Maywood Terrace Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Independence, Missouri.
- Location
- 10300 East Truman Rd, Independence, Missouri 64052
- CMS Provider Number
- 265404
- Inspections on file
- 18
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Maywood Terrace Living Center during CMS and state inspections, most recent first.
The facility failed to ensure that multiple residents received and had documented twice‑weekly bathing and individualized ADL care in line with their needs and preferences. Residents with amputations, paraplegia, morbid obesity, muscle weakness, and mobility impairments, all cognitively intact, were dependent on staff for bathing but often did not receive scheduled showers, and staff frequently charted "not applicable" instead of completed care or refusals. One resident lacked an ADL care plan for bathing, another had no documented bathing preferences despite communication difficulties, and several shower review forms were incomplete, missing care details and nurse signatures or even listing the wrong name. Residents reported not getting regular baths, wanting evening showers or showers after pain medication, and feeling unclean, while staff interviews revealed confusion about documentation, missing or delayed MDS and care plans, and reliance on CNAs to complete both paper and EMR records without consistent follow‑through.
A resident with chronic pain and spinal stenosis received Oxycodone 20 mg from the pharmacy, but an RN failed to count the medication with the delivery driver and did not document the full quantity received. Multiple shift-to-shift narcotic counts lacked required dual signatures, and staff interviews revealed inconsistent practices in handling and documenting controlled substances.
The facility failed to maintain cleanliness and sanitation in the kitchen and dry storage areas, as well as proper waste management, which are essential for food safety. Observations included a dislodged refrigerator gasket, food splatters, residue on utensils, and a deeply dented can. The dumpster lid was not properly closed, posing a pest risk. Interviews revealed the absence of a Dietary Manager and new kitchen staff, with persistent issues noted in follow-up inspections.
The facility did not complete a timely Facility Assessment to determine necessary resources for resident care. The assessment was outdated and did not reflect the current resident demographics and needs, including those with complex care requirements such as indwelling catheters, tube feedings, and dementia. The new Administrator had not updated the assessment since starting three months prior.
The facility did not employ a dedicated Infection Preventionist (IP) on at least a part-time basis, as required. The Administrator, who had been in the role for one month, was acting as the IP, dedicating about three and a half hours per week to infection prevention activities. Previously, the former Administrator also served as the IP. The Corporate Nurse acknowledged the impracticality of the Administrator fulfilling the IP role given the requirement for part-time dedication to infection control and antibiotic stewardship activities.
The facility's call light system was found deficient, lacking audible notifications necessary for timely resident assistance. Observations showed lit call lights without audible alerts, and one call light was out of a resident's reach. The Emergency Preparedness plan also lacked alternative communication methods for power outages. Interviews revealed staff were unaware of the system's issues.
A facility failed to ensure nursing staff availability for residents in the dementia SCU, leaving two residents without supervision for 33 minutes. One resident, with vascular dementia and a history of falls, required constant supervision, while another resident, also with dementia, was dependent on staff for all ADLs. Staff interviews confirmed the need for continuous supervision to ensure safety and prevent anxiety.
The facility did not post nurse staffing information in an accessible location for residents and visitors, failing to include necessary details such as the facility name, daily census, and hours worked by RNs, LPNs, and CNAs. Observations confirmed the absence of this information, and interviews revealed a lack of clarity and responsibility among staff regarding the posting process.
The facility failed to properly store, label, and date medications, with observations showing unlocked and unattended medication carts and expired medications. Staff interviews confirmed the expectation for secure storage and regular audits, but practices did not align with policies.
The facility failed to verify, administer, or document influenza and pneumococcal vaccinations for several residents, including those with cognitive impairments. Despite policies requiring vaccination offers and documentation, records showed no evidence of vaccines being offered or administered, nor any refusals documented. Interviews with staff confirmed the lack of documentation in residents' medical records.
The facility failed to offer and document COVID-19 vaccination and education for four residents, including those with cognitive impairments. Interviews with an LPN and the DON confirmed that vaccination status should be documented in medical records, but this was not done for the affected residents.
The facility failed to provide a SNF ABN to two residents discharged from Medicare Part A services, informing them of potential liability for non-covered services. Instead, only a NOMNC was issued, indicating the end of skilled services. Interviews revealed confusion among staff about responsibility for issuing the SNF ABN, despite being informed in advance of therapy service termination.
The facility failed to complete quarterly assessments for two residents and a significant change MDS for a resident admitted to hospice. The MDS coordinator position was vacant, and staff were unaware of the assessment requirements, leading to incomplete documentation.
