Mccrite Plaza At Briarcliff Skilled Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Missouri.
- Location
- 1301 Tullison Rd, Kansas City, Missouri 64116
- CMS Provider Number
- 265869
- Inspections on file
- 20
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Mccrite Plaza At Briarcliff Skilled Facility during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and no history of diabetes was mistakenly identified as another resident and received a finger-stick blood glucose check and 20 units of long-acting insulin from an LPN after two CNAs incorrectly confirmed the resident’s identity. The resident, who had care plans for immobility and fall risk but no diabetes-related interventions, was in the wrong bed, there were no ID armbands or consistent door name identifiers, and EMR photos were not governed by a policy for updating. The resident’s blood sugar dropped, leading to hospital admission with hypoglycemia and acute metabolic encephalopathy attributed to accidental insulin administration.
A resident with severe cognitive impairment, non‑ambulatory status, and multiple comorbidities who required maximum assistance for sit‑to‑stand was transferred manually with a gait belt instead of with a mechanical lift as required by facility policy. Two CNAs looped their arms through the resident’s arms and lifted and pivoted the resident without ensuring the resident’s feet were on the floor, during which one CNA stumbled, kicked the wheelchair backward, and set the resident on the bed with excessive force, causing the resident to moan. The resident’s care plan lacked specific transfer instructions, one CNA was unaware a mechanical lift was present in the room or who updated transfer status, and leadership interviews confirmed that residents unable to bear weight should be transferred with a mechanical lift and that staff should not lift residents by the arms.
Staff failed to follow policy for signing in and securing a controlled substance after pharmacy delivery, resulting in the loss of oxycodone intended for a resident with multiple medical conditions and moderate cognitive impairment. The medication was not found despite searches and review of delivery records, and the required documentation and security procedures were not followed.
A resident with a documented DNR order experienced a medical emergency during therapy and became unresponsive. Despite the DNR status being available in the electronic medical record and a DNR book, staff initiated CPR after failing to find the appropriate visual indicator on the resident's door. CPR continued until EMS arrived and pronounced the resident deceased. Interviews confirmed that staff should have checked the DNR documentation and honored the resident's wishes.
The facility failed to follow professional standards for food service safety, with staff neglecting to date and label food products and leftovers, and not discarding expired items. Additionally, daily temperature logs for refrigerators, freezers, and dishwashers were not maintained. These deficiencies were observed in various storage and kitchen areas, posing a risk of foodborne illnesses to residents.
The facility failed to ensure proper authorization for DPOA to sign OHDNR forms for two residents with cognitive impairments, as incapacitation letters were missing. Additionally, a resident's code status was inconsistently documented as both Full Code and DNR. Staff interviews confirmed the expectation for consistent documentation, which was not met.
The facility failed to maintain a clean and homelike environment, with observations of unclean areas, holes in carpets, and stained furniture. Staffing challenges, including a vacant floor technician position, contributed to these deficiencies. The Administrator expected a clean environment, but understaffing and communication issues led to the observed problems.
The facility failed to complete criminal background checks for five employees before their start date, contrary to its policy to prevent abuse and neglect. The DON and Administrator confirmed that HR is responsible for these checks, but the deficiency was noted as the checks were not completed in time.
The facility failed to recognize and report significant weight changes in four residents, as required by their policy. Despite visible calculations of weight changes in the electronic medical record, there was no documentation of notification to the primary care providers or the Registered Dietician Nutritionist (RDN). Interviews with staff revealed a lack of awareness of residents with weight concerns and uncertainty about scale calibration procedures.
The facility failed to provide complete perineal care to residents with severe cognitive impairments and dependencies on staff for personal hygiene. Observations showed that staff did not adequately clean all areas that urine or feces had touched, particularly failing to spread the skin and clean all skin folds. This deficiency affected four residents, each with conditions such as Alzheimer's disease and Parkinson's disease. Interviews confirmed that staff were aware of proper procedures but did not follow them during care.
The facility failed to ensure proper transfer techniques for residents, leading to deficiencies in care. A resident was left swinging in a mechanical lift without stabilization, while another had incorrect brake usage during a sit-to-stand lift. Additionally, staff used improper gait belt techniques, and a resident was improperly positioned in a sling during a transfer.
