Maranatha Village, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Missouri.
- Location
- 233 East Norton Road, Springfield, Missouri 65803
- CMS Provider Number
- 265475
- Inspections on file
- 19
- Latest survey
- June 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Maranatha Village, Inc during CMS and state inspections, most recent first.
A resident with multiple chronic conditions experienced a fall and later developed low oxygen saturation, but staff failed to document timely assessments, monitor the resident adequately, and notify the physician as required by facility policy. Despite observing hypoxia symptoms and applying oxygen without an order, staff did not consistently record interventions or communicate the resident's declining condition to the physician, resulting in delayed medical intervention.
A staff member accepted multiple checks totaling about $7,000 from a resident who required substantial assistance with daily activities and was cognitively intact. The staff member discussed personal financial hardships with the resident, who then signed checks written out by the staff member. Facility policy prohibits staff from accepting money or gifts from residents, and interviews with staff confirmed this expectation. The issue was discovered by the resident's family and reported to the facility, leading to an internal investigation and police involvement.
A facility failed to document the specific needs it could not meet for a resident who was issued a discharge notice. The resident, with a history of COPD, CHF, anxiety disorder, and chronic kidney disease, exhibited delusions and rejected care multiple times a week. The facility did not document attempts to meet the resident's needs or the services available at the receiving facility. Interviews revealed the resident felt targeted for eviction, lacked 24-hour physician coverage, and had fired the medical director, contributing to the deficiency.
A resident with a history of flaccid neuropathic bladder experienced undignified treatment during a Foley catheter replacement by an LPN. The LPN made inappropriate sexual comments and failed to use lubricant initially, causing discomfort. Witnesses, including CNAs, reported the incident, which violated the facility's policies on resident dignity and respect.
The facility failed to maintain food safety and hygiene standards, including staff not wearing hairnets, improper storage of the ice scoop, and inadequate handwashing during meal service. These actions led to potential food contamination.
The facility failed to maintain their infection prevention program for Legionella by not following their water management program, neglecting preventative steps, and failing to educate staff. The Maintenance Director incorrectly believed Legionella could not grow in the pipes due to city water use, and the Director of Nursing confirmed lapses in monitoring and recording water temperatures. The Infection Preventionist was not involved in the water maintenance program as previously instructed by the Administrator.
The facility failed to provide required Bed Hold Notifications to residents and/or their responsible parties during hospital transfers for three residents. Interviews with staff revealed a lack of awareness regarding this requirement.
The facility failed to update comprehensive care plans for several residents, omitting critical information such as the use of oxygen and anticoagulant medication. These deficiencies were confirmed through medical records, observations, and staff interviews.
The facility failed to respect a resident's preference for nighttime care, causing distress and fear, and did not protect another resident's health information from public viewing, violating HIPAA regulations.
The facility failed to provide respiratory care per standards of practice when staff administered oxygen to two residents without physician orders. Both residents were observed receiving oxygen at two LPM without current orders, and staff confirmed the lack of proper authorization.
The facility failed to accommodate a diabetic resident's dietary preferences, providing high-carb meals and desserts despite clear instructions to avoid such items. Interviews revealed that dietary staff did not follow the resident's dietary card, leading to inappropriate meal service.
The facility failed to provide the pneumococcal vaccine as ordered for two residents. The vaccines were found in the medication room, and the RN confirmed that the IP was supposed to administer them but was unaware of their presence. Both the IP and DON stated that the expectation was for the vaccines to be administered as ordered.
Failure to Document and Notify Physician After Fall and Low Oxygen Saturation
Penalty
Summary
Staff failed to provide care according to standards of practice for a resident who experienced a fall and subsequently developed low blood oxygen levels. After the fall, the resident was found with injuries including skin tears and a hematoma on the forehead. Although a head-to-toe assessment and neuro checks were initiated, there was a lack of thorough and timely documentation regarding follow-up monitoring and the resident's condition in the days following the incident. The facility's policy required prompt notification of the physician and documentation of changes in condition, but these steps were not consistently followed. The resident, who had a history of pulmonary hypertension, chronic respiratory failure, heart failure, cerebral infarction, and sleep apnea, exhibited significantly low oxygen saturation readings, including a documented level of 72%. Despite facility protocols and physician orders requiring staff to notify the physician if oxygen saturation fell below 90%, there was no documentation that the physician was notified at the time of these low readings. Staff applied oxygen without a physician's order and did not consistently document assessments, interventions, or physician notifications related to the resident's declining condition. Multiple staff interviews revealed confusion about the facility's protocols for oxygen administration and physician notification. Staff reported difficulty obtaining accurate oxygen saturation readings and observed signs of hypoxia, such as bluish fingertips and confusion, but failed to document these findings or notify the physician in a timely manner. The lack of timely and complete documentation, monitoring, and physician notification contributed to a delay in appropriate medical intervention for the resident, who was eventually sent to the hospital after further deterioration.
