Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maywood Terrace Living Center during CMS and state inspections, most recent first.
A resident on hospice with multiple serious conditions received a significantly incorrect dose of methadone after family-supplied medications, including an opened methadone bottle, were accepted without pharmacy verification and hospice medication reconciliation was declined. Hospice orders specified methadone 10 mg/mL, 0.5 mL via G-tube every eight hours, but the facility’s POS and MAR were entered as methadone 5 mg/5 mL, 5 mL TID. Several LPNs administered methadone by relying either solely on the MAR or solely on the bottle, without comparing the two, and acknowledged not following the 5 rights of medication administration. One LPN administered 5 mL instead of 0.5 mL based on the incorrect MAR entry, despite noticing a discrepancy with the bottle, and did not alert the DON before giving the dose. The DON later confirmed the order had been entered incorrectly and that the resident had received a total of 25 mg instead of the prescribed 5 mg, constituting a significant medication error.
Unsafe medication storage and labeling were observed in the medication carts and storage rooms. An open morphine bottle and an open lorazepam bottle were not properly dated or labeled for a resident receiving hospice care, another resident’s morphine concentrate lacked an open date, and an unlabeled, undated insulin pen was found on a counter with the needle still attached. Surveyors also found expired suppositories and wound dressings, food and drinks stored with meds and supplements in the refrigerator, and dirty refrigerators with ice buildup, spills, residue, dust, and debris.
Kitchen sanitation and food handling deficiencies were identified when surveyors observed dust buildup in the dishwasher vent and on light fixtures, a damaged mitten, no air gap at the ice machine drain, unrefrigerated lemon juice, debris in a utensil container, missing chlorine test strips, damaged cutting boards, an unlit range hood bulb, and a damaged margarine brush handle. The DM stated the lemon juice had been left out for about two weeks, the cutting boards had not been on a regular inspection program, the light bulb had been out for months, and the food processor in the upstairs kitchenette had been washed without dishwashing liquid because that was how it had been done in the past.
The facility failed to follow infection control practices during catheter care, incontinence care, wound care, eye drop administration, and use of shared equipment. Staff were observed using improper glove and hand hygiene technique, handling a dropped glove, placing a catheter bag on a mattress, applying wound treatment with the same gloves used for cleansing, touching resident items during peri-care without hand hygiene, and using a shared BP cuff without sanitizing it before or after use. A resident with an indwelling catheter also had no EBP signage, and PPE carts were not fully stocked.
Hot water temperatures were not maintained within the required 105 F to 120 F range in multiple resident rooms, with readings documented both below 105 F and above 120 F. Surveyors also found no inline temp gauges on the water heaters serving the [NAME] and North Halls, and interviews identified a janitor’s closet with removed faucet handles and open hot and cold lines that allowed crossover and contributed to sporadic water temps. A leaky sink was also observed in the [NAME] Hall shower room.
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.
Unsafe Environment and Torn Transfer Sling: The facility left a restroom floor damaged, allowed heavy dust buildup on fans in several resident rooms and the therapy room, and used a torn sling to transfer a resident who was cognitively intact but dependent on staff for transfers, toileting, and wheelchair mobility. The resident said staff used the torn sling and that he/she had asked for a different one, while a CNA said the sling was taken from the clean utility closet without checking for damage and the DON said CNAs were expected to inspect slings for rips or tears.
Inaccurate MDS, Matrix, and Care Plan Documentation: The facility failed to accurately reflect residents’ care needs on the MDS, Facility Matrix, and care plans. One resident with neurocognitive disorder had documented wandering, agitation, combativeness, and intrusive behaviors before and after admission, but the admission MDS and care plan did not capture those behaviors or the specific interventions staff used. Two other residents had documented respiratory care, diabetes/insulin use, and opioid-related orders on the POS, but those care areas were not accurately reflected on the MDS or in the care plans.
Failure to Post Daily Staffing and Census Information: The facility did not post the daily census or the actual hours worked for RN, LPN, CMT, and CNA staff responsible for resident care, and the posting was not updated daily for resident, family, and visitor viewing. Observations and staffing sheet reviews showed missing census and staffing details across multiple shifts, and the Administrator stated there was no Staffing Coordinator and that staffing sheets should be posted daily and completed fully.
Room tray food temperatures were not maintained at safe, appetizing levels for multiple residents. Pancakes and sausage were observed hot on the steam table, but later on room trays they measured in the 80s F. CMT staff said dietary was not checking tray temperatures on the halls, and the DM said no one had been sent to do so and noted prior complaints about cold food. Two cognitively intact residents reported receiving cold meals several times per week, especially when eating in their rooms.
The facility failed to document required nurse aide and nursing staff training in dementia care, ANE, and behavior management for four of five sampled staff members. Relias records and in-service documentation showed no completed hours for CNA D, CNA J, LPN C, and RN A in the required topics, and one CNA only had a behavior-related course listed without recorded hours. Interviews also showed there had been no nursing staff skills checkoffs in the past year, despite staff and leadership stating training was expected through Relias, in-services, and onboarding.
Resident Not Fully Informed About Xanax Risks and Benefits: A cognitively intact resident with anxiety was ordered Xanax 0.5 mg TID, but the EHR showed no evidence the resident was informed of the medication's risks and benefits. The resident did not recall anyone explaining the medication or obtaining consent, and the care plan lacked goals or interventions for psychotropic use. An LPN and the DON both stated a consent form and care plan should have been in place.