A resident with muscle wasting and vascular dementia experienced multiple falls that were inaccurately documented on the MDS. Despite having a hematoma from a fall, the MDS did not reflect this as a non-major injury. The facility's policy requires accurate MDS documentation, but the position of MDS Coordinator was vacant, leading to this deficiency.
A facility failed to follow physician's orders for wound care on a resident with a surgical wound from a right above the knee amputation. The Treatment Administration Record (TAR) showed multiple instances of missing documentation for the required daily treatment. Interviews with the ADON and DON indicated that the charge nurse was responsible for documenting wound care, and if not documented, it was assumed not completed.
A resident with legal blindness and a right leg amputation reported an unwitnessed fall, but the facility failed to conduct a thorough investigation or update the care plan. Despite the resident's report of hitting their head and experiencing a headache, no neurological assessments were documented. Interviews with staff revealed that the facility's protocol for unwitnessed falls was not followed, resulting in a deficiency.
A facility failed to ensure proper catheter care and hand hygiene for a resident with an indwelling catheter. The CNA did not sanitize the catheter port or perform hand hygiene during a tubing change, and the facility lacked complete physician's orders for catheter size. The DON confirmed the need for proper hand hygiene and catheter size orders.
A resident with PTSD was not provided with trauma-informed care due to the facility's failure to include PTSD in the care plan and lack of staff awareness of the resident's condition. The resident's care plan did not address PTSD triggers or interventions, and staff interviews revealed a lack of knowledge about the resident's diagnosis and care needs. The facility's administration acknowledged the oversight, noting the absence of a responsible MDS Coordinator.
A facility failed to address medication irregularities identified by a pharmacy consultant for a resident. The resident's medication orders lacked a diagnosis or indication for use, which was not resolved by the facility staff or the pharmacy consultant. Interviews with staff revealed confusion about responsibilities for ensuring medication orders included necessary documentation.
The facility failed to ensure that physicians reviewed and acted on pharmacy recommendations for Gradual Dose Reduction (GDR) of psychotropic medications for two residents. One resident, severely cognitively impaired, was on multiple psychotropic medications without a GDR attempt, despite pharmacist recommendations. Another resident was taking antidepressants without a documented diagnosis or indication for use. Interviews revealed a lack of clarity on responsibility for addressing pharmacy recommendations and ensuring medication orders included a diagnosis or indication for use.
A resident with hemiplegia and chronic kidney disease was admitted with scabs and edema, but the facility failed to document these conditions or notify the physician. Weekly skin assessments were not conducted, and an anticoagulant medication error occurred due to poor communication. These deficiencies led to severe medical interventions, including amputations.
A resident with partial paralysis and other risk factors developed a coccyx wound after returning from the hospital. The facility failed to conduct weekly assessments and documentation of the wound, as required by policy. An LPN did not follow hand hygiene protocols during wound treatment, which included not washing hands between glove changes and before applying Santyl. The DON acknowledged previous lapses in wound care documentation, leading to staff changes.
A resident with a urinary catheter did not receive proper catheter care, as a CNA failed to follow hand hygiene protocols and did not retract the foreskin or cleanse the catheter adequately. An LPN observed these deficiencies and discussed them with the CNA, while the DON confirmed the expectations for proper care.
A resident receiving hospice care was found with side rails on their bed without a proper assessment, physician's order, or informed consent. The side rails were installed by a hospice company, and facility staff were unaware of the change. The facility lacked a side rail policy, and licensed nurses failed to report the presence of side rails to the administrator.