Staff Member Accepted Multiple Checks from Resident, Violating Facility Policy on Misappropriation
Penalty
Summary
A facility staff member, a Certified Nurse Aide (CNA), received multiple checks totaling approximately $7,000 from a resident after discussing personal financial hardships with the resident. The resident, who was cognitively intact but required substantial assistance with daily activities due to multiple sclerosis, insomnia, and depression, reported that the CNA would write out the checks and the resident would sign them. The checks were written over several months, and the CNA was working at the facility on the days most of the checks were issued. The facility's policy strictly prohibits exploitation, theft, and misappropriation of resident property, including the acceptance of money or gifts from residents by staff. Interviews with various staff members, including RNs, CNAs, and the DON, confirmed that it is not appropriate for staff to ask for or accept money from residents, and that such actions constitute misappropriation of resident funds. The DON and Administrator both stated that staff are expected to report any such incidents to the appropriate supervisory personnel. The incident came to light when the resident's family discovered the checks and reported the matter to the facility, prompting an internal investigation and a police report. The facility's investigation confirmed that the CNA had received the checks from the resident, and that this was in violation of facility policy, regardless of the resident's stated intent to give the money as gifts.
Inadequate Documentation for Resident Discharge
Penalty
Summary
The facility failed to ensure proper documentation for the discharge of a resident, identified as Resident #1, who was issued a facility-initiated discharge notice. The resident's medical record lacked documentation detailing the specific needs the facility could not meet, the attempts made by the facility to meet those needs, and the services available at the receiving facility to address those needs. Additionally, there was no documentation from the resident's physician regarding the basis for the discharge, which is required when a discharge is due to the resident's welfare and unmet needs. Resident #1 had a history of chronic obstructive pulmonary disease, congestive heart failure, anxiety disorder, and chronic kidney disease. The resident was cognitively intact but exhibited delusions and verbal behaviors directed at others multiple times a week. The resident also rejected evaluation and care, including medications and assistance with activities of daily living, several times a week. Despite these challenges, the facility did not document any care plan addressing the resident's noncompliance with medical care or orders. Interviews with the resident and facility staff revealed that the resident felt the facility was trying to evict them and had received multiple eviction letters. The resident's physician was not available 24 hours a day, and the resident had fired the medical director, leading to a lack of after-hours physician coverage. The facility's administrator and staff had discussed the need for 24-hour physician coverage with the resident, but no solution was found. The facility's failure to document these issues and the lack of a physician's input on the discharge decision contributed to the deficiency.
Inappropriate Conduct by LPN During Catheter Procedure
Penalty
Summary
The facility failed to ensure that staff treated all residents with dignity and respect, as evidenced by an incident involving a Licensed Practical Nurse (LPN) who made inappropriate and degrading comments during a medical procedure. The incident occurred during the replacement of an indwelling Foley catheter for a resident with a history of flaccid neuropathic bladder and other medical conditions. The resident, who had intact cognition and functional impairments, was subjected to rude remarks by the LPN, who referenced sexual activity in a derogatory manner. The inappropriate behavior was witnessed by Certified Nursing Assistants (CNAs) who provided written statements detailing the LPN's conduct. The LPN reportedly did not use lubricant initially during the catheter insertion, causing discomfort to the resident, who exhibited signs of anxiety. The LPN's comments included references to the resident's sexual history and threats about the resident's leg positioning, which were deemed disrespectful and undignified. Interviews with facility staff, including the Director of Nursing (DON) and other CNAs, confirmed the inappropriate nature of the LPN's comments and actions. The facility's policies on resident rights and dignity, which emphasize respectful treatment and communication, were not adhered to in this instance, leading to a deficiency in maintaining the resident's right to a dignified existence.