The facility failed to maintain and document the maintenance of oxygen equipment for three residents, leading to deficiencies in respiratory care. A resident with chronic lung disease used an oxygen concentrator with outdated tubing and a water canister. Another resident had an oxygen concentrator with filters covered in lint, and staff were unaware of maintenance protocols. A third resident's oxygen concentrator and filters were caked in dust, with no documentation of maintenance. Staff interviews revealed a lack of knowledge and training regarding equipment maintenance.
The facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate. Two residents received eye drop medications incorrectly, with the dropper touching their eyes and insufficient lacrimal pressure applied. Staff acknowledged the errors, confirming that the dropper should not touch the eye and pressure should be applied for the correct duration.
The facility failed to properly store and supervise medications for three residents. A resident with cognitive impairment was observed taking medication unsupervised, while two other residents had unsecured medications in their rooms, including a decongestant spray and wound cleansers. Staff interviews confirmed these practices were against facility policy, and the issues were acknowledged by the DON and Administrator.
The facility failed to ensure that call lights were accessible to residents, as observed in two resident rooms and three common area bathrooms where pull cords were wrapped around handrails, making them inoperable. Interviews with the DON and Administrator confirmed that call lights should be within reach, but the facility's system for checking call light functionality was ineffective in preventing this issue.
A resident with severe cognitive impairment and mobility issues was not repositioned as per physician's orders, remaining in a wheelchair for extended periods. Despite staff expectations to reposition every two hours, the resident was left in the wheelchair, increasing the risk of pressure ulcers. Observations and interviews confirmed the facility's failure to adhere to care protocols.
Insulin Administered to Non-Diabetic Resident Due to Misidentification
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error when insulin was administered to a resident who was not diabetic. The resident had severe cognitive impairment, was non-ambulatory, and required maximum assistance with mobility, with documented diagnoses including non-Alzheimer’s dementia, traumatic brain injury, and heart disease. The resident’s care plan addressed risks such as pressure ulcer development and falls but contained no interventions related to diabetes management or care. On the evening of the incident, an LPN assisted a CNA in putting the resident to bed. The CNA was told by another CNA that the resident being assisted was a different resident, and that CNA went into the room and confirmed the incorrect identity. Relying on this information, the LPN performed a finger-stick blood glucose test, obtained a reading of 142, and administered 20 units of Insulin Glargine, a long-acting insulin, under the assumption that the resident was the diabetic resident. After the insulin was given, the LPN sought further verification with a certified medication technician and discovered that the residents had been placed in the wrong beds, and insulin had been administered to the wrong resident. The resident who received the insulin was not diabetic and subsequently experienced a drop in blood sugar, was transferred to the hospital, and was diagnosed with hypoglycemia and acute metabolic encephalopathy due to accidental insulin administration. Interviews revealed that the LPN had attempted to confirm the resident’s identity with two CNAs and the resident, but the resident was unable to self-identify, and the CNAs had incorrectly identified the resident. The LPN also used a CNA’s tablet to compare the resident’s picture in the EMR, in a setting where residents did not wear identifying armbands, there were no names on doors unless chosen by residents, and there was no policy on how often or by whom resident photos in the EMR should be updated.
