assessment, but it was not documented, and the resident's care plan and orders were not updated to reflect their ability to self-care.
The facility failed to document physician's orders for CPAP machines on the POS and care plans for two residents with sleep apnea. Observations showed CPAP masks and tubing were left uncovered, and staff interviews revealed a lack of adherence to storage protocols. The DON confirmed the expectation for detailed orders and care plans, which were not met.
A resident with significant cognitive impairment and an indwelling catheter did not have proper orders or documentation for catheter care during their stay. Facility staff acknowledged the need for care but cited the absence of an order as a barrier to documentation. The deficiency was noted when the resident was sent to the hospital for a wound infection, highlighting the lack of verifiable catheter care.
The facility's call light system was found deficient, impacting two residents' care. One resident, needing assistance with toilet hygiene, experienced delays when a family member's call light requests went unanswered, requiring them to seek help at the nurse's station. Another resident, with Spina Bifida, reported past issues with the system, which allowed staff to turn off call lights from the nurse's station without entering rooms. Recent changes now require staff to enter rooms to turn off call lights, addressing previous complaints.
Failure to Ensure Safe Environment Due to Dislodged Bathroom Track Door
Penalty
Summary
A deficiency occurred when a resident with multiple risk factors, including unspecified dementia, generalized muscle weakness, abnormal gait, cognitive communication deficit, and a need for assistance with personal care, was found on the floor outside their bathroom with the bathroom track door also on the floor. The resident had moderately impaired cognition and required partial to moderate assistance with toileting hygiene. On the day of the incident, staff heard a loud bang from the resident's room and found the resident in a left lateral position, asking for help to get up. The resident sustained a hematoma on the face and additional bruising, and subsequent X-rays revealed a left femoral neck fracture. The bathroom door was found next to the resident, but not on top of them, and the resident was unable to describe what happened. Interviews with staff, the maintenance director, and the resident's roommate indicated that there were no prior reports or documented issues with the bathroom track door before the incident. The maintenance director and several staff members stated they had not received any requests or notifications regarding problems with the door. The maintenance director noted that the door could potentially come off the track if bumped with enough force, but all safety mechanisms were reportedly intact at the time of the incident. The roommate did not witness the fall but heard the noise and believed the resident may have fallen against the door, causing it to come off the track. The facility had a system in place for staff to report maintenance issues, and both housekeeping and nursing staff were expected to report any concerns. However, no work orders or complaints about the bathroom track door were submitted prior to the event. The incident was unwitnessed, and the resident's cognitive impairment limited their ability to provide details. The deficiency centers on the failure to ensure a safe environment free from accident hazards, as the bathroom track door became dislodged during the resident's fall, contributing to the accident and resulting injuries.
Medication Error Due to Distraction and Incorrect Administration
Penalty
Summary
A medication error occurred when a nurse administered the medications intended for one resident to another resident. The nurse was preparing medications for two residents at the same time and typically labeled the medication cups with the residents' names. However, during this medication pass, the nurse accidentally grabbed the wrong cup and gave the incorrect medications to the resident. The nurse realized the error immediately after administration. The resident who received the wrong medications had a medical history that included end-stage renal disease, respiratory syncytial virus pneumonia, generalized anxiety disorder, pulmonary hypertension, and dependence on renal dialysis. The resident was cognitively intact at the time of the incident. After receiving the incorrect medications, the resident appeared lethargic and sleepy, prompting the facility to send the resident to a local hospital for evaluation, where no treatment was required. Interviews with staff revealed that interruptions during medication passes, such as questions from other residents and the presence of a student, contributed to the error. The nurse involved reported being distracted and stated that the pre-popping method of preparing medications, which was not taught by the facility, was used to expedite the medication pass. The Director of Nursing and another RN both identified that the administration of certain medications, such as Losartan Potassium, could have had significant negative outcomes.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures during the care of residents, specifically in the areas of hand hygiene and the use of enhanced barrier precautions. During the care of a resident with a colostomy and a suprapubic catheter, an LPN did not follow the facility's hand hygiene policy. The LPN entered the resident's room without washing or sanitizing hands, failed to perform hand hygiene between glove changes, and did not wear a gown as required by the enhanced barrier precautions policy. This lack of adherence to proper infection control practices was acknowledged by the LPN and confirmed by interviews with other staff members, including the Assistant Director of Nursing and the Director of Nursing. Another deficiency was observed in the care of a resident with a left ankle wound and on enhanced barrier precautions. Staff members, including an LPN and CNAs, entered the resident's room and provided care without performing hand hygiene or wearing the required personal protective equipment, such as gowns and gloves. Despite the presence of signage indicating the need for enhanced barrier precautions, staff failed to comply with these protocols during direct care activities, such as transferring the resident using a mechanical lift. Interviews with staff revealed a lack of awareness and adherence to the enhanced barrier precautions policy. Additionally, the facility did not ensure timely tuberculosis screening for a dietary aide, as required by the facility's policy. The employee's initial TB test was not completed within the required timeframe, and there was no documentation of a previous TB test prior to or upon hire. This oversight was acknowledged by the Director of Nursing and the President of Clinical Operations, who stated that TB tests should be completed before orientation and two weeks after the first step TB test.