Failure to Maintain Food Safety and Hygiene Standards
Penalty
Summary
The facility failed to protect food from possible contamination in accordance with professional standards of practice. Observations revealed that staff did not consistently wear hairnets in the kitchen, which is a requirement to prevent hair from contaminating food. Specifically, a CNA was seen scooping ice without a hairnet, and the Maintenance Director repeatedly entered the kitchen without a hairnet, even after being instructed to wear one. Additionally, the ice scoop was improperly stored inside the ice container, potentially contaminating the ice. This was observed when a CNA and a CMT both placed the scoop back into the ice after use, despite being instructed otherwise by the Dietary Manager. Further observations during meal service showed improper hand hygiene practices. A Dietary Aide handled food and kitchen equipment without washing hands between tasks, which included placing a can of soup into bowls, retrieving a divider that fell into noodles, and serving the noodles to residents. These actions were performed without proper handwashing, potentially contaminating the food served to residents. The Dietary Manager confirmed that staff had been trained on these procedures but failed to follow them during the observed incidents.
Failure to Maintain Infection Prevention Program for Legionella
Penalty
Summary
The facility failed to maintain their infection prevention program to reduce the likelihood of Legionella in the water. The facility did not follow their water management program by neglecting to complete the preventative steps outlined and failing to ensure staff were educated regarding the water management program. The facility's policy required specific measures to control the introduction and spread of Legionella, monitoring control limits, and documentation of the program. However, the facility's documentation showed lapses in inspections and monitoring, with the last recorded eye wash inspection on 12/26/23 and the last recorded water temperature check on 03/18/24. The Maintenance Director (MD) incorrectly believed that Legionella could not grow in the pipes due to the facility using city water and was unable to report any control measures in place. The Director of Nursing (DON) and Infection Preventionist (IP) also demonstrated a lack of involvement and awareness regarding the water management program. Interviews revealed that the DON was aware that water should not sit still for more than two to three days and that unoccupied resident rooms should have their water flushed every two to three days. However, the DON confirmed that weekly water temperatures had not been monitored and recorded since 12/28/23, and the last meeting to review the Water Management Program was held on 06/22/21. The IP stated that she was previously told by the Administrator that the MD would handle the water maintenance program, leading to her lack of involvement. The facility census was 85 at the time of the survey, indicating a significant oversight in maintaining a critical aspect of infection prevention and control.
Failure to Provide Bed Hold Notifications During Hospital Transfers
Penalty
Summary
The facility failed to provide the required Bed Hold Notification to residents and/or their responsible parties (RP) during hospital transfers for three residents. Resident #30, who was severely cognitively impaired, was transferred to the hospital and returned without any documentation of Bed Hold Notification. Similarly, Resident #50, who was cognitively intact, was discharged to the hospital and returned without receiving the Bed Hold Notification. Resident #50 confirmed during an interview that they did not receive any bed hold information and assumed everything would remain the same upon their return. Resident #67, also severely cognitively impaired, was transferred to the hospital and returned without any Bed Hold Notification documentation. The resident's family member confirmed they were notified of the transfer via phone but did not receive any written notification or Bed Hold Notification. Interviews with facility staff, including the Director of Resident Services (DRS), Director of Social Services (DSS), and Director of Nursing (DON), revealed a lack of awareness regarding the requirement to provide Bed Hold Notifications. The DRS and DSS both stated that they notified the RP by phone and sent an Emergency Transfer Notice but were unaware of the need to send Bed Hold Notices. The DON acknowledged that the Bed Hold Policy was included in the Admission Agreement Packet but was not aware of the need to provide a Bed Hold Notification at the time of hospital discharge.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to maintain and update comprehensive care plans for several residents, leading to deficiencies in care. Specifically, the care plans for four residents did not include the use of oxygen, despite medical records and observations indicating that these residents required oxygen therapy. For instance, one resident with acute and chronic respiratory failure and heart disease had an order for oxygen, but this was not reflected in their care plan. Similarly, another resident with heart disease and heart failure had an order for oxygen, which was also not included in their care plan. These omissions were confirmed by the Minimum Data Set Coordinator (MDSC) during interviews. Additionally, the care plan for a resident with chronic obstructive pulmonary disease (COPD) and heart disease did not include the use of oxygen, even though their medical records and observations showed they were receiving oxygen therapy. Another resident with a pulmonary embolism and COPD had an order for continuous oxygen, but this was not documented in their care plan. These discrepancies were also confirmed by the MDSC during interviews. Furthermore, the facility failed to care plan the use of anticoagulant medication for a resident with a prosthetic heart valve who was prescribed warfarin. The resident's care plan did not include any mention of the anticoagulant, despite the resident's medical records and personal confirmation of taking the medication. This oversight was acknowledged by both the MDSC and the Director of Nursing (DON) during interviews, indicating a failure to adhere to the facility's policy on comprehensive, person-centered care plans.