A resident with chronic pain, morbid obesity, bilateral hip OA, anxiety, and reduced mobility was approved for bedrails to support bed mobility and self-transfers, and the care plan stated the resident used bedrails daily. However, repeated observations found no rails installed on the bed, and the resident was unable to reposition independently. The resident said the missing bedrails limited independence and caused distress, while the LPN, PTA, DON, and Maintenance Director all acknowledged the resident would benefit from bedrails and that the installation process had not been completed.
Failure to submit TPL forms after resident deaths. Two residents died with resident trust account balances of $20.15 and $0.00, but the BOM stated the required TPL paperwork was not sent to MO HealthNet within the required timeframe. The BOM attributed the missed submissions to facility changes and items being dropped.
Inaccurate blood pressure readings were obtained when a CMT used a wrist cuff with a resident’s arm left below heart level during medication pass. Two residents with hypertension-related diagnoses were affected; in one case, the CMT held metoprolol based on a low reading without rechecking it. The CMT and DON both stated the wrist cuff should be held at heart level for best accuracy.
A resident with an indwelling urinary catheter had the drainage bag placed on the lap during a transfer, then at bed level and later on the floor during incontinence care, and the tubing was not cleaned. Another resident with a suprapubic catheter had tubing dragging on the ground and being rolled over by the wheelchair, while the catheter was not addressed in the care plan and EBP signage was not posted on the door. Staff interviews confirmed the expected catheter positioning and EBP requirements were not followed.
A resident with COPD and other significant conditions had oxygen ordered nightly and PRN nebulizer treatment ordered, but staff did not document weekly tubing changes and respiratory supplies were found improperly stored in the room. The NC tubing was dated months earlier, was connected to oxygen cylinders or draped over them instead of being bagged, and a nebulizer mask and tubing were also hanging on the oxygen tank. Staff stated the tubing should be dated, changed weekly, and stored in a labeled plastic bag, but the DON was unaware the resident still had the tubing and oxygen cylinder in the room.
Incomplete Dialysis Communication and Missing Dialysis Contract: A resident with CKD and CHF required hemodialysis, but the facility did not secure a signed dialysis contract and repeatedly failed to ensure dialysis communication forms were completed by both dialysis and nursing staff. Records showed multiple missing or blank sections on the forms, and after one dialysis visit the resident returned with nausea/vomiting and a bleeding, hot left arm fistula/shunt that required EMS and hospital transfer. The resident also reported that nursing had not yet checked the chest catheter port or shunt after returning from dialysis.
A resident with dementia, cognitive communication deficit, delusions, amnesia, hallucinations, and major depressive disorder did not have dementia addressed in the care plan. The MDS showed moderate cognitive impairment, social isolation, ADL assistance needs, depression, and routine antipsychotic and antidepressant use, while the care plan only included ADL deficits and impaired thought processes related to dementia. The DON said the care plan was not person centered or complete, and the MDS Coordinator said the resident should have been care planned for dementia.
Improper Use of Insulin Pen During Administration: A resident with Type II DM and an order for Basaglar KwikPen insulin received the dose in an unsafe manner when the DON accessed the prefilled pen with a syringe, injected air into the pen, and drew up insulin into a syringe instead of using the pen with the correct needle. The DON said the facility did not have the proper pen needles and was unaware of the facility policy; the pharmacist stated the order required use of the pen with a needle cap and that injecting air into the pen was not best practice.
A resident who required pureed food was served sausage that was not smooth and contained many bits of meat. The Dietary Manager prepared the sausage without an open recipe book, added an unmeasured amount of gravy, and processed it for only 30 to 40 seconds. The R.D. said information had been left about replacing the food processor, the recipe format may have changed, and training had not occurred because the DM was not present.
A resident was served pork sausage despite a documented preference for no pork of any kind. The resident stated pork was against his/her religion, and the meal ticket reflected the restriction. The DM said there was no substitute meat available for the two residents who did not eat pork, while the resident’s relative said staff were told about the religious preference at the care plan meeting attended by the Administrator, DM, and DON.
Hospice services were not consistently documented or communicated for a resident receiving palliative care. The resident had dementia, failure to thrive, malnutrition, pain, anxiety, and other chronic conditions, and was receiving Hospice for symptom management. Hospice records lacked updated nursing, bath aide, and interdisciplinary documentation, while facility staff reported they often had to contact Hospice about pain meds and that bathing was frequently provided by facility aides instead of the Hospice bath aide.
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.
