Maryville Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Maryville, Missouri.
- Location
- 524 North Laura, Maryville, Missouri 64468
- CMS Provider Number
- 265354
- Inspections on file
- 25
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Maryville Living Center during CMS and state inspections, most recent first.
A resident with cognitive impairment, stroke-related weakness, and mobility issues fell while attempting to get into bed and was returned to bed with a mechanical lift, but no thorough post-fall assessment was documented and the fall was not added to the care plan. Over the next several days, CNAs and therapy staff observed non-verbal signs of pain and leg swelling, and the family reported hip/leg pain, yet nursing documentation showed incomplete assessments, pain scores of 0, and no administration of ordered PRN acetaminophen. A mobile x-ray was ordered but delayed, and the resident was not sent to the hospital when the x-ray could not be obtained as planned; when imaging was finally completed, it revealed an acute right hip fracture, confirming that the facility failed to provide timely follow-up care and pain management after the fall.
A resident with atrial fibrillation, vertigo, and moderate cognitive decline reported having a large amount of cash upon admission. The SSD and a charge nurse counted over $2,000, after which the SSD secured most of the cash, along with a checkbook and bank cards, in an unsecured box in an office desk drawer and locked only the office door. By the next day, when the SSD went to retrieve the funds for the family, $600 in cash was missing, although the checkbook and bank cards remained. The facility’s investigation found that the desk drawer and box did not lock, the emergency key box for room keys in the medication room was found unlocked, and multiple staff had potential access to the SSD office key. A grievance was filed on behalf of the resident for the missing $600, and the resident was not reimbursed until weeks later.
A resident with severe cognitive impairment and total dependence for transfers was injured when a staff member failed to follow the care plan, using a gait belt instead of a mechanical lift with two staff as required. The improper transfer led to the resident being lowered to the floor and later diagnosed with a right lower leg fracture. Staff interviews confirmed that the correct procedures were not followed and that the aide did not check the care plan prior to the transfer.
A resident with dementia and impaired vision was served hot coffee by an LPN from an unauthorized coffee pot without a temperature check, in violation of facility policy. The resident, left unsupervised, spilled the coffee and sustained burns to the chest and abdomen, requiring wound care and additional medical treatment.
Two residents with cognitive impairment were subjected to physical abuse by another resident with a history of escalating behavioral issues, including hair pulling and being struck with a water pitcher, resulting in physical injury and distress. Staff and medical records confirmed the aggressive resident's ongoing agitation and prior incidents, but the facility did not prevent repeated access and harm to other residents.
Several staff members took unauthorized photos and a video of four residents, most with dementia, and shared them in a group chat on social media, including images with demeaning captions. The residents were unaware of being recorded, and staff violated facility policies on privacy, abuse prevention, and use of personal devices, despite having received relevant training.
A resident with dementia was hit by a CMT in the face during an incident in the SCU. Despite facility policy, the CMT remained in contact with the resident for over 2.5 hours before being removed. Staff interviews revealed confusion about reporting procedures, contributing to the delay in addressing the abuse.
The facility failed to maintain a sanitary kitchen, with unclean surfaces, improper food storage, and incomplete cleaning logs. Food temperatures were not consistently checked, and sanitation procedures were not followed, including improper handwashing and lack of sanitizer use. The facility also lacked a policy for dating and labeling foods, leading to undated items in storage.
The facility failed to serve food at safe and appetizing temperatures, as observed in a sample of residents. Hot foods were served below the required 120 degrees Fahrenheit, with items like fish and carrots falling short. Residents reported dissatisfaction with food temperatures and quality, noting cold hot foods and unappetizing meal appearances. Despite expectations from dietary staff to maintain proper temperatures, these were not met, resulting in the deficiency.
The facility failed to ensure residents were free from accident hazards and provided with adequate supervision. A resident was not served the correct therapeutic diet, another had medication left unattended, and improper techniques were used during a sit-to-stand lift transfer, causing discomfort and potential risk of injury.
The facility experienced significant staffing shortages, leading to multiple deficiencies in resident care. A resident with severe cognitive and mobility impairments did not receive regular showers, and meal services were consistently delayed, affecting all residents. Medications were administered late, and the Activity Director was often pulled to cover staffing gaps, resulting in canceled activities. The facility lacked policies for staffing and showers, contributing to these issues.
The facility had a medication error rate of 32.14%, with staff failing to follow manufacturer guidelines for insulin administration, not removing a Lidocaine patch on time, and improperly crushing medications. Additionally, eye drop administration did not adhere to policy, affecting multiple residents.
The facility failed to secure medication carts, leaving them unlocked and unattended, and did not properly manage medications for a resident with severe cognitive impairment. Additionally, an expired Influenza Vaccine was not discarded, and a Lactulose Solution lacked a pharmacy label. These deficiencies were observed despite existing policies requiring secure storage and proper labeling of medications.
The facility failed to provide adequate dietary staffing, resulting in delayed meal service and unsanitary kitchen conditions. Observations showed meals were served late, and the kitchen was unclean with incomplete cleaning logs. Staff reported high turnover and insufficient training, contributing to the issues.
The facility failed to respect the rights of six residents by not providing adequate grooming and privacy. Three residents were not groomed properly, with facial hair not being shaved regularly despite their preferences and needs. Additionally, the facility did not respect the privacy of three residents, with personal care instructions being visible to others and blood sugar checks being conducted in the hallway.