Improper Manual Transfer Performed Instead of Required Mechanical Lift
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer for a resident who required a mechanical lift, resulting in staff using an improper manual transfer with a gait belt. The facility’s Safe Lift, Transfer and Repositioning Policy and Mechanical Lift Transfer Policy required that residents who are unable to bear weight, or who are totally dependent or require extensive assistance, be transferred with a mechanical lift and full body sling. The resident’s care plan identified risks related to immobility, including potential for pressure ulcer development and high fall risk due to deconditioning and gait/balance problems, but did not include documented interventions specifying how the resident was to be transferred. The MDS showed the resident had severe cognitive impairment, was non‑ambulatory, and required maximum assistance with sit‑to‑stand, and received scheduled pain medication, with diagnoses including non‑Alzheimer’s dementia, traumatic brain injury, and heart disease. During an observed transfer, two CNAs transferred the resident using a gait belt rather than a mechanical lift. CNA D applied the gait belt by sliding it down the back of the resident’s head and along the spine. CNA C looped an arm through the resident’s right arm and grasped the gait belt behind the resident’s back, while CNA D looped an arm through the resident’s left arm and also grasped the gait belt at the back. Without first asking the resident to scoot forward or ensuring the resident’s feet were on the floor, CNA D counted to three and both CNAs lifted and pivoted the resident onto the edge of the bed. During this maneuver, CNA D stumbled and kicked the wheelchair, propelling it backward, and then set the resident on the bed with excessive force, during which the resident moaned. Interviews revealed that CNA D believed the resident was a one‑person transfer but chose to use two staff for safety, was unaware that a mechanical lift was already in the resident’s room, and did not know who updated residents’ transfer statuses. CNA D stated that if a resident can bear weight, their feet should touch the ground during transfer. The DON stated that transfer statuses are documented in the EMR and updated by the interdisciplinary team, that residents unable to bear weight should be transferred with a mechanical lift, that during a stand‑pivot transfer the resident’s feet should remain on the ground, and that staff should not loop their arms into residents’ arms or lift at armpit level. The Administrator stated that residents listed as two‑person transfers should be able to bear weight with feet on the ground, that residents totally dependent on staff for lifting should be transferred with a mechanical lift, and that transfer and mobility status changes should be updated in the care plan so staff know what type of transfer is needed.
Failure to Secure and Account for Controlled Substance Results in Missing Medication
Penalty
Summary
Facility staff failed to secure a controlled substance, specifically oxycodone, for a resident with multiple medical conditions including a right femur fracture, osteoporosis, major depressive disorder, pain, reduced mobility, falls, obesity, and anemia. The resident had moderately impaired cognition and was receiving both scheduled and as-needed pain medication. On the afternoon following a pharmacy delivery, a nurse attempted to administer an as-needed dose of oxycodone but discovered the medication was missing from the medication cart and safe. Investigation revealed that the pharmacy had delivered a card of 18 oxycodone 5mg tablets, which was signed for by an LPN. The facility's policies required that controlled substances be properly signed in, counted, and secured in a locked compartment immediately upon receipt. However, the medication and its count sheet were not found during searches of all medication carts and lock boxes. The nurse who signed for the medication was unable to account for its whereabouts, and the missing medication was not recovered despite a review of camera footage and interviews with staff present at the time of delivery. The incident was reported to the pharmacy, facility administration, and the resident's physician. The facility's investigation confirmed that the required procedures for signing in and securing the controlled substance were not followed, resulting in the loss of the medication. The resident's pain management was temporarily affected until replacement medication was provided.
Failure to Honor Resident's DNR Order Resulting in Unwanted CPR
Penalty
Summary
Facility staff failed to honor a resident's Do Not Resuscitate (DNR) order when the resident became unresponsive during a therapy session. Despite the resident having a clearly documented DNR status in both the electronic medical record and a DNR book at the nurses station, staff initiated Cardiopulmonary Resuscitation (CPR) after the resident slumped over and became nonresponsive. The charge nurse checked the back of the resident's door for a butterfly or heart symbol, which were used to indicate DNR or full code status, but found no indicator and proceeded with CPR. The Director of Nursing arrived with the DNR paperwork, but CPR continued until Emergency Medical Services arrived and pronounced the resident deceased. Interviews with staff revealed that DNR status was accessible in multiple locations, including the electronic medical record and a designated book, and that visual indicators were intended to be placed on resident doors. However, the absence of the visual indicator led to the initiation of CPR, contrary to the resident's documented wishes. The nurse practitioner and Director of Nursing both confirmed that staff should have followed the resident's DNR order and not performed CPR.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as evidenced by multiple observations of improper food storage and labeling practices. Staff did not date the receipt of incoming products in the dry storeroom, nor did they label and date used products in the freezer and refrigerator. Additionally, leftovers in the refrigerator were not labeled or dated, and expired leftovers were not discarded. The facility also failed to monitor refrigerator, freezer, and dishwasher temperatures on a daily basis, which is a critical component of food safety management. These lapses were observed in various areas, including the dry kitchen storage room, the main kitchen dry storeroom, and the main prep area kitchen. Interviews with staff revealed a lack of adherence to the facility's policies regarding food storage and labeling. Staff members acknowledged the requirement to date opened products and discard items not used within a specified timeframe, yet these practices were not consistently followed. The Registered Dietician and the Administrator both expressed expectations for proper labeling and daily maintenance of temperature logs, which were not met. The failure to follow these procedures placed all residents at risk for foodborne illnesses, given the potential for contamination and spoilage of improperly stored food items.