Significant Methadone Dosing Error Due to Incorrect Order Entry and Failure to Follow 5 Rights
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when methadone was ordered, entered, verified, and administered incorrectly. The resident, who was non-verbal, on hospice care, and had multiple serious diagnoses including epilepsy, PURA syndrome, pneumonitis, sepsis, dysphagia, and gastrostomy status, was admitted with hospice orders for Methadone 10 mg/mL concentrate, 0.5 mL (5 mg) via G-tube every eight hours as needed for pain. Hospice documentation showed this order and indicated the methadone had been last filled shortly before admission. However, the facility’s Physician’s Order Sheet and MAR were entered as Methadone HCL oral solution 5 mg/5 mL, with instructions to give 5 mL three times a day for pain, which did not match the hospice order or the concentration on the bottle brought from home. The resident’s medications were supplied by family from home, including an opened bottle of methadone, contrary to the facility’s policy that discouraged use of medications brought in from outside and required verification of contents and labeling by the DON, attending physician, and consultant pharmacist. The DON stated the medications from home were supplied by a family member who was also an LPN at the facility, and that the facility pharmacy did not verify these medications. The hospice Medical Director and facility pharmacist both indicated that hospice medications were normally verified by hospice pharmacy and that opened bottles from home would not typically be accepted by a facility because contents could not be verified. Hospice RN A reported that when they attempted to perform medication reconciliation at the facility, staff declined, stating the medications had already been verified and entered into the computer system. Multiple nurses failed to follow the facility’s policies and the five rights of medication administration by not comparing the MAR orders to the methadone bottle label. LPN A, on the first day working with the resident, administered 5 mL of methadone instead of the intended 0.5 mL, relying solely on the MAR entry and not checking the bottle against the order, despite noticing a discrepancy between the computer screen and the bottle. LPN B reported administering methadone doses by following the directions on the bottle but did not compare them to the computer order and also signed off a dose that another nurse actually gave. LPN C stated they administered the dose on the bottle without looking at the MAR and acknowledged not following the five rights. The DON confirmed that the methadone order had been entered incorrectly into the MAR as 5 mL instead of 0.5 mL and that the error was only discovered when LPN A requested assistance documenting a spilled dose in the narcotic tracking system, revealing that the resident had received a total of 25 mg instead of the prescribed 5 mg. On the day of the significant medication error, LPN A prepared and administered the methadone dose via the resident’s feeding tube according to the incorrect MAR order of 5 mL three times a day. After spilling the initial dose, LPN A obtained and administered a replacement dose and later approached the DON to help document the waste in the electronic narcotic tracking system. During this process, they discovered that the system indicated a 0.5 mL dose, not the 5.0 mL that had been given. The DON reported that the nurse had not performed required safety checks, had not alerted the DON before administration despite noticing a discrepancy, and that the resident had been sleeping with respirations of 14–16 per minute when assessed later that day. The hospice Medical Director confirmed that the correct dose was 0.5 mL of a 10 mg/mL solution and that 5.0 mL equaled 50 mg, far exceeding the intended dose. These combined failures in order transcription, medication reconciliation, pharmacy verification, and adherence to medication administration policies led to the resident receiving a significantly higher dose of methadone than prescribed. The facility’s own policies required that medications be administered in accordance with prescriber orders, that staff verify the five rights of medication administration by checking the label three times against the MAR, and that medications brought in from outside be discouraged and, if used, verified by the DON, attending physician, and consultant pharmacist. Despite these policies, the methadone order from hospice (0.5 mL of a 10 mg/mL concentrate) was not accurately transcribed into the facility’s electronic system, the opened bottle from home was accepted without verification by the facility pharmacy, and multiple nurses administered methadone without reconciling the MAR with the bottle label. Hospice RN A stated that if they had been allowed to complete medication reconciliation, they would have caught the discrepancy between the order and the bottle. The combination of incorrect order entry, failure to reconcile hospice and facility records, acceptance of unverified home medications, and repeated failure by nursing staff to follow the five rights directly led to the significant medication error for this resident.
Unsafe Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure safe storage and labeling of narcotic medications, expired supplies, and refrigerator contents in the medication storage areas. Surveyors observed that one medication cart contained an open morphine bottle for a resident receiving hospice care after a stroke with no date on the bottle or box when opened, and an open lorazepam bottle that was not labeled with the resident’s name or dated. A supplemental resident’s morphine concentrate box also had no date on the box or bottle when opened. The facility’s medication policy stated insulin pens should be labeled with the resident’s name and that the date opened should be recorded on multi-dose containers. In the north unit medication storage room, surveyors observed excessive ice buildup in the refrigerator freezer section, visible debris, dried spills, and residue on the refrigerator interior surfaces, along with food and drink items stored with medications and supplements. The refrigerator contained an opened ice cream dessert cup, a can of soda/energy drink, and resident food, drink, supplements, and medications together. The room also contained 15 expired bisacodyl suppositories, expired wound care bandages, and an unlabeled, undated NovoLog insulin pen with a pen needle still attached on the counter. The room also had visible dust and residue on surfaces and the floor. In the west medication storage room, surveyors observed visible debris, dried spills, residue, and dust on the refrigerator interior surfaces and floor, along with paper and cardboard on the floor. Interviews with nursing and housekeeping staff showed differing understanding of cleaning and defrosting schedules, and the DON stated the medication refrigerators should be cleaned weekly and defrosted as needed. The facility’s maintenance and cleaning log form for refrigerator cleanings was blank, with no entries documented.
Kitchen sanitation and food handling deficiencies
Penalty
Summary
The facility failed to maintain food service equipment and supplies in sanitary condition during kitchen observations and meal preparation. Surveyors observed a buildup of dust inside the vent over the clean side of the dishwasher, dust on light fixtures over the freezer and dishwashing area, one damaged mitten, no air gap between the ice machine drain pipe and the floor drain, unrefrigerated lemon juice, debris at the bottom of the utensil container, and the absence of chlorine test strips to match the sanitizer in use. The observation also identified a pink substance in the ice machine, one yellow cutting board with damage and stains that could not be removed, numerous indentations on the cutting board at the steam table, one light bulb on the range hood that was not illuminated, and a damaged margarine brush handle that could not be cleaned. During interview, the Dietary Manager stated he/she had taken over the position two weeks earlier and reported that the lemon juice had been left out for about two weeks. The DM also stated the dietary department had not started a regular inspection program for the cutting boards, the light bulb had been out for a couple of months, the food processor in the upstairs kitchenette had been washed without dishwashing liquid because that was how it had been done in the past, the dust on the light fixtures had not been noticed, the chlorine test strips had to be ordered, the cutting board at the steam table had had those indentations for about a year, the mitten with holes needed to be thrown out, and the margarine brush handle was very damaged from being melted many times.