Failure to Provide and Document Scheduled Bathing and ADL Care per Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to assess, care plan, provide, and document bathing and other activities of daily living (ADLs) in accordance with resident needs, preferences, and facility policy. The facility’s ADL policy required that residents who could not perform ADLs independently receive appropriate support with personal hygiene, including bathing, in accordance with the care plan, and that refusals be explained to the resident/representative, alternative interventions offered, and refusals documented. The facility also had a Skin Monitoring: Comprehensive CNA Shower Review form that required CNAs to visually assess skin during showers, document the type of personal care provided, obtain charge nurse and DON signatures, and document refusals with resident signatures or staff witnesses after multiple attempts. Surveyors found that these processes were not followed for multiple residents. One resident with bilateral lower extremity amputations and a history of stroke required staff assistance for showering and had scheduled bath days twice weekly. The care plan identified a self-care performance deficit and need for assistance with showering, but the shower review form for one date only contained a CNA signature without documentation of the type of personal care provided or a charge nurse signature. The facility could not provide additional documentation that showers were provided twice weekly over a one‑month period, and electronic records only showed that the resident required assistance, not that showers were completed. This resident, who was cognitively intact and able to make needs known, reported needing assistance for all personal care and not receiving baths/showers twice a week, and could not recall the last shower. Another resident with paraplegia, neuromuscular bladder dysfunction, and a suprapubic catheter had an admission care plan that noted a lack of patience for assistance but did not include an ADL care plan specifying the type of assistance needed for baths/showers or the resident’s bathing and personal care preferences. The admission MDS showed the resident was cognitively intact but had difficulty communicating needs, and the admission MDS and care areas had not been completed or submitted by the time of the survey. Shower review forms for this resident on two dates contained the wrong first name, only a CNA signature, no description of personal care provided, and no charge nurse signature. Documentation showed only two showers out of eight scheduled opportunities, with no additional records of showers or refusals over several weeks. The resident reported concerns about not receiving assistance with care and bathing, needing help with transfers, and having difficulty with speech and expressing needs. Additional residents with muscle weakness, morbid obesity, mobility impairments, and dependence on staff for bathing also did not receive scheduled baths twice weekly, and their care plans lacked complete ADL/bathing interventions. One cognitively intact resident with upper and lower extremity impairments required substantial/maximal assistance for bathing but had no ADL care plan for cares. Paper bath sheets and EMR entries showed multiple missed baths over several weeks, with staff documenting “not applicable” instead of completed baths or refusals. This resident was observed with body odor, greasy uncombed hair, and reported not getting showers as scheduled and wanting evening showers, which staff did not provide due to staffing issues. Two other cognitively intact residents, both with morbid obesity and mobility limitations, were dependent or substantially dependent on staff for bathing and had care plans indicating ADL self‑care deficits and total dependence for showers. Bath sheets and EMR documentation showed that each missed multiple baths out of scheduled opportunities, again with “not applicable” recorded instead of completed baths or refusals. These residents reported not getting baths regularly, attributing this to insufficient staff and the lack of a bath aide, and one resident stated a preference for bathing after pain medication due to stiffness and soreness, while another preferred evening or night showers and expressed dissatisfaction with messy, uncombed hair. Staff interviews confirmed that residents were supposed to receive two showers per week on assigned bath days, that preferences should be reflected in care plans or other tools, and that CNAs were responsible for documenting showers and refusals in both shower sheets and the EMR. The administrator, DON, LPN, CNA staff, and MDS coordinator acknowledged missing documentation, confusion between “not applicable” and refusal, incomplete ADL care planning, and delays in completing MDS and care plans, all contributing to the failure to ensure scheduled, documented bathing and individualized ADL care for the affected residents.
Failure to Account for and Document Controlled Substance Delivery and Shift Counts
Penalty
Summary
The facility failed to properly account for the delivery and documentation of a controlled substance, specifically 120 tablets of Oxycodone 20 mg, for a resident with chronic pain syndrome and spinal stenosis. The medication was delivered from the pharmacy and signed for by an RN, but the RN did not count the medication with the delivery driver or confirm the correct quantity before signing the receipt. The facility's controlled substance receipt/record showed a discrepancy, with only 60 tablets documented as received, despite the pharmacy delivering 120 tablets. Additionally, the RN did not perform a full narcotic count with the oncoming nurse during shift change, and there were multiple instances where required dual signatures for shift-to-shift controlled drug counts were missing over several days. The resident involved was cognitively intact and reported not missing any pain medication doses, with staff providing alternative pain management if needed. Interviews with staff revealed inconsistent practices regarding the receipt, counting, and documentation of controlled substances, as well as a lack of adherence to the facility's expected procedures for shift-to-shift narcotic counts. The facility was unable to provide a policy and procedure for controlled substances prior to the survey exit.