Inconsistent Advance Directive Documentation and DPOA Authorization
Penalty
Summary
The facility failed to ensure that an invoked Durable Power of Attorney (DPOA) was in place before allowing designated agents to sign Outside of Hospital Do Not Resuscitate (OHDNR) forms for two residents. Resident #22, who had significant cognitive impairments and was dependent on staff for daily activities, had an OHDNR form signed by their spouse without an incapacitation letter in the medical record. The Social Services Director (SSD) was unable to locate the incapacitation letter, which is necessary to validate the DPOA's authority to make such decisions. Similarly, Resident #18, who also had severe cognitive impairments and was dependent on staff, had an OHDNR form signed by their husband without any DPOA paperwork or incapacitation letter found in the medical record. The SSD acknowledged the absence of these critical documents, which should have been obtained at admission and placed in the resident's chart to ensure proper authorization for the DPOA to act on the resident's behalf. Additionally, the facility failed to ensure that Resident #295's code status was consistent across their medical records. Although the resident was cognitively intact and had signed a DNR form, discrepancies were found in the documentation, with the resident's code status listed as both Full Code and DNR in different parts of their medical record. Interviews with staff, including LPNs and the Director of Nursing (DON), revealed that the code status should be consistent throughout the resident's chart, but this was not the case for Resident #295.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment, as evidenced by multiple observations of unclean and poorly maintained areas. Surveyors noted several deficiencies, including holes in the carpet, stained furniture, and unclean food and medication carts. Additionally, there were areas with scraped and missing paint, stained ceiling tiles, and dirty windows. These observations were made in various parts of the facility, including the dining room, east hall, and rehab hallway. Interviews with facility staff revealed that the housekeeping department was understaffed, with only four staff members responsible for the entire building. The floor technician position had been vacant for approximately a week, leading to overlooked vacuuming and floor maintenance. The Housekeeping Supervisor indicated that maintenance was responsible for fixing and repairing walls, while the floor technician was responsible for vacuuming and maintaining floors, windows, and furniture. Due to the vacancy, housekeeping staff had to assist with floor technician duties after completing their primary responsibilities. The Maintenance Technician confirmed awareness of the carpet holes and repair needs in the dining room, with plans to replace the carpet in main areas. The Administrator expressed expectations for a safe, clean, and homelike environment, including clean and sanitized food carts, debris-free floors, and maintained walls and furniture. Despite these expectations, the facility's current staffing challenges and communication issues contributed to the observed deficiencies.
Failure to Complete Timely Background Checks for New Employees
Penalty
Summary
The facility failed to complete criminal background checks for five out of ten sampled employees before their employment start date, which is a requirement to prevent abuse, neglect, and exploitation. The facility's policy mandates that all potential employees undergo a criminal background check and other screenings before they begin working with residents. However, the review of new hire employee packets revealed that five employees had started their employment before the facility received their criminal background check results. This includes a maintenance employee, a cook, a CNA, a housekeeper, and an activity assistant. Interviews with the Director of Nursing (DON) and the Administrator confirmed that an employee's hire date is considered their first day of orientation, and that the Human Resources department is responsible for ensuring all new employees have completed the necessary background checks. Despite these procedures, the facility did not adhere to its policy, resulting in the deficiency noted by the surveyors.