The facility failed to honor the choice of two residents regarding their wake-up times, as care plans did not specify their preferences. One resident with cognitive impairment was left waiting in a wheelchair despite expressing a desire to lay down, while another resident with severe cognitive impairment and pressure ulcers was not consulted about their schedule. Staff interviews revealed a lack of communication and documentation regarding residents' preferences, leading to a deficiency in honoring their rights.
The facility failed to address grievances and recommendations from the resident council, affecting all residents involved. Residents were unaware of the grievance process and expressed concerns about care issues like cold food and long call light response times. The facility did not document attempts to resolve these concerns, and staff interviews revealed inconsistencies in the grievance process.
The facility failed to inform residents about the grievance process, resulting in unaddressed concerns about food quality, call light response times, and bathing schedules. Residents were unaware of how to file grievances, and staff interviews revealed inconsistent knowledge and follow-up on grievances. A family member reported a lack of follow-up on grievances, and grievance reports lacked documentation of resolution or notification to complainants.
The facility failed to create individualized care plans for two residents, neglecting to address dehydration, falls, and code status. One resident, with a history of falls and dehydration, lacked specific interventions in their care plan despite recent incidents. Another resident's care plan did not reflect their DNR status. Staff interviews confirmed these issues should have been care planned.
The facility failed to administer medications within the appropriate time frame for three residents. A resident received Levothyroxine late due to staff cleaning delays, while another resident's multiple medications, including Levothyroxine and Ropinole, were administered late. Additionally, a third resident's Gabapentin was given past the scheduled time. The DON acknowledged the delays, noting that medications should be administered within one hour of their scheduled time.
The facility failed to provide necessary assistance with ADLs, affecting four residents. Two residents did not receive regular showers, and two others did not receive complete incontinence care. Observations showed residents with unkempt appearances and improper cleaning techniques by staff. Interviews revealed insufficient staffing and lack of dedicated shower aides.
Two residents in a facility were found with inaccessible call lights, despite their care plans and staff expectations. One resident, with severe cognitive impairment and mobility issues, had the call light out of reach, requiring family intervention. Another resident, with dementia and impaired vision, was observed multiple times with the call light on the floor or hanging out of reach, necessitating leaving the bed to seek help. Staff interviews confirmed the expectation for call lights to be within reach, highlighting a failure to meet this standard.
A resident with a left hip fracture and dementia developed a Stage II pressure ulcer on the left heel, which was not identified by the facility staff until discovered by the family. The facility failed to conduct timely skin assessments and implement preventive measures, despite the resident being bedridden and requiring assistance for transfers. Interviews confirmed that the resident was not admitted with the ulcer, and weekly skin assessments were not completed as required.
A facility failed to protect residents' privacy when an LPN left a medication cart computer screen unattended and visible with resident information accessible. This occurred multiple times, with the screen left open in public areas. Interviews confirmed that staff were expected to lock or shut down screens when unattended, as per facility policy.
The facility failed to serve meals according to residents' dietary needs, with staff not following recipes or using correct portion sizes. Observations showed inconsistent meal preparation, with incorrect ingredients and serving utensils used. Interviews revealed staff did not adhere to menu guidelines, leading to potential nutritional deficiencies for all residents.
A resident with dementia and malnutrition was served food inconsistent with their dietary orders, receiving regular bacon and scrambled eggs instead of the prescribed minced and moist diet. Despite staff awareness and in-service education, incorrect diets were an ongoing issue, with the dietary manager acknowledging the problem and emphasizing the importance of following physician-ordered diets to prevent choking.
A resident with severe cognitive impairment and multiple care needs was not provided care in a manner that prevented infection, as staff failed to wash hands between dirty and clean tasks. Observations showed that a CNA, LPN, CMT, and NA did not adhere to hand hygiene protocols during care, despite the resident being on enhanced barrier precautions. Interviews revealed inconsistencies in staff understanding and implementation of handwashing practices.
Failure to Timely Assess, Manage Pain, and Obtain Evaluation After Resident Fall With Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up care, assessment, and pain management after a resident sustained a fall and subsequently was found to have a right hip fracture. The resident had significant cognitive deficits, stroke with right-sided weakness, COPD, and TIA, and was dependent on staff for toileting and bathing. The care plan identified the resident as at risk for falls with walking and balance problems and specified that the resident should not be left alone in the wheelchair or bathroom and should have the call light within reach, but the fall that occurred on 02/10/26 and the resident’s pain were not added to the care plan. After the fall, documentation showed the resident was found on the floor near the bed after attempting to get into bed and was transferred back to bed with a mechanical lift. Following the fall, there was no documented post-fall assessment on the day of the incident, and subsequent nursing notes did not include complete assessments of gait, grasp, or upper and lower extremity movement. CNA and therapy staff reported the resident was grunting, groaning, grimacing, and turning red with movement, and that the leg appeared swollen, but these observations were not reflected in the nursing documentation. Pain assessments recorded on the MAR for several days after the fall consistently showed a pain score of 0 on all shifts, and no acetaminophen or other pain medication was administered, despite family reports of pain and therapy staff concerns. The facility’s policies required assessment and treatment of injuries after a fall, notification of the practitioner for accidents or new pain, and support of residents’ right to optimal pain assessment and management, including recognition of non-verbal expressions of pain. When the resident’s family reported pain in the right leg/hip area, an order was obtained for a mobile x-ray of the right hip. The mobile x-ray service was unable to perform the x-ray as initially scheduled and delayed it until the following day, yet the resident was not sent to the hospital that night despite ongoing pain complaints. Nursing notes during this period still lacked complete assessments of lower extremity movement. The x-ray ultimately showed an acute right hip fracture, and the resident was then sent to the hospital by ambulance. Interviews with staff revealed that therapy had notified an LPN about the resident’s pain and that multiple CNAs had reported pain complaints after the fall, but nursing staff did not treat the pain or promptly arrange hospital evaluation when mobile x-ray was unavailable, resulting in several days without appropriate pain management or timely diagnostic follow-up.
