Johnson County Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Warrensburg, Missouri.
- Location
- 122 East Market Street, Warrensburg, Missouri 64093
- CMS Provider Number
- 26E256
- Inspections on file
- 18
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Johnson County Care Center during CMS and state inspections, most recent first.
The facility failed to implement Enhanced Barrier Precautions (EBP) for multiple residents with chronic foot wounds, vascular leg wounds, and documented wound infections, despite having a written EBP policy and CDC guidance requiring gown and glove use during high-contact care such as wound care, hygiene, and dressing changes. Observations showed that the DON performed wound care using gloves and hand hygiene but without a gown, and there were no EBP signs or PPE supplies posted outside resident rooms. Additional residents with diabetic ulcers and chronic plantar wounds received daily wound treatments without EBP measures in place. Interviews with a CMT, an LPN, the DON, the Administrator, and the Infection Preventionist revealed that staff were not educated on EBP, gowns were rarely used for wound care, some nurses were reported to perform wound treatments without gloves, and key leaders were unaware of or had not implemented EBP in the facility.
The facility failed to maintain RN coverage for eight consecutive hours daily from July 2023 to March 2024, with the DON serving as charge nurse despite a census over 60 residents. The DON was the only RN, and the facility lacked a staffing policy document.
The facility failed to maintain a comprehensive infection prevention and control program, lacking a Legionella risk management plan, CDC toolkit, and proper infection tracking. The infection control book was incomplete, missing 12 months of data and details on infections. Additionally, two residents did not receive required TB assessments. The Maintenance Supervisor and DON were unaware of full program requirements.
The facility failed to implement an effective antibiotic stewardship program, as evidenced by incomplete infection tracking logs and missing documentation of lab results and symptoms for antibiotic use. The Director of Nursing, responsible for the program, could not locate necessary records, indicating non-compliance with the facility's policy.
The facility did not designate a qualified individual as the Infection Preventionist (IP) for its Infection Prevention Control Program. The DON was intended to take on the IP role but had not completed the necessary certification classes. The Administrator, who held an IP certificate, had a degree in Social Work, which is not an approved primary professional medical training. The facility also lacked a policy on the required training for the IP role.
A resident with an unstageable pressure ulcer did not receive appropriate care due to the facility's failure to have a policy or physician's order for a low air loss mattress, incorrect mattress settings, and incomplete wound assessments. The care plan was not updated to reflect the current stage of the ulcer, and documentation inconsistently identified the wound type and lacked detailed descriptions. Staff interviews revealed a lack of awareness and adherence to proper procedures.
A facility failed to follow professional standards for verifying gastrostomy tube placement, using outdated methods instead of measuring and documenting tube length. A resident with cerebral palsy, reliant on tube feeding, experienced inconsistencies in feeding infusion due to incorrect physician orders and lack of proper verification by staff. The DON and other staff were unaware of current standards, leading to deficiencies in care.
The facility failed to provide Trauma Informed Care (TIC) assessment and care planning for two residents diagnosed with PTSD. The care plans lacked interventions specific to TIC needs, such as identifying triggers and steps to mitigate them. Staff interviews revealed a lack of awareness and training regarding the residents' PTSD diagnoses and TIC principles. The facility's failure to incorporate TIC assessments and care planning resulted in a deficiency in providing trauma-informed and culturally competent care.
A facility failed to ensure timely physician response to a pharmacist's recommendation for gradual dose reduction (GDR) of psychotropic medications for a resident with severe cognitive impairment and multiple mental health diagnoses. The consultant pharmacist recommended GDRs for several medications, but there was no documented physician response, and a GDR had not been attempted or documented as clinically contraindicated. The DON, responsible for reviewing and implementing pharmacy recommendations, did not follow up with the physician to obtain a reason for not following the recommendation.
The facility did not post daily staffing information, including staff titles and hours worked, on the second and third floors, potentially affecting all residents. The MDS Coordinator noted the information was posted by the time clock on the first floor, not visible to upper floors. The DON stated the BOM was responsible for posting it visibly for all residents and visitors.