Deficiencies in Kitchen Sanitation and Waste Management
Penalty
Summary
The facility failed to maintain cleanliness and sanitation in the kitchen and dry storage areas, as well as proper waste management, which are essential for food safety. During the survey, it was observed that the reach-in refrigerator had a dislodged gasket, and various food splatters were present on the stove and grill. A meat knife was found with residue, and a scoop was improperly stored in a sugar bin. Ladles had food residue, and a cutting board was excessively scored, posing a risk of contamination. Additionally, a deeply dented can of creamed corn was found in the dry storage room, and the floor was littered with trash and debris. The dumpster lid was not properly closed, which could attract pests. Interviews revealed that the facility did not have a Dietary Manager at the time of the initial inspection, and all kitchen employees were new, as the previous staff had quit. The new Dietary Manager, hired after the initial inspection, stated that the day-cook and dishwasher were responsible for cleaning, and damaged items should be reported and replaced. Despite these statements, follow-up inspections showed persistent issues, including the improperly closed dumpster lid. The facility's census was 44 residents, with a licensed capacity for 86, indicating that these deficiencies had the potential to affect a significant number of individuals.
Failure to Update Facility Assessment
Penalty
Summary
The facility failed to complete a timely Facility Assessment to determine the necessary resources to meet the needs of its residents. The assessment, which should be conducted annually and updated with any changes in facility status, was not completed by the new Administrator who had been in position for approximately three months. The facility's policy, dated 8/8/17, mandates an annual review of the facility-wide assessment, including evaluations of the resident population and the resources required for their care. However, the assessment dated 10/26/22 did not reflect the current resident demographics and needs as observed during the survey conducted from 7/9/24 to 7/16/24. The facility's resident census and condition report showed a variety of complex care needs among the 44 residents, including those with indwelling catheters, tube feedings, pressure ulcers, dementia, infections, significant weight loss, and falls. Additionally, the facility had a specialized memory care unit and residents receiving hospice care and oxygen. Despite these diverse needs, the facility assessment was outdated, failing to account for the current resident population and the necessary staff competencies, physical plant requirements, and technology resources needed to provide adequate care.
Failure to Employ a Dedicated Infection Preventionist
Penalty
Summary
The facility failed to employ a dedicated Infection Preventionist (IP) on at least a part-time basis, as required by their own policy. The facility's census was 44 residents at the time of the survey. The Administrator, who had been in the position for one month, was acting as the IP and dedicated approximately three and a half hours per week to infection prevention activities. Prior to this, the previous Administrator, who had been at the facility for about a year, also served as the IP. The facility's Corporate Nurse acknowledged that it was impractical for the Administrator to fulfill the IP role given the requirement for part-time dedication to infection control and antibiotic stewardship activities.
Deficient Call Light System in Facility
Penalty
Summary
The facility was found to have a deficient call light system that failed to provide audible notifications, which is crucial for meeting residents' needs promptly. During inspections, it was observed that several resident rooms had their hallway ceiling call lights lit, but there was no audible notification at the nursing station or in the rooms themselves. Additionally, in one instance, a call light button was not within reach for a resident while lying in bed, further compromising the ability to call for assistance. These observations indicate a systemic issue with the call light system's functionality, affecting the facility's ability to respond to residents' needs effectively. The facility's Emergency Preparedness plan lacked a policy or procedural plan for an alternate method for residents to contact staff during a power outage, which could exacerbate the issue of inoperable call lights. Interviews with the Director of Maintenance and the Administrator revealed a lack of awareness regarding the malfunctioning audible notification system. The Director of Maintenance was unaware of the issue, and the Administrator believed the system was functioning at times, indicating a communication gap and oversight in monitoring the system's performance.