Failure to Protect Resident Dignity and Confidentiality
Penalty
Summary
The facility failed to protect the dignity of Resident #50 by not respecting their preference for nighttime care. Despite the resident's cognitive intactness and clear communication of their discomfort with CNA #3's method of care, the CNA continued to handle the resident in a manner that made them feel unsafe and disrespected. The resident expressed that CNA #3 would roll them too close to the edge of the bed, causing fear of falling, and did not allow the resident to assist in their own care. This issue was corroborated by the resident's family member, who noted the resident's distress after being cared for by CNA #3. The facility administration and DON were unaware of the issue until it was brought to their attention during the survey, and CNA #3 admitted to not altering their care approach despite the resident's expressed concerns. Additionally, the facility failed to protect the health information of Resident #39 from public viewing. The resident, who was severely cognitively impaired and on hospice care, had a sign on the outside of their door indicating a fluid restriction. This sign was visible to other residents, staff, and visitors, which is a violation of HIPAA regulations. The resident was unaware of the sign's meaning, and the unit charge nurse and MDS Coordinator acknowledged that the sign should not have been placed on the door. This oversight exposed the resident's private health information to the public, compromising their confidentiality and dignity.
Failure to Obtain Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to provide respiratory care per standards of practice when staff administered oxygen to two residents without physician orders. Resident #37, who was admitted with diagnoses including pleural effusion, unspecified fibrillation, heart disease, and hypertension, was observed on multiple occasions receiving oxygen via nasal cannula at two liters per minute (LPM) without a corresponding physician's order. The resident's nurse's progress notes documented the use of oxygen, but no orders were found in the electronic medical record (EMR) to support this treatment. The resident was cognitively intact and had a quarterly Minimum Data Set (MDS) assessment that did not include oxygen usage, further indicating the lack of proper authorization for the treatment provided. Similarly, Resident #9, who had diagnoses of acute and chronic respiratory failure with hypoxia and heart disease, was also receiving oxygen at two LPM without a current physician's order. The resident's care plan and significant change MDS did not include the use of oxygen, and the last documented physician's order for oxygen had been discontinued months prior. Despite this, the resident was observed receiving oxygen on multiple occasions, and interviews with staff confirmed the lack of a current order. The Director of Nursing (DON) and other staff members acknowledged that oxygen was being administered without proper authorization, which is against the facility's policy and federal guidelines.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to accommodate a resident's known dietary preferences, specifically for a resident with diabetes. The resident's admission record and dietary notes indicated a regular diet with no breads or desserts, and the resident was noted to be cognitively intact. Despite this, the resident received meals that included high-carb items such as breaded fish filet, hush puppies, and desserts, which were not suitable for a diabetic diet. The resident expressed dissatisfaction with the meals, noting that they were too sweet and did not meet their dietary requests, such as meat loaf, side salad, and tomato juice. Interviews with the Dietary Manager and Director of Nursing revealed that the dietary staff failed to follow the resident's dietary card, which clearly stated no breads or desserts. The Dietary Manager admitted that the dietary aide responsible for preparing the trays did not read the card properly. The Director of Nursing confirmed that the expectation was for staff to offer menu items and alternatives as per the resident's choice, which was not adhered to in this case. This led to the resident receiving inappropriate meals that did not align with their dietary needs and preferences.
Failure to Administer Pneumococcal Vaccine as Ordered
Penalty
Summary
The facility failed to provide the pneumococcal vaccine as ordered for two residents out of the seven reviewed for immunization. For Resident #43, the PCV 20 vaccine was ordered and scheduled to be administered on either 11/21/23 or 11/22/23. However, the vaccine was not administered, and there was no documentation explaining the failure. The vaccine was found in the medication room with a fill date of 11/08/23, and the RN confirmed that the Infection Preventionist (IP) was supposed to administer it but was unaware of its presence. Similarly, for Resident #75, the PCV 20 vaccine was ordered to be administered on either 03/11/24 or 03/12/24. The vaccine was not administered, and the only documentation noted that the resident was sleeping. The vaccine was found in the medication room with a fill date of 03/01/24, and again, the RN confirmed that the IP was supposed to administer it but was unaware of its presence. During interviews, the IP stated that the expectation was for the residents to receive the vaccine as ordered. The Director of Nursing (DON) also confirmed that the expectation was for the nurse on duty to administer the vaccine upon its arrival. The facility's policy on the pneumonia vaccine, revised in March 2022, did not address the procedure for who should administer the vaccine when it arrived at the facility, contributing to the oversight and failure to administer the vaccines as ordered.
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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