Failure to Safeguard Resident Funds Resulting in Missing Cash
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s money from misappropriation after it was placed under the facility’s control. A resident with atrial fibrillation, vertigo, and moderate cognitive decline (BIMS score of 8) was admitted and reported having cash in a purse. The Social Services Designee (SSD) and a charge nurse counted $2,137 in cash, along with a checkbook and three bank cards. The resident chose to keep $20, and the SSD took the remaining $2,117 in cash, plus the checkbook and bank cards, and placed them in a box in a desk drawer in the SSD office. The SSD documented the amount in a progress note and notified the resident’s family to pick up the money and valuables. The SSD reported that the box used for storage was in a desk drawer and that neither the box nor the drawer locked. After placing the money and valuables in the box, the SSD left for the day, locking only the SSD office door. The next day, the SSD returned to work, was in and out of the office, and later went to retrieve the money to give to the resident’s family. At that time, the SSD observed that the cash was not in the same position as previously placed, and upon recounting, discovered that $600 was missing, leaving $1,517. The checkbook and bank cards remained in the box. The SSD confirmed that the Administrator and DON had keys to the SSD office and that an additional SSD office key was kept in an emergency key box in the medication room, to which nurses and certified medication technicians had access. The facility’s own investigation documented that the safe box and desk drawer in the SSD office did not lock and that the emergency key box in the medication room was found unlocked, with the zip lock seal missing, while the SSD key was still present inside. Staff working during the relevant time frame were interviewed and denied knowledge of the missing money or accessing the SSD office. A grievance was filed on behalf of the resident stating that $600 went missing while being held in the SSD office. Law enforcement was notified and obtained details from the Administrator and SSD about how the money was acquired, stored, and later found to be short. The facility did not reimburse the resident for the missing $600 until several weeks after the incident, despite the money having gone missing while in the facility’s custody and control.
Failure to Follow Care Plan During Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when facility staff failed to follow a resident's care plan during a transfer, resulting in the resident sustaining a right lower leg fracture. The resident, who had severe cognitive impairment and was dependent on staff for all transfers and activities of daily living, was care planned to require a mechanical lift with the assistance of two staff members for all transfers. Despite this, a nursing aide attempted to transfer the resident using only a gait belt and without the required mechanical lift or a second staff member present. The aide was not aware of the resident's transfer requirements and did not check the care plan prior to the transfer, stating that they did not have time to look up the information. During the transfer, the aide was unable to safely move the resident and had to lower them to the floor. At the time, no immediate signs of injury were noted, and the resident was assisted back to bed. However, the following morning, the resident was found to have swelling, bruising, and pain in the right ankle, which was subsequently diagnosed as a fracture of the distal tibia and fibula. The resident's care plan and facility policy both clearly indicated the need for mechanical lift transfers with two staff, and this information was accessible in the electronic medical record and care plan documentation. Interviews with staff revealed that the majority were aware of the proper procedures for transferring residents who require mechanical lifts, including the need for two staff members and the prohibition of using gait belts for such residents. The aide involved in the incident admitted to not checking the care plan and not being familiar with the resident's specific needs. Other staff present at the time confirmed that the correct transfer method was not used, and that the aide had been advised to use the mechanical lift but did not comply.
Failure to Follow Hot Beverage Policy Results in Resident Burns
Penalty
Summary
A deficiency occurred when the facility failed to ensure a safe environment and adequate supervision for a resident with moderate cognitive impairment, dementia, impaired vision, and a need for assistance with activities of daily living. The facility's hot beverage policy required that coffee and hot water be cooled to 130 degrees before serving to residents, and that only dietary staff provide hot beverages after checking the temperature. However, a staff member brought a personal coffee pot to the nursing station, and an LPN served hot coffee to the resident without checking its temperature, in violation of the policy. The resident, who had diagnoses including dementia, seizure disorder, and anxiety, requested coffee and a snack. The LPN provided the coffee, which the resident subsequently spilled on their chest and abdomen while unsupervised. The incident resulted in burns, with progress notes documenting reddened areas, blisters, and wounds to the chest and abdomen. The resident required wound care, including cleansing, application of antibiotic ointment, and dressings, as well as additional supplements and medications as ordered by the provider. Interviews and record reviews confirmed that the coffee pot was not authorized, the temperature of the coffee was not checked, and the resident was left unsupervised. Staff interviews revealed that the hot liquid policy was in place prior to the incident, but not followed. The resident's care plan and medical records indicated a need for supervision and assistance, which was not provided at the time of the incident, directly leading to the resident's injury.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect two residents on the Memory Care Unit from physical abuse by another resident. One resident, who had moderate cognitive loss and a history of verbal and physical behaviors, became increasingly agitated and aggressive over a period of weeks. This resident pulled another resident's hair and later struck a different resident, who was also the spouse, with a full water pitcher, causing physical injury and mental distress. Staff interviews and medical record reviews confirmed that the aggressive resident had exhibited escalating behaviors, including yelling at staff, throwing objects, and physical altercations with other residents. The first incident occurred when a resident with extensive cognitive loss and no prior behavioral issues was walking out of the dining room and interacted with the aggressive resident's spouse. The aggressive resident responded by yanking the other resident's hair and pulling them down. The second incident involved the aggressive resident entering the spouse's room and striking them in the head with a water pitcher, resulting in abrasions and redness. Staff members heard distress sounds and intervened, but not before the aggressive resident made contact multiple times. The spouse was found in a defensive posture, and the aggressive resident was removed from the room. Medical records and staff interviews indicated that the aggressive resident had a documented history of behavioral problems, including physical aggression toward staff and other residents, and had been seen by psychiatric professionals for increased agitation. Despite these known risks, the resident was able to access and harm other residents on multiple occasions. The facility's failure to prevent these incidents resulted in physical and psychological harm to the affected residents.