Facility Fails to Maintain Clean Environment in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment in several resident rooms, as evidenced by the presence of cobwebs and a buildup of dust. Observations conducted on various rooms revealed dust accumulation behind beds, armoires, and in corners next to cabinets. Cobwebs were also found in multiple locations, including behind chairs and in corners next to beds and armoires. These conditions were observed during a walkthrough with the Environmental Services (EVS) Director, indicating a lapse in the facility's cleaning processes. Interviews with the Lead Housekeeper revealed expectations for housekeepers to use tools such as dust mops to clean behind and under beds and to remove cobwebs. The housekeepers were instructed to move beds when possible and to take their time to ensure thorough cleaning. Despite these expectations, the presence of cobwebs and dust in numerous rooms suggests that the cleaning procedures outlined in the facility's policy were not adequately followed, potentially affecting at least 23 residents out of a census of 87.
Failure to Obtain Physician Order for Self-Administration of Medication
Penalty
Summary
The facility failed to obtain a physician order for self-administration of medication at bedside and did not evaluate or document the ability of a resident to self-administer medication. This deficiency was identified for one resident out of a sample of 19, in a facility with a census of 87 residents. The resident in question had moderately impaired cognition and was observed with a bottle of Miconazole Nitrate 2% powder and a medication cup with an unidentified pill in their room, neither of which were stored in a locked drawer as required by the facility's policy. The facility's policy mandates that self-administration of medications must be determined by a physician order, and medications should be kept in a locked drawer. However, the resident had been using the Miconazole Nitrate Powder without an order or assessment for self-administration. Interviews with staff revealed a lack of clarity and enforcement regarding the assessment and documentation process for self-administration, with no clear timeframe for completing assessments and no designated personnel to ensure compliance. The Assistant Director of Nursing and the Director of Nursing acknowledged that an order and assessment should have been completed prior to the resident's use of the medication. Despite the facility's policy, the resident's care plan did not include self-administration, and the medication was not stored securely. The oversight in following the facility's policy and ensuring proper documentation and assessment led to the deficiency identified by the surveyors.
Failure to Document and Assess Resident Wounds
Penalty
Summary
The facility failed to assess, describe, and measure wounds weekly for a resident who had a left knee wound and a right hip surgical incision. The facility's Wound Policy and Procedure required that wounds be assessed upon admission and weekly thereafter, including details such as location, measurement, appearance, and drainage. However, the resident's records from admission through several weeks showed no measurements or descriptions of the wounds, despite the resident being at risk for skin integrity issues and requiring daily treatment for a surgical site on the right hip. Interviews with facility staff, including LPNs, the ADON, the Wound Nurse, and the DON, revealed a lack of awareness and documentation regarding the resident's wounds. The staff were expected to perform detailed skin assessments and document all wounds, but this was not consistently done. Observations confirmed the presence of a right hip surgical wound and scars on the left knee, yet these were not adequately documented in the resident's records. The facility's failure to adhere to its wound assessment policy resulted in a deficiency in the care provided to the resident.
Failure to Apply Ordered Splint Device for Resident
Penalty
Summary
The facility failed to ensure the proper application of a splint device for a resident with limited mobility, as ordered by the physician. The resident, who was severely cognitively impaired and dependent on staff for upper body dressing, had a diagnosis of stroke and hemiplegia, which resulted in upper extremity range of motion impairment on one side. The resident's care plan included the use of a left functional resting hand splint during waking hours to maintain or improve mobility. However, observations on two consecutive days showed the resident in a wheelchair without the splint device in place. Interviews with facility staff revealed a lack of adherence to the care plan. A CNA reported not applying the splint because the resident grimaced, while an RN was unaware of the resident's splint status and acknowledged there was no reason for the splint not being applied. Despite this, the Treatment Administration Record documented the splint's application on the days in question. The Director of Nursing expressed an expectation for staff to apply ordered devices and not to document their application if they were not applied.