Infection Control Failures During Resident Care and Shared Equipment Use
Penalty
Summary
The facility failed to implement infection control practices during catheter care, incontinence care, and wound care for a resident with a stage IV coccyx pressure injury and an indwelling urinary catheter. During observation, CNA staff entered the room without EBP signage posted, did not wear gowns, and one CNA dropped a glove on the floor and then put that glove on before providing catheter and incontinence care. The same gloved hands were used to complete front care, turn the resident, and provide care to the resident’s bottom. The urinary catheter drainage bag was also placed on the mattress at the foot of the bed during care, and staff changed gloves without sanitizing their hands between tasks. During wound care, an LPN cleansed the wound and then, with the same gloved hands, applied collagen particles powder directly into the wound bed and applied the dressing. The facility also failed to ensure appropriate hand hygiene and sanitary practices during incontinence care for another resident who was dependent on staff for ADLs. During observation, a CNA donned gloves without performing hand hygiene, completed perineal care, removed gloves without hand hygiene, touched the resident’s belongings and room items, and returned to resident care without cleaning hands between dirty and clean tasks. On multiple observations, uncovered basins were found lying directly on the bathroom floor in the resident’s bathroom. Staff interviews stated that hand hygiene should occur before and after care and between glove changes, and that basins should not be kept on the floor. The facility further failed to follow infection prevention practices for residents with indwelling devices and for shared equipment. A resident with an indwelling catheter had no EBP signage outside the room, and several PPE carts on the hall were missing gowns, hand sanitizer, and gloves. Shared medical equipment was not sanitized before or after use when a CMT used a shared blood pressure wrist cuff on two residents. During eye drop administration for another resident, a CMT applied pressure to the inner corner of each eye with a gloved finger without using a barrier between the glove and the eye area. The report also states that five of nine sampled employees did not complete TB testing timely upon hire.
Hot Water Temperatures Out of Range and Plumbing Deficiencies
Penalty
Summary
The facility failed to maintain the plumbing system so resident room hot water temperatures stayed within the required range of 105 F to 120 F. Surveyors documented temperatures below 105 F in resident rooms 31, 34, 25, 23, 24, and 19, and temperatures above 120 F in resident room [ROOM NUMBER], 13, 12, 11, 9, 7, and 4. The facility’s weekly temperature log guidelines directed staff to check random rooms per wing, keep resident room water between 105 F and 120 F, and call for service if temperatures remained out of range. Facility records and direct observations showed repeated out-of-range readings. On 2/27/26, 3/2/26, and 3/11/26, documented room temperatures included readings as low as 101.0 F and as high as 119.1 F, with one room at 101.0 F on 3/11/26. During a 3/10/26 observation with the Maintenance Director and Maintenance Person B, multiple resident room temperatures remained below 105 F after water had been flowing for two minutes or more, including 101.9 F, 102.2 F, 101.6 F, 102.7 F, and 90.5 F. The same observation also found multiple temperatures above 120 F, including 123.9 F, 132.2 F, 126.3 F, 125.2 F, 122.7 F, 121.6 F, 121.1 F, and 123.4 F on recheck. Surveyors also observed that the water heaters serving the [NAME] and North Halls did not have inline temperature gauges. At the boiler rooms, the heater serving the [NAME] Hall was set at 120 F and the heater serving the North Hall was set at 115 F. Interviews identified a janitor’s closet issue where both hot and cold water lines were left open and faucet handles had been removed, allowing water to continue flowing and causing cold water crossover into the hot water system on the [NAME] Hall. Staff also reported a leaky sink in the [NAME] Hall shower room and stated that the facility had sporadic water temperatures.
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.
Unsafe Environment and Torn Transfer Sling
Penalty
Summary
The facility failed to maintain the floor in the restroom of a resident room in good repair, with observation showing a 10-inch by 0.5-inch area of floor damage. During interview, the Maintenance Director stated the damage had been present for as long as he/she had worked at the facility. The facility also failed to keep fans free of heavy dust buildup in multiple resident rooms, Resident #10's room, Resident #9's room, and the therapy room. The District Housekeeping Manager stated the fans should be cleaned every 2 weeks. Resident #10, identified by MDS as cognitively intact, said he/she had the fan for a few weeks and housekeeping had not cleaned it. Resident #9, also identified by MDS as cognitively intact, said the last time his/her fan was cleaned was in the summer of 2025. The facility also failed to prevent a torn sling from being used to transfer Resident #3. Resident #3 had diagnoses including COPD, morbid obesity, discogenic back pain, bilateral primary osteoarthritis, and reduced mobility. The annual MDS showed the resident was cognitively intact, dependent on two or more staff for transfers and toileting, unable to walk, and dependent on two or more staff for wheelchair mobility. Observation showed a torn sling in the resident's room, and later the same torn sling was observed under the resident while sitting in a wheelchair in the therapy room. The resident stated staff used that sling to transfer him/her and that he/she had told them a different sling was needed because it was torn. The PTA said the sling needed to be replaced, CNA E said he/she used a sling from the clean utility closet without checking it for damage, and the DON stated CNAs were expected to check for rips or tears and that the handles and loops were in order.