Staff Shared Unauthorized Resident Photos and Videos on Social Media
Penalty
Summary
The facility failed to protect four residents from abuse when three staff members took unauthorized photos and one staff member took a video of the residents and posted them to social media. Two of the images included demeaning comments about the residents. The residents involved had varying degrees of cognitive impairment, with three diagnosed with dementia and some unable to understand or consent to being photographed or recorded. All four residents were unaware that their images had been captured or shared online. The staff involved used a Snapchat group chat to share these images and videos among themselves. The group included five nurse aides, and the content was shared without the knowledge or consent of the residents or their legal representatives. In some cases, the residents were depicted in vulnerable situations, such as wearing only a hospital gown or being the subject of derogatory captions. The facility's policies explicitly prohibited the use of personal devices to take photos or videos of residents and required staff to respect residents' privacy and dignity at all times. Interviews and record reviews confirmed that the staff had received training on abuse prevention, HIPAA, and the facility's cell phone and social media policies. Despite this, the staff members involved knowingly violated these policies. Some staff admitted to recognizing the actions as violations but failed to report them promptly. The incident was eventually reported by one staff member, leading to an internal investigation. The residents' cognitive limitations and inability to provide informed consent were significant factors in the deficiency, as was the staff's disregard for established protocols regarding resident privacy and abuse prevention.
Failure to Protect Resident from Abuse and Delay in Reporting
Penalty
Summary
The facility failed to protect a resident from abuse when a Certified Medication Technician (CMT) hit the resident in the face with an open hand. This incident occurred in the Special Care Unit (SCU) and involved a resident with significant cognitive loss, dementia with psychosis, and other conditions that required moderate assistance for activities of daily living. The resident was found on the floor by the CMT, and during the process of assisting the resident back to bed, the CMT reacted by smacking the resident across the face when the resident was swinging arms and kicking. Despite the facility's policy that mandates immediate removal of any alleged perpetrator from resident contact, the CMT remained in direct contact with the resident for over 2.5 hours after the incident. The incident was not reported to the Charge Nurse until nearly two hours later, and the CMT was not removed from the facility until the MDS Coordinator arrived and found the CMT still in the resident's room. The MDS Coordinator admitted to not instructing the Charge Nurse to remove the CMT from resident care, which was a mistake. Interviews with staff revealed a lack of clarity and training on reporting procedures for abuse. Both the Nurse Aide and Certified Nurse Aide involved in the incident were unsure of the proper steps to take and who to report the abuse to. The Director of Nursing and the Administrator were not informed of the incident until later, and the Administrator was unaware that the CMT had remained in contact with the resident until arriving at work. The facility's failure to immediately remove the CMT from resident contact and the delay in reporting the incident contributed to the deficiency.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed by surveyors. The kitchen was found to have unclean surfaces, including tables that had not been cleaned after breakfast, a trash can lid with food residue, and a stove top with burnt food residue. Additionally, the steam table contained food particles, and the microwave was not clean. The dry storage room had spilled food items, and the walk-in cooler had eggs stored directly on the floor. The kitchen floors were littered with food particles, and there were no paper towels available at the handwashing sink. The facility's cleaning logs were incomplete, with no entries for several days, and the monthly cleaning schedule had no entries at all. The facility also failed to adhere to proper food temperature protocols. Staff did not take food temperatures on the steam table before service, and foods were not reheated to safe temperatures before serving. Observations showed that chicken fritters, minced meat, and macaroni were added to the steam table without temperature checks. Baked beans were reheated in the microwave but not temperature checked before being added to the steam table. The dietary manager and staff did not consistently document food temperatures, and some foods were not held at appropriate temperatures during meal service. Furthermore, the facility did not follow proper sanitation procedures. Clean cups were stored upright, and there was no thermometer in the refrigerator unit. The three-compartment sink was not properly sanitized, with test strips showing 0 parts per million of sanitizing solution. Staff did not wash their hands after contamination, and there were no sanitizer buckets prepared in the kitchen. The facility lacked a policy for dating and labeling foods, resulting in undated and unlabeled food items in storage. Staff also failed to wash hands between handling dirty and clean dishes, and there were no paper towels available for handwashing.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that hot food was not served at an appetizing temperature to three residents out of a sample of fifteen. The facility's policy required hot foods to be at least 120 degrees Fahrenheit when served, but several food items were found to be below this temperature during a meal test tray observation. For instance, fish was served at 99.2 degrees, carrots at 111.9 degrees, and baked beans at 104.6 degrees, all below the required serving temperature. Resident interviews highlighted dissatisfaction with the food temperatures and quality. One resident reported that hot food was typically cold, and cold food was too warm, while another resident mentioned that their food was cold. Additionally, the appearance and texture of the meals were noted to be unappetizing, with overcooked vegetables and soggy chicken nuggets. The dietary manager and dietician both expressed expectations that staff should ensure food is served at the correct temperature, with procedures in place to reheat food if necessary. However, these expectations were not met, leading to the deficiency.