Nursing Staff Unavailability in Dementia Care Unit
Penalty
Summary
The facility failed to ensure that nursing staff were available at all times for residents in the dementia Special Care Unit (SCU). On July 9, 2024, it was observed that two residents, who were in their respective beds on the SCU, were left without nursing staff for 33 minutes. During this time, only non-nursing staff such as laundry and housekeeping personnel were present on the unit. This lack of supervision occurred despite the facility's staffing sheets indicating that a Licensed Practical Nurse (LPN) and two Certified Nurse Assistants (CNAs) were scheduled to be on the SCU. Resident #4, who was admitted with diagnoses including vascular dementia with agitation and behavioral disturbance, was severely cognitively impaired and required maximal assistance for activities of daily living. The resident had a history of falls and was at high risk for further falls due to unsteady gait and cognitive impairment. Interviews with staff revealed that the resident often attempted to get out of bed without assistance and required constant supervision to prevent falls and ensure safety. Resident #21, also diagnosed with dementia with behavioral disturbance, was severely cognitively impaired and dependent on staff for all activities of daily living. The resident had safety awareness problems and required total care, including assistance with feeding and ensuring beverages were within reach. Staff interviews confirmed that the resident needed frequent checks and should not be left alone due to the risk of anxiety and emotional distress. The Director of Nursing acknowledged that it was unsafe for residents to be left without nursing staff on the unit.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information in a location that was easily accessible to residents and visitors on both the Long Term Care and Rehabilitation units. The required information, including the facility name, daily census, and actual hours worked per shift for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs)/Certified Medication Technicians (CMTs), was not posted in a prominent location. Observations on multiple occasions confirmed that the staffing information was not visible to residents and visitors, which is a requirement for transparency and compliance. Interviews with the facility's Administrator and Director of Nursing (DON) revealed a lack of clarity and responsibility regarding the posting of staffing information. The Administrator acknowledged being responsible for posting staffing but admitted to not having a staffing coordinator and was in the process of hiring one. The Administrator also mentioned that the schedule was posted by the time clock, which was not accessible to residents and visitors. The DON, who had recently started at the facility, was unaware of who was responsible for posting the staffing information and did not verify its completion. Both the Administrator and DON expressed expectations that the staffing information should be posted daily and be accessible to all residents and visitors, indicating a gap between expectations and actual practice.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and dating of medications in the medication room and on two of the three medication carts. Observations revealed that the North medication cart was left unlocked and unattended on multiple occasions, with staff members walking by without securing it. Additionally, the North treatment cart was found unlocked and unattended, containing three undated cups of unknown medication. In the medication room, the refrigerator lock box for controlled substances was unlocked, and an opened vial of tuberculin PPD lacked an open date. Furthermore, six bottles of over-the-counter calcium tablets were found to be expired. Interviews with facility staff, including a CNA, ADON, LPN, and DON, confirmed that medication carts and refrigerator lock boxes should be locked when unattended, and that nursing staff are responsible for ensuring medications are not expired. The ADON and DON acknowledged their responsibility for auditing medication carts and rooms, with the DON stating that audits should occur monthly. Despite these expectations, the facility's practices did not align with their policies, leading to the observed deficiencies.
Failure to Ensure Vaccination Status and Documentation
Penalty
Summary
The facility failed to ensure that residents' influenza and pneumococcal vaccination statuses were verified, administered, or refused, and that the risks and benefits of these vaccinations were communicated to residents or their representatives. This deficiency was identified for four residents out of a sample of twelve, with a total facility census of 44 residents. The facility's policies required that influenza vaccines be offered annually between October 1st and March 31st, and pneumococcal vaccines be assessed and offered within thirty days of admission. However, the records for Residents #22, #25, #40, and #42 showed no documentation of being offered or receiving these vaccines, nor any record of refusal. Resident #22, who was severely cognitively impaired, had not received or been offered the influenza vaccine during the 2023-2024 season. Resident #25, also severely cognitively impaired, had an outdated pneumococcal vaccination status and had not been offered the vaccine. Resident #40, with severe cognitive impairment, had neither received nor been offered both the influenza and pneumococcal vaccines. Resident #42, moderately cognitively impaired, had an outdated pneumococcal vaccination status and had not been offered the vaccine. Interviews with facility staff, including an LPN and the DON, confirmed that vaccination information should be documented in the residents' medical records, but this was not done for the affected residents.
Failure to Document COVID-19 Vaccination Offer and Education
Penalty
Summary
The facility failed to ensure that four residents were offered the COVID-19 vaccination, provided with education regarding the benefits and risks of the vaccine, and had signed consent or refusal documented. This deficiency was identified for four out of twelve sampled residents, with a facility census of 44 residents. The residents involved included those who were severely or moderately cognitively impaired, as well as those who were cognitively intact. The medical records of these residents did not contain any documentation indicating that they were offered the vaccine, received education about it, or had consented to or refused the vaccination. Interviews with facility staff, including an LPN and the DON, confirmed that each resident should have documentation in their medical record regarding their COVID-19 vaccination status, including whether they were offered the vaccine and if they consented or refused. The LPN stated that this information should be found under the vaccine tab in the medical records, while the DON emphasized the importance of offering the vaccine and providing information about its benefits and risks to residents or their decision-makers. Despite these procedures, the records for the four residents in question lacked the necessary documentation, indicating a failure in the facility's adherence to its vaccination policy.