Failure to Implement Enhanced Barrier Precautions for Residents With Wounds
Penalty
Summary
The deficiency involves the facility’s failure to implement its own Enhanced Barrier Precautions (EBP) policy and CDC-recommended practices for residents with wounds and infection risks. The facility’s EBP policy required gown and glove use for residents with certain infections, wounds, and/or indwelling medical devices during high-contact resident care activities such as dressing, bathing, transferring, providing hygiene, changing linens and briefs, toileting assistance, device care, and wound care. CDC guidance similarly called for hand hygiene for everyone entering and leaving the room and gown and glove use for high-contact care activities for residents who meet EBP criteria. Surveyors found that EBP was not being used for any of the sampled residents with wounds, and staff and leadership reported they had not discussed or implemented EBP in the facility. One resident had diabetes, a skin infection, and a non-pressure chronic ulcer of the left foot, with a documented diabetic foot ulcer and wound infection. The care plan identified skin impairment related to diabetes and a chronic wound, and the treatment record showed ongoing wound care to the left great toe, including cleansing and application of Iodoflex and dressings. A wound care provider note documented a chronic left great toe wound, prior IV antibiotics for chronic osteomyelitis, and a long-standing diabetic ulcer with specific measurements and wound characteristics including serosanguineous exudate, slough, granulation tissue, and necrotic tissue. During observed wound care by the DON, there were no EBP signs or PPE outside the room, the DON wore gloves and performed hand hygiene but did not wear a gown, and the DON stated they had not talked about or used EBP at the facility. Another resident with diabetes had documented abrasions to both knees and a vascular wound to the left lower leg, with physician orders for daily cleansing and application of calcium alginate and foam dressings to the left lower extremity wound. Observation showed dressings on both shins and no EBP signage or PPE outside the room. The DON again stated that EBP had not been discussed or used. A third resident had an open wound on the left foot, osteomyelitis, and a chronic foot wound, with care plan entries for risk of infection and actual skin integrity impairment related to a chronic foot wound. Treatment orders included cleansing and dressing of plantar areas on both feet and application of calcium alginate to an open wound on the right foot, with skin observation documenting a callous on the left foot and a chronic wound on the right plantar surface. During observation, there were no EBP signs or PPE outside the room, the DON reported the resident had wounds on the bottom of both feet, and confirmed that EBP had not been discussed or used. Staff interviews further demonstrated the lack of implementation of EBP and incomplete use of PPE during wound care. A Certified Medication Technician reported hardly ever seeing nurses use gloves during wound treatments, seeing nurses perform wound treatments without gowns, and not knowing where gowns were located. The DON stated they had not talked about EBP and had not used EBP for any residents. The Administrator reported that EBP had not been done and did not believe the facility had an EBP policy, despite the written policy reviewed by surveyors. The Infection Preventionist stated they had never heard of EBP prior to the survey date. An LPN reported that administration had not instructed staff to use EBP, that they only wore gloves during wound treatments, and that they did not wear gowns when performing wound care. These observations and interviews show that the facility did not implement EBP for residents with wounds as required by its policy and CDC guidance.
Deficiency in RN Staffing and DON Role Compliance
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, during multiple months spanning from July 2023 to March 2024. This deficiency was identified through observation, interviews, and record reviews, which revealed that there were several days each month without RN coverage for the required hours. Additionally, the Director of Nursing (DON) was found to be serving as the charge nurse on days when the facility census exceeded 60 residents, which is against regulatory requirements. The facility census was noted to be 69 residents during these instances. The facility's staffing issues were further highlighted by the fact that the DON was the only RN available and had to cover shifts as the charge nurse due to the lack of other RNs. The facility had an RN available on a PRN basis, but this individual did not work many hours. The administrator acknowledged the staffing shortfall and indicated efforts were being made to hire more RNs. The absence of a facility RN staffing policy and procedure document prior to the survey exit further compounded the issue.