Inaccurate MDS, Matrix, and Care Plan Documentation
Penalty
Summary
The facility failed to accurately assess and document resident care areas on the Facility Matrix for two residents with respiratory care, opioid use, and insulin use needs, and failed to complete an accurate assessment and select behavior as a care plan area for one resident with known behaviors before and after admission. The report states that the facility census was 49 residents and that these issues were identified through observation, interview, and record review. One resident was admitted with neurocognitive disorder, diabetes, high cholesterol, and high blood pressure. Records from the transferring facility documented wandering, anxiety, depression, repeated entry into other residents’ rooms, difficulty with redirection, agitation, screaming, crying, yelling, and resistance to care. The resident also had an elopement evaluation showing a history of attempting to leave the facility, wandering toward exits, and staying near exit doors. Behavior notes after admission continued to show restlessness, agitation, combative behavior when redirected, pushing other residents in wheelchairs, taking belongings, and wandering in and out of rooms. The resident’s care plan included general behavior interventions, but it did not identify the specific behaviors documented before and after admission or the specific interventions used, such as coloring, reading, snacks, a baby doll, and medication. The admission MDS dated 3/4/26 did not show the resident’s documented behavior symptoms or combativeness, despite records and staff interviews showing those behaviors were present. For another resident, the annual MDS did not indicate diabetes, insulin use, or oxygen therapy, and the care plan did not include diabetes or insulin-related interventions. However, the POS showed blood glucose monitoring twice daily, Victoza for diabetes, and oxygen at 3 liters via nasal cannula with exertion for COPD, along with respiratory medications. For a third resident, the admission MDS did not indicate opioid use and did not include oxygen/respiratory care or pain/opioid care plan areas, even though the POS showed head-of-bed elevation for shortness of air, oxygen at 3.5 L/min, respiratory treatments, pain assessments every shift, and oxycodone as needed for pain. Observation also showed this resident receiving a breathing treatment via nebulizer. The MDS Coordinator stated the assessments should be accurate and reflect the resident’s health status, and the DON stated the MDS, matrix, and care plan should reflect the resident’s current status and documented behaviors.
Failure to Post Daily Staffing and Census Information
Penalty
Summary
The facility failed to post the facility census and the actual hours worked for RN, LPN, CMT, and CNA staff directly responsible for resident care per shift, and failed to update the posting daily for residents, family members, and visitors to view. The facility census was 49 residents. Observations on 3/9/26, 3/13/26, and 3/16/26 showed there was no posting that included the facility name, date, census, or the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. Review of the staffing sheets showed missing documentation across multiple days. The 3/9/26 sheet had no census documentation for the day or night shifts. The 3/10/26 observation showed the staffing sheet did not document actual hours worked for RNs for the day or night shift and did not document the census for the night shift. The 3/11/26 and 3/12/26 observations showed no census documentation for the day or night shifts. The 3/13/26 staffing sheet did not document actual hours worked for RNs for the day or night shift and did not document the census for the day or night shifts. During interview on 3/13/26 at 12:24 P.M., the Administrator stated the facility did not currently have a Staffing Coordinator, that he/she often acted in that role, that staffing sheets should be posted daily and filled out completely, and that either he/she or the DON would be responsible for this. The 3/16/26 staffing sheet also had no documentation of the census for the day or night shifts.
Room Tray Food Temperatures Not Maintained
Penalty
Summary
The facility failed to ensure hot foods on room trays for at least 5 residents on the [NAME] Hall were maintained at or above 120 F. On 3/12/26 at 8:16 A.M., pancakes were observed at 152.7 F and sausage patties at 170.6 F on the steam table. At 9:01 A.M., the food cart was loaded with meals for room trays and delivered to the hall, and by 9:17 A.M. pancakes on a room tray that was refused by a resident measured 88.7 F and sausage measured 85.8 F. At 9:24 A.M., pancakes on another refused room tray for Resident #18 measured 86.3 F. During interviews, CMT C said he/she usually worked day shift and had not seen dietary staff come to the halls to check room tray temperatures. The DM said he/she had not sent anyone from dietary to the halls to check room tray temperatures, and stated there had been complaints in the past about cold food on room trays. The DM also said he/she had not been trained on the state regulations when hired. Resident #32, identified by the admission MDS dated 2/27/26 as cognitively intact, said he/she had been served cold food in the past, especially French fries and meat loaf, received cold food at least three times per week, and no longer had access to the microwave. Resident #39, identified by the quarterly MDS as cognitively intact, said lunch meals were often cold when eaten in the room and that cold food was received three or four times a week. The RD said he/she would expect someone from dietary to check room tray temperatures on an interval basis.
Missing Required Nurse Aide Training and Skills Documentation
Penalty
Summary
The facility failed to provide the required 12 hours of nurse aide in-service training for dementia care, Abuse, Neglect and Exploitation (ANE), and behavior management for four of five sampled nursing staff members. Review of Relias training records and in-service documentation showed that CNA D, CNA J, LPN C, and RN A did not have documented completion of the required topics and, in several cases, had 0.0 hours recorded for the required training areas. CNA J had completed one Relias course titled Managing Aggressive Behaviors, but no hours were provided, and there was no documentation showing completion of the required dementia and ANE topics or the number of hours met. Interviews confirmed that staff training was expected to occur through Relias, in-services, onboarding, and skills checkoffs, but the DON stated there had not been any nursing staff skills checkoffs in the past year. CNA H and LPN B reported that training was completed through Relias and in-services, with in-services usually held monthly, but LPN B also stated there had not been a skills fair since working at the facility. The DON and Administrator stated they were responsible for ensuring required training was completed, and the Administrator reported the facility planned to include QAPI Performance Improvement Projects.