Deficiencies in Resident Care and Supervision
Penalty
Summary
The facility failed to ensure residents were free from accident hazards and provided with adequate supervision to prevent accidents. Specifically, Resident #27 was not served the correct therapeutic diet as ordered by the physician. Despite having a diagnosis of dementia and dysphagia, the resident was repeatedly served the wrong type of meat, which was not minced and moist as required. This issue was observed multiple times, and the Speech Language Pathologist (SLP) had to intervene to correct the diet. The dietary staff and kitchen personnel were aware of the resident's dietary needs but failed to consistently follow the prescribed diet orders. Resident #49, who was severely cognitively impaired, had a controlled medication, clonazepam, left on a card table in their room for two days. The medication was not administered as per the physician's orders, and there was no documentation of missed doses. The facility's policy required staff to remain with the resident while they took their medication, but this was not followed, leading to the medication being left unattended. This oversight was contrary to the facility's inservice training, which emphasized that medications should not be left in resident rooms. Additionally, the facility did not use proper techniques during the use of a sit-to-stand lift for Resident #43, who required substantial assistance with transfers. The lift pad slid up past the resident's armpits during a transfer, causing discomfort and potential risk of injury. The staff did not follow the manufacturer's guidelines for the lift, which included keeping the legs of the lift open for stability and ensuring the brakes were locked when raising or lowering the resident. The resident expressed pain during the transfer, indicating improper handling by the staff.
Staffing Shortages Lead to Multiple Deficiencies
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of its residents, resulting in several deficiencies. One resident, who required substantial assistance with activities of daily living due to severe cognitive impairment and mobility issues, did not receive regular showers. The resident's shower schedule was inconsistent, with significant gaps between showers, and family members reported that they often had to request showers after two weeks without one. Interviews with staff revealed that there was no dedicated shower aide, and the responsibility was assigned to aides on the halls, leading to missed showers when staff were unavailable. Additionally, the facility experienced delays in meal service, affecting all residents. Observations showed that meals were consistently served late, with lunch trays being delivered and served well after the scheduled times. Staff interviews indicated that the delays were often due to insufficient staffing, with only two staff members available to assist residents to the dining room. This shortage also impacted other aspects of care, such as timely administration of medications and the ability to lay residents down after meals. The facility also failed to provide timely medication administration for several residents. Medications that were scheduled for early morning administration were given late, as observed during the survey. The Director of Nursing was seen administering medications hours after they were due, citing staffing issues as a reason for the delay. Furthermore, the Activity Director was frequently pulled from their role to cover staffing shortages on the floor, resulting in canceled activities for residents. The facility did not provide policies for staffing or showers, contributing to the deficiencies observed.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 32.14% due to nine errors out of 28 opportunities. This affected five residents, including those who received insulin injections not administered according to manufacturer guidelines. Specifically, the Assistant Director of Nursing (ADON) did not hold the insulin needle in the skin for the required six seconds, as observed with two residents. The ADON admitted to counting only three or four seconds, contrary to the manufacturer's instructions. Additionally, the facility did not adhere to proper procedures for transdermal patch application and removal. A Licensed Practical Nurse (LPN) failed to remove a Lidocaine patch from a resident's hip at the designated time, leaving it on overnight. The patch was supposed to be removed after 12 hours, but it was not dated, timed, or initialed, indicating a lapse in following physician orders and facility policy. The facility also did not follow proper procedures for medication administration, including crushing medications that should not be crushed. A Certified Medication Technician (CMT) crushed several medications, including Metformin ER and multivitamins, which should have been administered whole. Furthermore, the CMT did not apply lacrimal pressure after administering eye drops to a resident, as required by the facility's policy and manufacturer guidelines.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored securely, as observed on multiple occasions where medication carts were left unlocked and unattended. Registered Nurse (RN) and Licensed Practical Nurse (LPN) were seen leaving medication carts unlocked in various areas, such as the dinette and hallway, without any staff in visual contact. This occurred despite the facility's policy requiring medication carts to be locked when unattended. Interviews with the nursing staff confirmed that they were aware of the requirement to lock the carts but failed to do so consistently. Additionally, the facility did not properly manage medications for a resident with severe cognitive impairment. The resident, who was on antipsychotic, antianxiety, and antidepressant medications, was found to have a clonazepam tablet left unsecured in their room. The medication administration record showed a missed entry for clonazepam, and the resident had no assessments to self-administer medications. This oversight was acknowledged by the LPN, who confirmed the pill belonged to the resident and should not have been left in the room. The facility also failed to discard an expired vial of Influenza Vaccine and did not ensure a bottle of Lactulose Solution had a pharmacy label. The Director of Nursing (DON) confirmed that the expired vaccine should have been discarded and that the Lactulose should have been labeled with the resident's name. These lapses in medication management were identified during an observation and interview in the medication room, highlighting a lack of adherence to proper medication storage and labeling protocols.