Failure to Monitor and Report Significant Weight Changes
Penalty
Summary
The facility failed to provide services that met professional standards of quality by not recognizing and reporting significant weight changes in four residents. The facility's policy required immediate notification of significant weight loss to the physician, resident, and/or legal representative, and a referral to the Registered Dietician Nutritionist (RDN) for recommendations. However, there was no documentation of such notifications or referrals for the affected residents, despite visible calculations of weight changes in the electronic medical record. Resident #28 experienced a significant weight loss of 35.5 lbs., or 20.5% over 35 days, without any documented notification to the primary care provider or the RDN. Similarly, Resident #295 lost 11.8 lbs., or 6.2% in five days, yet there was no documentation of notification to the primary care provider or the RDN. Resident #244 had weight fluctuations, losing 6.9 lbs. in seven days and then gaining 6.2 lbs. in five days, but again, there was no documentation of notification to the primary care provider or the RDN. Resident #294 lost 11.2 lbs., or 5.29% in four days, with no documentation of notification to the primary care provider or the RDN. Interviews with staff revealed a lack of awareness of residents with weight concerns and uncertainty about scale calibration procedures. The facility's policies and procedures for monitoring and reporting weight changes were not followed, leading to the deficiency.
Inadequate Perineal Care for Dependent Residents
Penalty
Summary
The facility failed to provide complete perineal care to residents who were unable to perform activities of daily living (ADLs) independently. Observations revealed that staff did not adequately clean all areas that urine or feces had touched, particularly failing to spread the skin and clean all skin folds. This deficiency affected four residents, each with severe cognitive impairments and dependencies on staff for personal hygiene due to conditions such as Alzheimer's disease, aphasia, and Parkinson's disease. For Resident #18, staff did not spread the skin and clean all areas during perineal care, despite the resident being frequently incontinent of bowel and bladder. Similarly, Resident #27, who required substantial assistance and was always incontinent, did not receive complete perineal care as staff failed to spread the skin and clean all necessary areas. Interviews with the staff involved confirmed that they were aware of the proper procedures but did not follow them during the observed care. Resident #22, who had a urinary catheter and was always incontinent of bowel, also did not receive proper catheter and perineal care. Staff failed to anchor the catheter tubing correctly, did not clean the port of the drainage bag, and did not separate and clean all skin folds. Additionally, Resident #14, who required extensive assistance with ADLs, did not receive thorough perineal care as staff failed to clean the skin folds and did not maintain proper hand hygiene during the process. Interviews with the Director of Nursing and the Administrator confirmed the expectations for staff to follow proper procedures, which were not met in these instances.
Improper Transfer Techniques in LTC Facility
Penalty
Summary
The facility failed to ensure proper techniques were used during resident transfers, leading to deficiencies in the care provided to four residents. For Resident #18, staff did not follow the manufacturer's guidelines for using a mechanical lift. The resident was left suspended in the lift without stabilization, as one CNA left the room, leaving the resident swinging back and forth. Both CNAs involved acknowledged the need for two staff members to operate the lift, with one stabilizing the resident, which was not adhered to during the incident. Resident #27 experienced a similar issue with the sit-to-stand mechanical lift. The CNA locked only one of the rear brakes instead of leaving them unlocked as per the guidelines, and the RN involved also failed to ensure both brakes were unlocked during the transfer. This improper handling of the lift was acknowledged by both staff members, who admitted to not following the correct procedure. For Resident #28, the staff failed to perform a safe gait belt transfer. Instead of using the gait belt correctly, the staff hooked their arms under the resident's arms, which is against the facility's policy. Both the CNA and CMT involved admitted to the incorrect technique. Additionally, Resident #14 was improperly positioned in the sling during a mechanical lift transfer, with the resident's bottom hanging over the edge and arms dangling, which was recognized by the CNA but not corrected during the transfer.
Failure to Maintain and Document Oxygen Equipment Maintenance
Penalty
Summary
The facility failed to provide proper respiratory care for three residents by not maintaining and documenting the maintenance of oxygen equipment. Resident #244, who has multiple health conditions including chronic lung disease and emphysema, was observed using an oxygen concentrator with tubing and a water canister that had not been changed or dated for over 30 days. The resident reported not seeing any staff clean or change the oxygen equipment, despite using it continuously and experiencing lightheadedness without it. Resident #11, who has severe cognitive impairment and requires substantial assistance, was observed without a nasal cannula and with oxygen concentrator filters covered in gray lint. Staff interviews revealed a lack of knowledge about the presence and maintenance of these filters, indicating a gap in training and protocol adherence. The resident's care plan required oxygen therapy, but there was no corresponding physician order documented. Resident #28, with moderate cognitive impairment and conditions such as Parkinson's disease and pulmonary fibrosis, was observed with an oxygen concentrator and filters caked in dust. Staff interviews showed uncertainty about who was responsible for cleaning the filters, and the Director of Nursing confirmed that there were no logs to document filter changes, which should occur weekly. This lack of documentation and maintenance highlights a systemic issue in the facility's respiratory care practices.