Inadequate Infection Control and TB Screening in LTC Facility
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program, specifically for Legionella and other water-borne pathogens, as required by CMS guidelines. During inspections, it was observed that the facility lacked a facility-specific risk management plan, a completed CDC toolkit, and a schematic or flowchart of the water system with explanations and assessments of potential stagnation locations. Additionally, there were no documented testing protocols, control measures, or site log books for maintenance activities. Interviews revealed that the Maintenance Supervisor was responsible for the Legionella program but had only received basic education on the requirements. The facility's infection control surveillance policy was outdated, and the infection control book lacked 12 months of tracking and trending data. The logs did not specify whether infections were facility-acquired or present upon admission, nor did they include information on the resolution of infections, the type of infectious organisms, or the utilization of an antibiotic stewardship program. The Director of Nursing, who took over the infection control book in February 2024, was unaware of the full scope of information required for tracking and trending logs. Furthermore, the facility did not have a policy for resident TB testing and screening. Two residents were identified as not having completed TB assessments as required. One resident did not have a two-step TB skin test upon admission, and another resident's last TB assessment was outdated. The Director of Nursing acknowledged the oversight and stated that TB tests should be completed by the admitting charge nurse upon admission, with annual screenings documented in the medical record.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an effective antibiotic stewardship protocol and a system to monitor appropriate antibiotic use for its residents. The facility's existing Antibiotic Stewardship policy, dated 2018, aimed to apply best practices for monitoring antibiotic use, ensuring appropriate prescriptions, and reducing the risk of adverse events from unnecessary or inappropriate antibiotic use. However, the facility's Infection Control tracking log was incomplete, lacking 12 months of infection tracking or antibiotic use logs, with only records from February to August 2024 available. The logs were supposed to document essential details such as the date, room number, resident name, infection type, antibiotic name, order, labs, and organism, but they did not include lab results or logs indicating signs or symptoms of infections for antibiotic use. During an interview, the Director of Nursing, who had been responsible for the Infection Control tracking log and antibiotic stewardship program since February 2024, admitted to entering prescribed antibiotics on the log along with the resident's room number and type of infection. However, the Director could not locate lab or X-ray results in the tracking book, and the book did not include signs or symptoms of infections being treated with antibiotics. This lack of documentation and monitoring indicates a failure to adhere to the facility's own antibiotic stewardship policy, which included protocols for common infections and criteria for initiating antibiotic use.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual with the required primary professional training as the Infection Preventionist (IP) for its Infection Prevention Control Program. The Director of Nursing (DON) was intended to assume the role of the IP but had not completed any certification classes necessary for the position. Additionally, the facility did not have a policy outlining the required primary professional training for the IP role. The Administrator, who held an IP certificate and dedicated a few hours weekly to infection control duties, had a degree in Social Work, which is not among the approved primary professional medical trainings. The previous IP had left the facility, and the current DON was expected to become the primary IP without having completed the necessary training.
Deficient Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for a resident with an unstageable pressure ulcer. The facility did not have a policy or physician's order addressing the settings for a low air loss (LAL) mattress, which is crucial for distributing the patient's body weight to prevent and treat pressure wounds. The resident's care plan was not updated to reflect the current stage of the pressure ulcer, and there was no documentation of the LAL mattress settings in the resident's treatment administration record (TAR). The LAL mattress was set incorrectly at 350 pounds, despite the resident weighing significantly less. The facility also failed to complete weekly wound/skin assessments with detailed descriptions, measurements, and accurate staging of the pressure ulcer. The documentation inconsistently identified the type of wound, often incorrectly labeling it as a stasis ulcer, and failed to include comprehensive details about the wound bed, drainage, odor, and measurements. There were significant gaps in the documentation of wound assessments, with no assessments completed between certain dates, and the resident's care plan did not mention the unstageable pressure ulcer or the LAL mattress settings. Interviews with facility staff, including the wound nurse, LPN, MDS/Care Plan Coordinator, and DON, revealed a lack of awareness and adherence to proper procedures for pressure ulcer management. The staff did not monitor the LAL mattress settings, and there was no physician's order for the LAL mattress. The care plan was not individualized to include the current stage of the resident's pressure ulcer, and the facility's pressure ulcer documentation lacked essential information. The DON acknowledged that the documentation should have included detailed descriptions of the wound, and the care plan should have been updated to reflect the resident's current condition.