Inadequate Dietary Staffing and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to provide adequate staffing in the dietary department, leading to delays in meal service and unsanitary kitchen conditions. Observations revealed that meals were consistently served late, with lunch trays being delivered and served well past the posted meal times. Residents reported that meals were often delayed by at least 30 minutes. The facility's open dining policy was not adhered to, as evidenced by the late delivery and serving of meals in both the memory care unit and the dining room. The kitchen was found to be in an unsanitary state, with unclean tables, food residue on various surfaces, and a lack of proper cleaning and maintenance. The cleaning logs were incomplete, with no entries for several days and weeks, indicating a failure to follow the facility's cleaning schedules. The dietary manager and staff reported high turnover and insufficient staffing, which contributed to the inability to maintain cleanliness and timely meal service. The dietary manager also lacked prior food service experience and adequate training, further exacerbating the issues. Interviews with staff highlighted the challenges faced due to the workload and lack of training. The dietary aide position was difficult to fill, and new employees often left shortly after starting due to the demands of the job. The dietary manager expressed the need for additional help and training to effectively manage the department. The facility did not provide a policy regarding dietary staffing, which may have contributed to the ongoing issues in the dietary department.
Deficiencies in Resident Grooming and Privacy
Penalty
Summary
The facility failed to respect the rights of six residents by not providing adequate grooming and privacy. Three residents were not groomed properly, with facial hair not being shaved regularly despite their preferences and needs. For instance, one resident with severe cognitive impairment was observed with facial hair on their chin, which was not consistently shaved during shower opportunities. Another resident, who was also severely cognitively impaired, expressed discomfort with their facial hair, yet it was not addressed by the staff. Additionally, the facility did not respect the privacy of three residents. One resident had their blood sugar checked in the hallway, which is against the facility's protocol. Another resident had a sign on their bathroom door detailing personal care instructions, including their name, which was visible to anyone entering the room. Similarly, another resident had multiple signs in their room detailing their care instructions, which were visible to other residents and visitors. Interviews with staff, including the Assistant Director of Nursing and the Director of Nursing, revealed that the facility's expectations were not met in these instances. Staff acknowledged that residents should be groomed regularly and that personal care instructions should not be visible to others. The facility also lacked a dignity policy, which contributed to these deficiencies in respecting resident rights.
Failure to Honor Resident Choice in Wake-Up Times
Penalty
Summary
The facility failed to ensure that residents were offered a choice of when they would like to get up in the morning, affecting two residents. Resident #30, who had moderate cognitive impairment and required substantial assistance, was observed sitting in a wheelchair at the nurse's station early in the morning, expressing a desire to lay down. Despite the resident's repeated requests, no staff responded promptly. Interviews revealed that staff were unaware of the resident's preferences, and the care plan did not specify the resident's desired wake-up time. Resident #43, with severe cognitive impairment and a history of pressure ulcers, was also affected. The resident was dressed and seated in a wheelchair at the nurse's station early in the morning. The care plan did not address the resident's preferred wake-up time, and the staff generally aimed to have residents up by 7:00 A.M. Interviews indicated that the resident's family was not consulted about their preferences, and the care plan lacked specific instructions regarding the resident's schedule. Interviews with staff, including the DON and ADON, highlighted a lack of communication and documentation regarding residents' preferences for wake-up times. The facility's policy emphasized resident self-determination, but the care plans did not reflect this, leading to a deficiency in honoring residents' rights to choose their daily schedules.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to honor the residents' right to organize and participate in resident/family groups by not adequately addressing grievances and recommendations made by the resident council. The facility did not maintain documentation of resident concerns, attempts to resolve these concerns, or follow-up actions. This affected all residents serving on the resident council and potentially other residents in the facility. During interviews, residents expressed that they were unaware of how to complete a grievance, did not have access to grievance forms, and did not know who the grievance officer was. They also raised concerns about showers not being given, tough meat, cold food, and long wait times for call lights, which resulted in incontinence and feelings of humiliation. The review of resident council minutes from April to June 2024 showed repeated concerns about food quality, call light response times, and other issues, with no documentation on how or if these concerns were addressed. Interviews with facility staff, including the Social Services Designee, Certified Nurse Aide, Administrator, and Director of Nursing, revealed inconsistencies in the grievance process and a lack of awareness among staff about the procedure. The Social Services Designee mentioned that grievances were located by the front door and that they would fill out grievances for residents if requested. However, there was no evidence that grievances were discussed in resident council meetings, and the facility's policy and goal to resolve issues within five days were not documented as being met.