Failure to Provide SNF ABN to Residents
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two residents who were discharged from Medicare Part A services. The SNF ABN is a required document that informs residents or their legal representatives about potential liability for services not covered by Medicare. In this case, the facility provided a Notice of Medicare Provider Non-Coverage (NOMNC) to the residents, indicating the end of skilled services, but did not issue the SNF ABN, which is necessary to inform them of their financial responsibilities for non-covered services. Interviews with facility staff revealed a lack of clarity and responsibility regarding the issuance of the SNF ABN. The Social Services Director, who had been at the facility for just over a month, was not aware of whether the previous Social Services Director or the Bookkeeper had issued the required notices to the residents. The Regional Nurse and the Director of Nursing confirmed that the Bookkeeper was responsible for ensuring residents received the SNF ABN when therapy services were expected to end. Despite being informed three days in advance of the end of therapy services, the residents did not receive the SNF ABN as required.
Failure to Complete Required MDS Assessments
Penalty
Summary
The facility failed to complete required quarterly assessments for two residents and a significant change Minimum Data Set (MDS) for one resident. Resident #5 did not have any MDS assessments completed after a quarterly MDS on January 9, 2024. The facility's administrator acknowledged that the MDS coordinator had left the position and that no one was monitoring the completion of MDS assessments. The Director of Nursing (DON) was unaware of any incomplete MDS assessments and had only been in the position for a week. Resident #7 was admitted to hospice services on June 21, 2023, but there was no documentation of a significant change MDS being completed after this admission. The resident's records showed multiple entries indicating hospice care, yet the quarterly MDS dated after the hospice admission did not reflect this status. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the DON, revealed a lack of awareness regarding the responsibility and frequency of MDS updates, as well as the absence of a current MDS coordinator.
Inaccurate Documentation of Resident Falls on MDS
Penalty
Summary
The facility failed to ensure that resident falls were accurately reflected on the Minimum Data Set (MDS) for one resident. The resident, who was admitted with diagnoses including muscle wasting and vascular dementia, experienced multiple falls that were not accurately documented in the MDS. On one occasion, the resident was found on the floor with a hematoma on the forehead after a fall, which was not recorded as a non-major injury in the MDS. Subsequent falls were also not accurately documented, with the MDS indicating only one fall since the prior assessment and zero non-injury or non-major injury falls. The deficiency was identified during an interview with the Director of Nursing and the Regional Nurse Manager, who acknowledged that the MDS Coordinator position was vacant and that the MDS information should be accurate at the time of submission. The facility's policy requires that the MDS reflect information consistent with progress notes, care plans, and resident observations, which was not adhered to in this case. The lack of accurate documentation of falls in the MDS represents a failure to comply with federally mandated assessment requirements.
Failure to Document and Administer Wound Care as Ordered
Penalty
Summary
The facility failed to adhere to physician's orders for wound care on a surgical wound for a resident with severe cognitive impairment and a right above the knee amputation. The resident's care plan indicated a healing surgical wound, and the physician's orders required daily treatment of the right distal stump with wound cleanser or normal saline, application of skin prep, and leaving it open to air. However, the Treatment Administration Record (TAR) for June and July 2024 showed multiple instances where there was no documentation of the treatment being completed, specifically 12 out of 30 opportunities in June and 15 out of 15 opportunities in July. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the charge nurse was responsible for documenting wound care on the TAR. Both the ADON and DON stated that if the wound care was not documented, they would assume it was not completed. The DON also mentioned that if the resident refused wound care, the charge nurse should document the refusal on the TAR. The lack of documentation and adherence to the physician's orders led to the deficiency identified by the surveyors.
Failure to Investigate and Document Resident Fall
Penalty
Summary
The facility failed to conduct a thorough investigation into a resident's fall, which was unwitnessed and reported by the resident after the fact. The resident, who was legally blind and had a right lower leg amputation, reported falling out of bed while reaching for a meal tray. Despite the resident's report of hitting their head and experiencing a headache, the facility did not document any neurological assessments or initiate a fall investigation. The resident's care plan, which identified them as at risk for falls due to their medical conditions, was not updated with new interventions following the reported fall. The facility's policy required a detailed investigation and documentation of any accidents or incidents, including unwitnessed falls, but this was not adhered to in this case. The resident was sent to the hospital after complaining of a headache, but no further actions were documented by the facility. Interviews with staff, including a CNA and the ADON, revealed that the facility's protocol for unwitnessed falls, which includes neurological checks and a root cause analysis, was not followed. The DON, who had recently started at the facility, confirmed that a complete investigation should have been conducted, including assessments for injuries and updates to the care plan. However, these steps were not taken, resulting in a deficiency in the facility's handling of the resident's fall.