Deficiency in Feeding Tube Management and Documentation
Penalty
Summary
The facility failed to adhere to professional standards for verifying the correct placement of gastrostomy (G-tube) feeding tubes, as evidenced by the lack of a comprehensive tube feeding policy. The policy did not instruct licensed nursing staff to measure and document the length of the feeding tube, nor did it provide guidance on verifying tube placement using current professional standards. Instead, outdated methods such as auscultation and aspiration were used, which are considered unreliable. This deficiency was observed in the care of a resident who was receiving tube feeding, where the facility did not ensure the physician's order was correct or that the tube feeding was infused according to the order. The resident in question had a diagnosis of cerebral palsy and was severely cognitively impaired, relying on a feeding tube for more than 51% of their caloric intake. Observations revealed that the resident's tube feeding was not consistently infused as ordered, with instances where the feeding pump was not running. The Director of Nursing (DON) was observed administering water through the G-tube without first verifying its placement, citing a lack of a stethoscope as the reason for not performing the check. The DON admitted to being unaware of the professional standard requiring the measurement and documentation of the tube's length. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the MDS Care Plan Coordinator, highlighted inconsistencies in the understanding and implementation of tube feeding protocols. The LPN acknowledged that the physician's order in the resident's electronic medical record was incorrect and needed correction. The MDS Care Plan Coordinator confirmed that aspiration was the only method known for checking tube placement and that this method was not included in the resident's care plan. These lapses in protocol and documentation contributed to the deficiency in providing appropriate care for the resident with a feeding tube.
Failure to Provide Trauma Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide Trauma Informed Care (TIC) assessment and care planning for two residents diagnosed with Post Traumatic Stress Disorder (PTSD). The facility's policy required a self-assessment and trauma questionnaire to be completed before admission, with updates every three years, and the use of the Brief Trauma Questionnaire for screening. However, for Resident #18, there was no documentation of the Brief Trauma Questionnaire, PTSD Checklist, or Psychological Well-Being evaluation in the medical records. The resident's care plan lacked interventions specific to TIC needs, such as identifying triggers and steps to mitigate them. Resident #18 had a history of extensive sexual abuse and other psychiatric diagnoses, including major depression and anxiety. Despite being cognitively intact and socially isolated, the resident's care plan did not address PTSD needs or include strategies to prevent triggers. Interviews with staff revealed a lack of awareness and training regarding the resident's PTSD diagnosis and TIC principles. The Social Services Director and other staff members were unaware of the resident's triggers and had not conducted a TIC assessment. Similarly, Resident #53's care plan did not include interventions specific to TIC needs, and there was no documentation of the required trauma assessments. The resident was also diagnosed with PTSD, anxiety, depression, and a personality disorder. The facility's failure to incorporate TIC assessments and care planning into the residents' care plans resulted in a deficiency in providing trauma-informed and culturally competent care.
Failure to Implement Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure timely physician response to a pharmacist's recommendation for gradual dose reduction (GDR) of psychotropic medications for a resident. The resident, who was severely cognitively impaired and had symptoms of depression, hallucinations, and diagnoses including anxiety disorder, depression, manic depression, and schizophrenia, was receiving multiple psychotropic medications. The consultant pharmacist recommended potential GDRs for several medications, including Escitalopram, Olanzapine, Trazodone, and Haloperidol. However, there was no documented response from the physician regarding these recommendations, and a GDR had not been attempted or documented as clinically contraindicated. The Director of Nursing (DON) was responsible for reviewing pharmacy recommendations and implementing GDRs. The DON took over this duty after discovering that pharmacy recommendations were not being addressed. The consultant pharmacist visited the facility monthly and emailed recommendations to the DON, who then contacted the physician. If the physician agreed to the recommendation, changes were made in the resident's electronic medical record (EMR). If the physician disagreed, a reason should have been documented. In this case, the physician did not provide a reason for not following the pharmacist's recommendation, and the DON did not follow up to obtain one.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that daily staffing information was posted correctly at the beginning of each shift, which could potentially affect all residents. The facility census was 69 residents. Observations on multiple days showed that the required staffing information, including staff titles and total hours worked, was not posted on the second or third floors. During an interview, the MDS Coordinator indicated that the staffing information was posted by the employee time clock on the first floor, which was not visible to residents on the upper floors. The Coordinator was unaware of who was responsible for posting the information but expected it to be available for residents and visitors. The DON stated that the BOM was responsible for posting the staffing information outside their office daily and expected it to be visible to all residents and visitors on the second and third floors.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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