Resident Not Fully Informed About Xanax Risks and Benefits
Penalty
Summary
The facility failed to ensure that a resident was fully informed about the risks and benefits of Xanax. Resident #41 was admitted and re-admitted with a diagnosis of anxiety, and the quarterly MDS dated 12/31/25 showed the resident was cognitively intact and taking antipsychotic medication. The physician order summary for March 2026 showed Xanax 0.5 mg by mouth three times daily for anxiety, but the EHR contained no evidence that the resident was informed of the risks and/or benefits of Xanax. The resident stated during interview that he/she knew the medication was for anxiety but did not remember the name of the medicine, did not remember anyone explaining the risks and/or benefits, and did not remember signing a consent before starting it. The resident's care plan did not include a focus, goals, or interventions for antipsychotic or antianxiety medications. An LPN stated the process should include a signed consent form for antipsychotic medication use listing risks and benefits, but the resident did not have a care plan or signed consent form. The DON also stated the resident should have received and signed a consent form for psychotropic medication use with all risks and benefits explained, and that the resident should have had a care plan for psychotropic drug use but did not.
Bedrails Not Installed Despite Order and Resident Need
Penalty
Summary
The facility failed to ensure bedrails were provided and used in accordance with a resident’s needs, physician orders, and care plan for one resident who had been approved for bedrails. The resident was admitted with chronic pain, morbid obesity, bilateral primary osteoarthritis of the hips, anxiety disorder, and reduced mobility. The annual MDS showed the resident was cognitively intact, needed assistance with ADLs, and was dependent on staff for transfers. The bedrail assessment recommended side rails on both sides of the bed as an enabler to promote independence, and the resident expressed a desire to have side rails or an assist bar. The resident’s POS included orders allowing bedrails for assistance with bed positioning and self-mobility, as well as grab bars for self-repositioning. The care plan stated the resident used bedrails daily, included a U rail to aid in bed mobility, and directed staff to ensure valid consent was on chart prior to initiating bedrails. However, observations on two separate dates showed the resident lying in bed with no rails of any kind installed on the bed or on the floor parallel to the bed. During both observations, the resident was unable to change position in bed independently. During interviews, the resident stated that bedrails or an assist bar would help with repositioning, sitting up in bed, and transferring in and out of bed without assistance, and said not having them caused the resident to call for help for these tasks and felt depressing, overwhelming, and helpless. Staff interviews showed the process for obtaining bedrails involved nursing assessment, therapy assessment, physician order, and maintenance installation, but staff were unclear on why the rails had not been installed despite an order dating back to the prior year. The LPN, PTA, DON, and Maintenance Director all acknowledged the resident would benefit from bedrails and that the process had not been completed, with no current work order available for the resident.
Failure to Submit TPL Forms After Resident Deaths
Penalty
Summary
The facility failed to ensure Third Party Liability (TPL) forms were completed and sent to Missouri HealthNet within 30 days of death for two discharged residents. Resident #101 died on 2/1/26 and had $20.15 remaining in the resident trust account, but the Business Office Manager stated during interview on 3/11/26 that a TPL was not submitted on the resident’s behalf and that changes in the facility caused some things to be dropped. Resident #102 died on 1/19/26 and had $0.00 in the resident trust account at the time of death; during interview on 3/11/26, the Business Office Manager stated there had been a lot of changes during the time of the resident’s death.
Inaccurate Blood Pressure Measurement With Wrist Cuff
Penalty
Summary
The facility failed to meet professional standards of practice when staff obtained blood pressure readings with a wrist cuff while the residents’ arms remained in a dependent position below heart level. Resident #41 had diagnoses including hypertensive heart disease with heart failure, essential hypertension, and hypertensive heart and chronic kidney disease with heart failure. During medication pass observation, Certified Medication Technician C applied a wrist blood pressure cuff to the resident’s left arm and obtained a reading without repositioning or supporting the arm at heart level. Resident #48 had diagnoses including hypertensive chronic kidney disease and heart failure and was ordered metoprolol tartrate 25 mg twice daily for hypertension, to be held if systolic blood pressure was less than 110 or pulse was less than 60. During observation, CMT C applied a wrist blood pressure cuff to the resident’s left arm while the arm remained below heart level, did not reposition or support it at heart level, and held the metoprolol based on a reading of 98/86 without rechecking it. In interview, CMT C stated the wrist cuff should be held at the level of the heart for proper use, and the DON stated the wrist blood pressure cuff should be held at heart level for best accuracy.