Deficiency in Catheter Care and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper sanitization and hand hygiene during catheter care for a resident with an indwelling catheter. The resident, who was severely cognitively impaired and had a history of urinary tract infection, was observed with sediment and discoloration in the catheter tubing. During a catheter tubing and drainage bag change, a CNA did not cleanse the end of the catheter with an alcohol pad, removed gloves without sanitizing hands, and attached new tubing without proper hand hygiene. The CNA acknowledged the lapse in hand hygiene and the failure to cleanse the catheter drainage port, noting that alcohol wipes were available but not used. Additionally, the facility did not have complete physician's orders for the size of the catheter for the resident. The Director of Nursing confirmed that all residents with indwelling catheters should have a physician order indicating the catheter size and that staff should perform hand hygiene before starting care, with all glove changes, and after finishing care. The deficiency was identified during a survey, highlighting the facility's failure to adhere to its own policies on catheter care and hand hygiene.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, who had experienced a traumatic car accident in 2022, was noted to have chronic symptoms of PTSD. Despite this, the resident's care plan did not address PTSD, nor did it include any information about the resident's triggers or interventions. The resident was on medication for anxiety and depression, but there was no specific mention of PTSD in the physician's orders. Interviews with staff revealed a lack of awareness and understanding of the resident's PTSD diagnosis and associated care needs. The resident expressed uncertainty about their PTSD diagnosis and mentioned feeling anxious around loud sounds and large crowds. Staff members, including a Certified Nurses Aide (CNA) and the Assistant Director of Nursing (ADON), were unaware of the resident's PTSD diagnosis, triggers, or interventions. The ADON and other staff members indicated that the care plan should have included this information, but it was not present. The facility's administration acknowledged the oversight, noting that the MDS Coordinator, who was responsible for care plan development, had recently left the position. The Director of Nursing (DON) and the Administrator both stated that the care plan should have accurately reflected the resident's condition, including PTSD triggers and interventions. The lack of a comprehensive care plan and staff awareness resulted in a failure to provide trauma-informed care for the resident with PTSD.
Failure to Address Medication Irregularities
Penalty
Summary
The facility failed to address medication irregularities identified by the pharmacy consultant during the monthly Drug Regimen Review (DRR) for one resident out of a sample of 12. The consultant pharmacist's review, which is supposed to be conducted monthly, identified medication orders for Resident #29 that lacked a diagnosis or indication for use. Despite the identification of these irregularities, the facility did not follow through with the necessary actions to resolve them, as required by their policy. Resident #29, who was cognitively intact, was using multiple medications, including anticoagulants, diuretics, antiplatelets, hypoglycemics, and others. The resident's care plan indicated a diagnosis of Type II Diabetes Mellitus. However, the July 2024 Physician's Order Sheet (POS) for the resident listed several medications, such as Lantus, Amlodipine, Aspirin, Plavix, and others, without any documented diagnosis or indication for use. This lack of documentation was not addressed by the facility staff or the pharmacy consultant, as expected by the facility's policy. Interviews with facility staff, including a Certified Medication Technician (CMT), the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), revealed a lack of clarity and follow-through regarding the responsibility for ensuring medication orders included a diagnosis or indication for use. The staff believed that the pharmacy consultant was responsible for checking the diagnosis on the POS, and there was an expectation that either the facility nurse or the pharmacy consultant would identify and clarify any medication orders lacking this information. However, this did not occur, leading to the deficiency identified in the report.
Failure to Review and Act on Pharmacy Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the resident's physician reviewed the pharmacist's recommendations for a Gradual Dose Reduction (GDR) of psychotropic medications for two residents. Resident #7, who was severely cognitively impaired and on multiple psychotropic medications, did not have a GDR attempted despite recommendations from the pharmacist. The physician's visit notes repeatedly showed that medications were reviewed and continued without addressing the pharmacy's recommendations for GDR. The facility could not locate any physician responses to these recommendations, indicating a lack of follow-through on the pharmacist's identified irregularities. Additionally, the facility did not address the pharmacy consultant's identification of medication orders without a diagnosis or indication for use for Resident #26. This resident, diagnosed with major depressive disorder, was taking antidepressants without a documented diagnosis or indication for use in the physician's order sheet. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed a lack of clarity on who was responsible for addressing pharmacy recommendations and ensuring that all medication orders included a diagnosis or indication for use. The report highlights a systemic issue within the facility regarding the management and review of psychotropic medication orders. The failure to act on pharmacy recommendations and ensure proper documentation of medication indications suggests a breakdown in communication and oversight among the facility's staff and healthcare providers. This deficiency was observed in the context of a facility with a census of 44 residents, where the Medication Regimen Review (MRR) policy was not effectively implemented.