Failure to Inform and Resolve Resident Grievances
Penalty
Summary
The facility failed to adequately inform residents about the grievance process, resulting in residents being unaware of how to file grievances or complaints. During a group interview, residents expressed that they did not know how to complete a grievance, lacked access to grievance forms, and were unaware of the grievance officer's identity or where to submit a grievance form. Additionally, concerns raised in resident council meetings, such as issues with food quality, call light response times, and bathing schedules, were repeatedly voiced over several months without resolution or follow-up. The facility's grievance policy was not effectively communicated or implemented, as evidenced by the lack of education on the grievance process during resident council meetings and the absence of documented resolutions for grievances. Interviews with staff, including the Social Service Designee and a Certified Nurse Aide, revealed a lack of knowledge about the grievance process and inconsistent follow-up on grievances. Furthermore, the facility's grievance reports for a specific resident's family member showed incomplete documentation, with no indication of resolution or notification to the complainant. The facility's failure to address grievances effectively was further highlighted by a family member's statement that grievances were not followed up on, leading to a lack of trust in the grievance process. The Administrator and Director of Nursing acknowledged that grievances should be discussed at resident council meetings, but this was not being done. The facility's grievance forms did not require signatures from residents or family members to confirm satisfaction with resolutions, indicating a gap in the grievance handling process.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized, person-centered comprehensive care plans for two residents, leading to deficiencies in addressing dehydration, falls, and code status. Resident #15, who was severely cognitively impaired and dependent on a walker, had a history of falls and dehydration but did not have these issues addressed in their care plan. Despite having a fall on 4/14/24 and being hospitalized for acute kidney injury and dehydration on 4/15/24, the care plan lacked specific interventions for these conditions. Interviews with facility staff, including the MDS Coordinator, Director of Nursing, and Assistant Director of Nursing, revealed an expectation that such issues should have been care planned. Resident #44, also severely cognitively impaired, had a DNR order signed on 8/23/22, but this was not reflected in their care plan as of 6/4/24. The resident's annual MDS indicated severe cognitive impairment and various diagnoses, including dementia and anxiety, but the care plan failed to address the resident's code status. Interviews with the MDS Coordinator, Director of Nursing, and Assistant Director of Nursing confirmed that code status should have been included in the care plan. The facility's policy on comprehensive care planning emphasizes the need for individualized plans with measurable goals and time frames, which should be revised as changes occur in a resident's condition. However, the facility did not adhere to this policy for Residents #15 and #44, resulting in deficiencies related to the lack of care planning for falls, dehydration, and code status. The facility census at the time was 59.
Medication Administration Delays
Penalty
Summary
The facility failed to ensure that medications were administered within the appropriate time frame, affecting three residents. Resident #28 was prescribed Levothyroxine to be administered at 5:00 A.M. for hypothyroidism, but it was documented as being administered late at 7:33 A.M. The Director of Nursing (DON) was observed administering the medication at 7:32 A.M. after initially being delayed by staff cleaning the resident. Resident #21 had multiple medications prescribed, including Levothyroxine and Ropinole, which were also administered late. The medications were due at 5:00 A.M. but were given at 7:45 A.M. The DON acknowledged the delay, stating that the medications were early morning doses. Similarly, Resident #29 was prescribed Gabapentin to be administered at 6:00 A.M., but it was documented as being administered at 7:47 A.M. The DON confirmed that medications should be passed within one hour before or after they were due.
Deficiencies in ADL Assistance and Incontinence Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for residents who required it, specifically in the areas of bathing and incontinence care. This deficiency affected four out of 17 sampled residents. Two residents did not receive regular showers, and two others did not receive complete incontinence care. The facility's policies on perineal care and resident rights were reviewed, but no policy on showers was provided. Resident #4, who had no cognitive impairment and required partial assistance with personal hygiene, was observed with greasy and uncombed hair, wearing the same clothes for consecutive days. The resident reported not receiving regular showers, with records showing infrequent showers over several months. Interviews with staff revealed a lack of dedicated shower aides and insufficient staffing to ensure regular showers for residents. Resident #43, with severely impaired cognitive skills and requiring substantial assistance with ADLs, also did not receive regular showers. Family members reported the resident received a shower approximately once a week, sometimes after two weeks. Incontinence care for Residents #33 and #40 was inadequately performed, with staff failing to follow proper procedures for cleaning and using the same area of wipes or washcloths for different skin areas. Interviews with staff confirmed these improper practices and acknowledged the need for correct cleaning techniques.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible for residents in their rooms, as observed in the cases of two residents. Resident #43, who had severe cognitive impairment, impaired mobility, and a history of falls, was found with the call light draped over the foot of the bed, out of reach. Despite the resident's care plan indicating the need for the call light to be within reach at all times, staff left the room without ensuring the call light was accessible, requiring family intervention to rectify the situation. Resident #44, who was severely cognitively impaired and had multiple health issues including dementia and impaired vision, was observed multiple times with the call light on the floor or hanging out of reach. This resident, who was at risk for falls, had to leave the bed to seek assistance, indicating a failure to provide the necessary accessibility to the call light. Staff did not ensure the call light was within reach even after assisting the resident back to bed. Interviews with various staff members, including a Registered Nurse, Licensed Practical Nurse, Certified Nurse Aide, MDS Coordinator, Director of Nursing, Assistant Director of Nursing, and the Administrator, all confirmed the expectation that call lights should be within residents' reach. Despite this, the observations showed a consistent failure to adhere to this standard, as evidenced by the repeated instances of inaccessible call lights for the two residents.