Catheter Care, Care Planning, and EBP Signage Failures
Penalty
Summary
The facility failed to ensure appropriate catheter care and urinary catheter positioning for a resident with an indwelling urinary catheter. Resident #5 had diagnoses including cerebral palsy, diabetes, dementia, cognitive communication deficit, and urinary retention, and was dependent on staff for all physical needs, including two-person transfers and toileting. The resident’s care plan stated the catheter should be positioned below the bladder and away from the room door, and physician orders included catheter care every shift, irrigation, and scheduled catheter and drainage bag changes. During observation, two CNAs transferred the resident from a wheelchair to bed for incontinence care. One CNA placed the catheter bag on the resident’s lap during the transfer, and the bag was then placed at the foot of the bed at the level of the bladder. While the resident was being cleaned, the catheter bag was later placed in a basin on the floor. The CNA did not clean down the catheter tubing during the incontinence care. In interview, the CNA stated the bag should have remained below the bladder and acknowledged not remembering whether the tubing was cleaned. The LPN and DON both stated the bag should never have been placed on the lap, bed, or floor, and that the tubing should have been cleaned away from the peri-area. The facility also failed to address a suprapubic catheter in the care plan and failed to maintain Enhanced Barrier Precautions signage for another resident. Resident #24 had paraplegia, neurogenic bladder, and a suprapubic urinary catheter. The resident’s care plan did not include the suprapubic catheter, and the admission MDS was not completed on time. During multiple observations, the resident’s catheter tubing was seen dragging on the ground, getting tangled under the wheelchair, and being rolled over by the wheelchair wheels, including while the resident was in the dining room and outside smoking. Staff interviews confirmed the tubing should have been secured under the wheelchair and that EBP signage should have been posted on the door, but the signage was not present.
Improper Storage and Monitoring of Respiratory Equipment
Penalty
Summary
The facility failed to properly store and label respiratory equipment and failed to monitor and change oxygen nasal cannula tubing for one resident with COPD and other significant medical conditions. The resident had diagnoses including acquired absence of both lower legs below the knee, stroke affecting the right side of the body, and COPD with acute exacerbation. The resident’s care plan identified altered respiratory status and difficulty breathing, but it did not include a care plan related to nightly oxygen use or PRN nebulizer treatments. The resident’s physician orders included oxygen at 3 liters per minute via nasal cannula every night, weekly tubing changes with the tubing dated and stored in a bag when not in use, and weekly nebulizer tubing changes with the tubing dated and bagged when not in use. Review of the MAR and TAR for the month showed no documentation that the oxygen tubing or nebulizer tubing had been changed weekly. During observations, the resident’s nasal cannula tubing was found dated 6/26/25, draped over oxygen cylinders or connected to the oxygen cylinders, and not stored in a plastic bag. A nebulizer mask and tubing were also observed hanging on the oxygen cylinder tank, and no respiratory tubing storage bag was found in the room. Staff interviews confirmed the expected practice was to date and store oxygen tubing and nebulizer tubing in a labeled plastic bag when not in use and to change the tubing weekly. A CNA stated nursing staff were responsible for monitoring and changing the tubing, and an LPN stated the resident’s oxygen tubing and nebulizer tubing should have been stored in a plastic bag and that the resident had not been getting nebulizer treatments. The DON stated night shift staff were responsible for weekly changes and that all staff were responsible for monitoring respiratory supplies, but was not aware the resident had tubing dated 6/26/25 in the room or that an oxygen cylinder was present.
Incomplete Dialysis Communication and Missing Dialysis Contract
Penalty
Summary
The facility failed to secure and obtain a signed dialysis contract and failed to ensure dialysis communication forms were completed and reviewed by facility staff and the dialysis clinic for a resident who required hemodialysis. The resident had stage 4 chronic kidney disease and congestive heart failure, with a care plan noting hemodialysis for stage four hypertensive CKD and fluid restriction of 2000 mL daily related to fluid overload secondary to CHF. The resident’s physician orders required dialysis clinic care on Monday, Wednesday, and Friday, completion of the dialysis communication form by facility and dialysis clinic staff, monitoring of the dialysis site for bleeding and signs or symptoms of infection every shift, and pre- and post-dialysis weights and vital signs documented on the form. Review of the resident’s dialysis communication forms showed repeated omissions. Forms dated 2/4/26, 2/6/26, 2/9/26, 2/11/26, 2/13/26, and 2/17/26 were missing the middle section completed by dialysis staff and the final section to be completed and signed by facility nursing staff. The resident’s alert note on 2/20/26 documented that after returning from dialysis the resident reported nausea and vomiting, later screamed and yelled for his/her mother, and was found with a new left arm dialysis fistula/shunt that was hot to touch, shiny, and bleeding; nursing held pressure and called EMS, and the resident was sent to the hospital for evaluation and treatment. Additional review showed the dialysis communication form dated 2/27/26 was also incomplete, and the resident’s March 2026 records showed only one form received between 3/1/26 and 3/12/26, with dialysis not completing the middle portion and facility nursing leaving the final portion blank. Several expected forms were not received at all. During interview, the resident stated that after returning from dialysis on 3/11/26, nursing had not yet checked the upper chest catheter port or left arm shunt and the resident did not have a completed copy of the dialysis communication sheet. The Regional Nurse stated the facility did not have a dialysis policy or current contract at that time, and the DON stated the form was to be completed pre- and post-dialysis by facility staff, but it did not always return completed by dialysis.
Failure to Care Plan Dementia-Related Needs
Penalty
Summary
The facility failed to ensure a resident with a diagnosis of dementia had a personalized care plan to support the resident’s highest level of functioning and psychosocial needs. Resident #41 was admitted with unspecified dementia, cognitive communication deficit, delusional disorders, amnesia, hallucinations, and major depressive disorder. The resident’s quarterly MDS dated 12/31/25 showed moderate cognitive impairment, a diagnosis of dementia, frequent social isolation, need for supervision or touching assistance with bathing, tub/shower transfers, walking, and turning, depression, and routine use of antipsychotic and antidepressant medications. Review of the resident’s undated care plan showed dementia was not addressed. The care plan included an ADL self-care performance deficit and impaired thought processes related to dementia, with interventions to communicate with family/caregivers about the resident’s capabilities and needs and to discuss confusion, disease process, and nursing home placement. During interview, the DON stated a resident with dementia should be care planned for that diagnosis and said the resident’s care plan was not person centered or complete. The MDS Coordinator stated the resident should be care planned for dementia and that he/she was responsible for updating the resident’s care plan.