Failure to Obtain Physician's Order for Self-Administered Colostomy Care
Penalty
Summary
The facility failed to obtain a physician's order for a resident to self-perform colostomy care and did not complete a full evaluation to assess the resident's ability to self-administer this care. The resident, who had moderately impaired cognition and an ostomy, was performing colostomy care independently without any documented assessment or physician's order authorizing self-administration. The facility's policy required a physician's order and a documented assessment for self-administration of treatments, which was not followed in this case. Interviews revealed that the resident had not been assessed for the ability to self-care for the ostomy, and no demonstration of the resident's ability to perform the care was requested by the staff. The Occupational Therapist noted that only certain parts of the self-care assessment were completed by therapy staff, and the nursing staff were responsible for the full assessment. However, there was no specific timeline for completing this assessment, and it was unclear if the nursing staff were aware of their responsibilities. The Assistant Director of Nursing and the Director of Nursing acknowledged that there was no specific assessment form for self-administration of treatments and that the resident's care plan and orders needed to be updated to reflect the resident's ability to perform ostomy care independently. Despite the resident's ability to self-administer ostomy care, the necessary documentation and physician's order were not in place, leading to a deficiency in the facility's compliance with its own policies.
Deficiency in CPAP Machine Documentation and Storage
Penalty
Summary
The facility failed to ensure that physician's orders for CPAP machines were documented on the Physician's Order Sheet (POS) and care plans for two residents. Resident #183, who was admitted with diagnoses including sleep apnea, did not have orders for the CPAP machine settings or duration of use documented on the POS. The resident's care plan also lacked information about the CPAP machine, its usage, and care instructions. Observations showed that the resident's CPAP face mask and tubing were left uncovered on the bed, contrary to the facility's expectations for storage when not in use. Similarly, Resident #280, diagnosed with obstructive sleep apnea, did not have a detailed physician's order for the use and care of the CPAP machine documented in the Treatment Administration Record (TAR) or Nursing Medication Administration Record (MAR). The resident's care plan did not include information about the CPAP machine or its care. Observations revealed that the CPAP face mask was left uncovered on the dresser, and there was no documentation of monitoring the resident's use of the CPAP machine. Interviews with staff, including CNAs and LPNs, indicated a lack of awareness and adherence to the facility's expectations for covering respiratory equipment when not in use. The staff also failed to ensure that physician's orders for CPAP machines were obtained and transcribed upon admission. The Director of Nursing and President of Clinical Operations confirmed the expectation for detailed physician orders and updated care plans for CPAP machine use and care, which were not met in these cases.
Lack of Catheter Care Documentation for Resident
Penalty
Summary
The facility failed to ensure proper orders and documentation for indwelling urinary catheter care for a resident, leading to a deficiency in care. The resident, who was significantly cognitively impaired and completely dependent on staff for toileting hygiene, had an indwelling catheter but lacked a physician's order for catheter care upon admission. This oversight meant there was no documentation of catheter care in the resident's Treatment Admission Record (TAR) until the day of discharge. Interviews with facility staff, including Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs), revealed a lack of clarity and responsibility regarding catheter care documentation. While staff acknowledged the necessity of catheter care, they indicated that without an order, there was no designated place to document the care provided. The Director of Nursing (DON) confirmed the expectation for catheter care to be performed every shift and during perineal care, but also noted the absence of an order prevented proper documentation. The deficiency was further highlighted when the resident was sent to the hospital for evaluation due to a wound infection. Despite staff assertions that catheter care was performed, the lack of an order and documentation made it impossible to verify. The facility's policy required a physician's order for catheterization, including care instructions, which was not in place for this resident until the day of discharge.
Deficiency in Call Light System Affects Resident Care
Penalty
Summary
The facility failed to ensure that the call light system was adequately equipped and functioning, affecting the care of two residents. The call light system was intended to allow residents to communicate with staff, but it was found that the system could be turned off at the nurse's station without staff entering the resident's room. This deficiency was highlighted by incidents involving two residents who required assistance with personal care and experienced delays in receiving help due to the call light system's inadequacies. One resident, who was moderately cognitively impaired and needed assistance with toilet hygiene, experienced a delay in receiving help when a family member pressed the call light multiple times without a response. The family member had to go to the nurse's station to request assistance, and although a CNA eventually came to help, the resident's request to speak with a nurse was not fulfilled before the family member left. This incident demonstrated the failure of the call light system to ensure timely and adequate communication between residents and staff. Another resident, who was cognitively intact but required assistance with toileting hygiene and lower body dressing due to Spina Bifida, reported past issues with the call light system. Although the resident noted improvements, the previous system allowed staff to turn off call lights from the nurse's station without entering the resident's room, which could lead to delays in care. Interviews with staff confirmed that the system had been recently changed to require staff to enter residents' rooms to turn off call lights, addressing previous complaints about response times.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