Failure to Identify and Document Pressure Ulcer
Penalty
Summary
The facility failed to identify, assess, and document a pressure ulcer for Resident #43, who was admitted with a left hip fracture and dementia. Upon admission, the resident's skin integrity was noted to have a surgical wound, but no other skin issues were documented. However, on 1/26/24, it was noted that the resident had developed a Stage II pressure ulcer on the left heel, which was not identified until the resident's family member discovered it. The ulcer measured 5 cm x 4 cm with a black center and serous drainage, indicating a lack of timely skin assessment and documentation by the facility staff. The resident's medical records and progress notes revealed that the resident had been primarily bedridden since admission and required assistance for transfers. Despite this, the facility did not implement adequate preventive measures such as heel protectors or regular repositioning to prevent pressure ulcers. The resident's condition was further complicated by cognitive impairment, requiring substantial assistance with daily activities, and the presence of a suprapubic catheter, which increased the risk of skin breakdown. Interviews with the Director of Nursing (DON) and Registered Nurse (RN) A confirmed that the resident was not admitted with a pressure ulcer on the left heel, and the weekly skin assessments were not completed as required. The DON acknowledged that the nurses should have identified the wound before the family did, indicating a lapse in the facility's wound care and prevention protocols. This deficiency highlights the facility's failure to adhere to its own policies for ongoing skin assessment and pressure ulcer prevention, leading to the development and progression of the resident's pressure ulcer.
Breach of Resident Privacy Due to Unattended Computer Screen
Penalty
Summary
The facility failed to protect residents' personal privacy when a Licensed Practical Nurse (LPN) left the medication cart computer screen unattended, unlocked, and visible with resident personal information accessible to anyone nearby. This occurred multiple times on the morning of June 11, 2024, with the computer screen being left open and visible to resident confidential information for several minutes at a time. The LPN left the medication cart unattended while entering various rooms and the dining area, leaving the computer screen exposed in a public area. Interviews with the LPN and the facility's Director of Nursing (DON) and Assistant DON revealed that the staff was expected to lock the computer screen or shut it down when leaving the medication cart unattended to protect residents' privacy. The facility's policy on electronic medical records and resident rights emphasized the importance of maintaining confidentiality and preventing unauthorized access to resident information. Despite these policies, the LPN did not adhere to the expected procedures, resulting in a breach of resident privacy.
Failure to Follow Dietary Guidelines and Portion Sizes
Penalty
Summary
The facility failed to ensure that meals were served according to the nutritional needs and dietary requirements of the residents. Observations revealed that staff did not follow the prescribed recipes and portion sizes as outlined in the facility's menu. Specifically, during meal preparation, staff did not use the correct ingredients or follow the recipes for minced and moist diets, and they failed to use the appropriate serving utensils, resulting in inconsistent portion sizes. This inconsistency in meal preparation and serving had the potential to affect all residents in the facility. Interviews with staff members, including the dietary manager and the dietician, confirmed that there was a lack of adherence to the menu and recipe guidelines. Staff members admitted to not using the menu book for preparing meals and instead relied on their own judgment or previous instructions from former managers. This led to incorrect portion sizes being served, with some residents receiving more or fewer pieces of chicken than specified in the menu. Additionally, the dietary manager acknowledged that prior to their tenure, staff were unaware of the location of the recipe book, indicating a lack of proper training and oversight. The dietary manager and dietician both expressed expectations that staff should follow the recipes and use the correct serving utensils as indicated in the menu. However, the staff's failure to do so resulted in meals that did not meet the nutritional needs of the residents. The administrator also expected adherence to the menu and recipe guidelines, but the observations and interviews highlighted a significant gap between these expectations and the actual practices in the kitchen.
Failure to Adhere to Dietary Orders for Resident
Penalty
Summary
The facility failed to prepare food in a form designed to meet individual needs, specifically for Resident #27, who was served food inconsistent with their dietary orders. Resident #27, who had a diagnosis of dementia and mild protein-calorie malnutrition, was on a therapeutic diet requiring minced and moist level 5 meats. However, observations revealed that the resident was served regular bacon and scrambled eggs instead of the prescribed minced and moist diet. This discrepancy was noted by the speech language pathologist (SLP), who intervened to correct the meal. Further observations showed that the resident was again served the wrong diet at lunch, receiving pureed meats instead of the ordered minced and moist meats. Interviews with staff, including the SLP, dietary manager, and certified nurses aides (CNAs), indicated that serving incorrect diets was an ongoing issue within the facility. The dietary manager acknowledged awareness of the problem and emphasized the importance of following physician-ordered diets to prevent choking incidents. Interviews with various staff members, including the Director of Nursing (DON) and Assistant DON, revealed a general expectation that dietary orders should be followed accurately. Despite in-service education provided to staff on ensuring correct diet orders, the issue persisted, with staff admitting to occasionally serving incorrect diets. The facility's failure to consistently adhere to dietary orders resulted in Resident #27 being served inappropriate meals, highlighting a significant deficiency in dietary management.
Inadequate Hand Hygiene Practices Observed
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by staff not washing their hands between dirty and clean tasks. This deficiency was observed during interactions with a resident who had severe cognitive impairment, required substantial assistance with daily activities, and had a suprapubic catheter and a Stage II pressure ulcer. The resident was on enhanced barrier precautions due to these conditions, which necessitated strict adherence to infection control protocols. During observations, it was noted that a CNA and an LPN did not wash their hands between glove changes while providing care to the resident. The LPN removed gloves after cleaning the resident's coccyx and applied new gloves without washing hands. Similarly, a CMT and another NA also failed to wash their hands between glove changes while assisting the resident with transfers and personal care. These actions were contrary to the facility's handwashing policy, which, although undated, aimed to reduce the transmission of organisms. Interviews with staff, including the DON, revealed a lack of consistent understanding and adherence to hand hygiene protocols. Staff members acknowledged the importance of washing hands when entering a resident's room, between glove changes, and after providing care, especially when dealing with fecal material. However, the observed practices did not align with these expectations, indicating a gap in the implementation of infection control measures.
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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