Improper Use of Insulin Pen During Administration
Penalty
Summary
The facility failed to ensure safe administration and use of a Basaglar insulin KwikPen for a resident with Type II Diabetes Mellitus who was cognitively intact and required insulin. The resident had a physician order for Basaglar KwikPen 30 units subcutaneously in the morning, and the facility’s medication policy stated that insulin pens are for single-resident use only, must be clearly labeled, and should be administered using the correct pen needle. During observation, the DON cleaned the rubber tip of the prefilled insulin pen and accessed the insulin with a syringe needle through the hub instead of using the pen as ordered. The DON then pushed air into the insulin pen and drew up 30 units into an insulin syringe from the Basaglar KwikPen before administering it into the resident’s left arm. The DON stated the facility did not have the correct needle tips for the pen and said he/she had been told at another facility that insulin could be drawn out of a pen with a syringe if no pen needle was available. The DON was not aware of the facility policy related to insulin pen administration. The pharmacist stated the order was to use the insulin pen with a needle pen cap, that staff should ensure the correct needle tips were available, that injecting air into the pen was not best practice, and that future doses could have been affected.
Pureed Sausage Not Prepared to Required Consistency
Penalty
Summary
The facility failed to ensure pureed sausage for one sampled resident was prepared to a smooth consistency and failed to ensure the recipe for pureed sausage included the quantities of liquids or thickeners needed. The report states that the resident was to receive pureed food, defined as food blended, chopped, mashed, or strained until soft and smooth, but the pureed sausage served was not smooth and contained many bits of meat. During observation, the Dietary Manager placed two sausage patties into a food processor without a recipe book open and added an unmeasured amount of gravy before processing the food for about 30 to 40 seconds. A taste test shortly afterward showed the sausage was not smooth. The Dietary Manager stated a new food processor was needed because the current one worked for mechanical soft foods but not pureed foods. The Registered Dietitian stated information had been left for facility personnel about replacing the food processor after a prior visit, that the recipe format may have changed, and that training the Dietary Manager had not occurred because the Dietary Manager was not present on the day of the visit.
Meal Served Contrary to Resident’s Religious Food Preference
Penalty
Summary
The facility failed to serve one sampled resident a meal that was compatible with the resident’s stated food preference of no pork of any kind. Resident #24’s meal ticket dated 3/12/26 indicated a regular diet, regular texture, double portions, and no pork of any kind. During observation on 3/12/26 at 8:58 A.M., the resident was served pork sausage and pancakes. During interview, the resident stated that eating pork was against his/her religion, and the resident’s MDS dated 2/20/26 identified the resident as cognitively intact. The Dietary Manager stated he/she did not have a substitute meat for pork for the two residents who did not eat pork, and later stated the facility’s food supplier had adequate substitutes. The resident’s relative stated the resident did not eat pork, had told staff this at the care planning meeting on 3/3/26, and that the Administrator, DM, and DON were present at that meeting.
Hospice Services Not Documented or Communicated
Penalty
Summary
The facility failed to ensure Hospice care and services were documented in the resident’s Hospice record and communicated to facility staff to support coordination of care for one resident receiving Hospice services. The resident had multiple significant diagnoses, including spinal stenosis, protein calorie malnutrition, pain, dementia, delusional disorder, anxiety, and failure to thrive. The resident’s care plan and Hospice contract showed the resident was on Hospice for palliative care, with Hospice responsible for managing care related to the terminal illness and related conditions and for communicating changes in the plan of care to the facility. Review of the resident’s Hospice record showed that the resident was admitted to Hospice with services including a bath aide twice weekly, nursing twice monthly, chaplain, and social worker as needed. However, the resident’s physician orders, Hospice care plan, and interdisciplinary notes were not updated after July 2025, and the most recent nursing visit note was dated January 2026. The most recent chaplain note was dated 3/11/26. There were no bath aide notes, no documentation showing when the bath aide visited, and no evidence that Hospice staff documented their visits and what occurred during those visits. Facility staff and the resident described ongoing Hospice involvement with pain management and bathing, but the documentation did not reflect consistent services. The resident stated that Hospice was supposed to provide showers twice weekly but usually only came twice monthly, and facility nursing staff often provided the baths instead. Nursing staff reported that they had to contact Hospice when pain medications were running low or when pain control was not adequate, and that Hospice was supposed to manage and order the resident’s pain medications. Interviews with facility leadership confirmed that Hospice nursing and bath aide visits were expected to be documented in the resident’s Hospice binder and that the DON was responsible for ensuring Hospice documentation and coordination of care were occurring.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 689 citations issued within 25 miles in the last 12 months — including the 18 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Independence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rosewood Rehab And Healthcare Center | 1.1 mi | ★★★★★ | 2 | 0 |
| Independence Manor Care Center | 1.4 mi | ★★★★★ | 17 | 0 |
| Carmel Hills Wellness & Rehabilitation | 2.9 mi | ★★★★★ | 1 | 0 |
| Parkview Healthcare | 3.6 mi | ★★★★★ | 6 | 1 |
| Abode Health And Wellness Center | 4.5 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.