Failure to Assess and Document Skin Conditions and Medication Errors
Penalty
Summary
The facility failed to adequately assess and document a resident's skin condition upon admission, leading to a series of oversights in care. The resident, who had a history of hemiplegia and chronic kidney disease, was admitted with scabs on the right foot, lower legs, and weeping edema in the left lower leg. However, these conditions were not documented in the nurse's progress notes or the daily skilled nurse's notes. Furthermore, there was no physician's order for treatment of these conditions, and weekly skin assessments were not properly conducted or documented, resulting in a lack of appropriate care and notification to the resident's physician. The facility also failed to follow the emergency room physician's instructions regarding the resident's anticoagulant medication. The resident was supposed to have two doses of Eliquis held due to hematuria, but this was not documented in the physician's orders or the medication administration record. Consequently, the resident received a dose of Eliquis that should have been withheld. This oversight was attributed to a lack of communication and review of hospital paperwork by the nursing staff upon the resident's return from the emergency room. Additionally, the facility's policies and procedures for skin assessments and medication administration were not followed. The previous Director of Nursing had instructed staff to discontinue highlighting weekly skin assessments, leading to a lapse in these assessments being completed. The facility also failed to notify the resident's physician of changes in the resident's condition, such as the development of necrotic toes and the need for emergency medical evaluation. These deficiencies in care and communication contributed to the resident's deteriorating condition, ultimately resulting in severe medical interventions, including amputations.
Deficiency in Pressure Ulcer Care and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for a resident, leading to a deficiency in care. The resident, who had a history of partial paralysis and other risk factors, was admitted without any skin breakdown. However, upon returning from a hospital visit, the resident was noted to have wounds on the coccyx area. The facility's policy required weekly assessments and documentation of pressure ulcers, but there was no further licensed nurse assessment of the resident's sacral wound after the initial observation. Additionally, the facility did not adhere to its hand hygiene policy during wound treatment. An LPN was observed removing a dressing and cleansing a slough-covered pressure ulcer without washing or sanitizing hands between glove changes and before applying Santyl to the wound. The LPN admitted to possibly not following hand hygiene protocols during the treatment, which was against the facility's policy that required hand hygiene before and after treatments, and between different wound care tasks. The facility's DON acknowledged that the wound nurse had not been performing their duties, including weekly documentation of resident wounds, leading to the termination of the wound nurse's employment. The new ADON was tasked with ensuring that weekly wound documentation was completed. Despite these administrative changes, the deficiency in pressure ulcer care and hand hygiene practices was evident during the surveyor's observation.
Improper Catheter Care and Hand Hygiene Deficiency
Penalty
Summary
The facility failed to provide correct catheter care for a resident, leading to a deficiency. The resident, who had mild cognitive impairment and occasional urinary and bowel incontinence, was at high risk for pressure ulcers and had a urinary catheter placed for wound healing. During an observation, a CNA did not wash or sanitize their hands before applying barrier cream and cleansing the resident's penis. The CNA also failed to retract the foreskin before cleansing the head of the penis and did not cleanse the catheter the required four inches from the insertion site. Interviews with the CNA, an LPN, and the Director of Nursing confirmed the improper catheter care. The CNA admitted to not following proper hand hygiene and catheter care procedures, such as retracting the foreskin and cleansing the catheter adequately. The LPN, who was present during the care, noticed these deficiencies and discussed them with the CNA. The Director of Nursing stated expectations for proper hand hygiene and catheter care, which were not met during the observed incident.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that side rails were not used unless a resident's assessment indicated they were safe. This deficiency was observed in the case of a resident who was admitted to the facility and was receiving hospice care. The resident had limited mobility and required assistance with activities of daily living. Despite this, side rails were installed on the resident's bed without an assessment, physician's order, or informed consent. The side rails were added when the hospice company switched out the resident's bed, and the facility staff, including the CNA and LPN, were unaware of the change until it was observed during a survey. The facility did not have a side rail policy available upon request, and the licensed nurses, who were in the resident's room daily, failed to report the presence of side rails to the facility administrator. The administrator and the DON acknowledged that the side rails were not part of the facility's standard practice and should not have been installed without proper assessment and consent. The deficiency was identified when the resident was found with side rails that extended from the head to halfway to the foot of the bed, despite the resident's inability to use them for positioning or turning.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