Medication Administration Errors in Eye Drop Application
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate. This deficiency was observed during the administration of eye drops to two residents. In the first instance, a Certified Medication Technician (CMT) administered Refresh Ophthalmic solution to a resident, during which the tip of the eye dropper touched the resident's eyelid and eyelashes. Additionally, the CMT applied lacrimal pressure for only 20 to 25 seconds instead of the required one to two minutes. The CMT acknowledged the error, stating that the dropper should not have touched the resident's eye and that lacrimal pressure should have been applied for a longer duration. In the second instance, another CMT administered Systane Ultra Ophthalmic Solution to a different resident. During this process, the tip of the applicator touched the resident's upper eyelashes, and the CMT failed to apply pressure to the inner corner of the resident's eyes after administering the medication. The CMT admitted that pressure should have been applied for two minutes and that the dropper should not have come into contact with any part of the resident's eye. Interviews with the Director of Nursing and an LPN confirmed the correct procedures for administering eye drops, which were not followed in these cases.
Medication Storage and Supervision Deficiencies
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with accepted professional principles for three residents. For Resident #12, there was no assessment for self-administration of medications, and the resident was observed taking medication unsupervised, with pills left in the room. The resident, who had moderately impaired cognitive skills and required substantial assistance with daily activities, was seen picking pills from a medication cup and taking them without supervision, contrary to facility policy. For Resident #28, medications were not stored securely. A bottle of decongestant nose spray was repeatedly observed on the resident's windowsill, with the room door open, indicating a lack of secure storage. The resident had no cognitive impairment but required extensive assistance with daily activities. Staff interviews revealed that the medication was brought in by the family and was not used by the resident, and it should have been stored in the medication cart. Resident #193 also had unsecured medications, with wound cleansers and protective spray found on the windowsill. The resident had recently returned from a hospital stay with multiple diagnoses, including a fracture and delirium. Staff interviews confirmed that wound cleansers should not be stored at the bedside but rather in a medication cart or a designated storage area. The facility's failure to adhere to its medication storage policies was acknowledged by the Director of Nursing and the Administrator.
Inaccessible Call Lights in Resident and Common Area Bathrooms
Penalty
Summary
The facility failed to ensure that residents had a means of directly contacting caregivers due to bathroom call light pull cords being wrapped around handrails, rendering them inoperable and inaccessible. This issue was observed in the rooms of two residents and in three common area bathrooms. The facility's policies on call lights and accident prevention did not adequately address the operability and accessibility of call lights for residents who might be lying on the floor in need of help. Interviews with the Director of Nursing (DON) and the Administrator revealed that call lights should always be within reach and easily usable by residents. The DON mentioned that the online call light system checks every room approximately every 30 days to ensure functionality. However, the observations indicated that this system was not effective in identifying and correcting the inaccessibility of call lights in certain areas, leading to the deficiency.
Failure to Reposition Resident as Per Physician's Orders
Penalty
Summary
The facility failed to provide quality care and treatment in accordance with professional standards of practice for a resident who was severely cognitively impaired and dependent on a wheelchair. The resident required substantial assistance with mobility and was at risk of developing pressure ulcers. Despite physician's orders to lay the resident down after lunch to offload pressure from the buttocks, staff did not comply with these orders, leaving the resident in a wheelchair for extended periods without repositioning. Observations over several days showed the resident remained in a wheelchair for hours without being laid down or repositioned, contrary to the care plan and physician's orders. Interviews with staff, including CNAs, CMTs, and LPNs, revealed an expectation for residents to be repositioned every two hours, yet this was not adhered to for the resident in question. The resident's representative also noted the presence of a sore on the resident's bottom, indicating a lack of proper care. The Director of Nursing and the facility Administrator both acknowledged the expectation for repositioning every two hours, especially for residents unable to reposition themselves. However, the facility's failure to follow these protocols resulted in the resident remaining in a wheelchair for prolonged periods, increasing the risk of pressure ulcers and compromising the resident's skin integrity.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
