Meyer Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Higginsville, Missouri.
- Location
- 1201 West 19th Street, Higginsville, Missouri 64037
- CMS Provider Number
- 265667
- Inspections on file
- 16
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Meyer Care Center during CMS and state inspections, most recent first.
A resident on hospice with multiple comorbidities, high fall risk, total care needs, and significant restlessness rolled from a low bed onto a floor mat during a night shift. An agency LPN and CNA lifted the resident back to bed without using the mechanical lift, did not obtain or document vital signs, did not complete an incident report, and did not notify the physician, hospice, family, or facility leadership, despite acknowledging awareness of these requirements. The next day, staff and hospice observed the resident to be lethargic with an awkwardly positioned, swollen, and painful right arm and wrist, and hospice documented severe non-verbal pain. Record review showed no nursing note for the day of the fall, no documentation of the fall event or immediate assessment, no documented notifications, and no documented investigation or root cause analysis of the possible arm injury after the fall was later acknowledged.
A resident with multiple fractures was billed for transportation services without being informed of the associated costs, as required by the facility's admission agreement. The facility could not produce a signed admission agreement or documentation that the resident or their representative had been notified about transportation fees, resulting in the resident incurring charges without prior knowledge.
The facility failed to provide adequate RN coverage for eight consecutive hours a day during Fiscal Year Quarter Two 2024, affecting all 53 residents. The PBJ data showed 26 days without proper RN coverage, contrary to the facility's policy. Staff interviews and document reviews revealed inconsistencies in RN coverage and recording, with the DON and MDS Coordinator often providing insufficient hours. The Administrator believed the PBJ data was accurate, despite noted discrepancies.
The facility was found to have deficiencies in kitchen cleanliness and food safety, including a buildup of grease on baffle vents, unsealed and unlabeled food packages, and improper cleaning of the food processor. Additionally, milk was stored at an unsafe temperature, and cutting boards were not in a cleanable condition. The Dietary Director was unaware of certain cleaning responsibilities.
The facility failed to submit required staffing data to the PBJ for two quarters, affecting all 53 residents. Confusion among staff about submission responsibilities and restrictions from a previous management company contributed to this deficiency.
The facility failed to follow infection control practices during incontinence care for a resident on Enhanced Barrier Precautions, as CNAs did not wear gowns despite signage. Additionally, an LPN did not perform adequate hand hygiene during medication administration for multiple residents, and the facility failed to timely screen employees for tuberculosis, compromising infection control measures.
A facility failed to monitor long-term antibiotic use for a resident on Macrobid for chronic UTIs. The resident, with cognitive impairments, was incorrectly prescribed Macrobid for candidiasis. The facility's Infection Control Program lacked a system to track long-term antibiotic use, as confirmed by staff interviews. The DON acknowledged the oversight, noting the incorrect diagnosis and lack of monitoring.
The facility failed to ensure CNAs received the required 12 hours of in-service education annually, including training on abuse, neglect, and dementia care. Documentation for five CNAs was unavailable, and the facility did not monitor or document the education received. The facility used Relias for training until bankruptcy issues arose, leading to a lack of access to records and a transition to in-person training. Staff interviews revealed confusion about responsibility for tracking and ensuring training completion, potentially affecting care quality for residents.
The facility did not prepare and deliver quarterly financial statements to the Public Administrator, the guardian for four residents with funds at the facility. The BOM, hired in April 2023, was not trained in this task, and the Administrator was unaware of the training gap, despite expecting the BOM to handle these responsibilities.
The facility did not follow its policies for timely criminal background checks and Nurse Aide Registry verification for new hires, affecting four employees. Delays and omissions were noted in the records of a cook, a CMT, a dietary aide, and a CNA, with the Human Resource Manager citing previous company practices and ongoing audits as contributing factors.
The facility had a medication error rate of 18.52%, exceeding the acceptable limit of 5%. Errors included improper insulin administration by a CMT who failed to prime insulin pens, and an LPN who incorrectly administered nasal spray and omitted medications without proper follow-up. These deficiencies affected the care of several residents.
The facility failed to ensure pureed eggs were palatable and hot foods on room trays were delivered at a safe temperature. Pureed eggs were bland due to improper preparation, and room tray items were not checked for temperature, leading to cold meals. Residents reported frequent issues with cold food, particularly at breakfast.
A resident with multiple health conditions was not invited to their care plan meeting, despite expressing a desire to participate. Facility staff interviews revealed confusion and inconsistency in the process of inviting residents, with the Social Services Designee unaware of the requirement for written invitations.
The facility failed to develop complete baseline care plans for two residents with significant health conditions within 48 hours of admission. One resident's care plan lacked documentation of a cholecystostomy drain and related interventions, while another resident's plan did not include details about a surgical site and necessary monitoring. Staff interviews confirmed the oversight, highlighting deficiencies in providing effective and person-centered care.
A resident with severe cognitive impairment and pressure ulcers had their low air loss (LAL) mattress incorrectly set at 450 pounds, despite their actual weight being around 160 pounds. Staff interviews revealed a lack of awareness regarding the correct settings, and observations showed that nursing staff failed to adjust or document the settings as required. The facility's failure to adhere to physician orders and monitor the mattress settings potentially impacted the resident's wound healing process.
A resident with COPD and heart failure did not have their oxygen supplies stored properly, as the nasal cannula and tubing were left uncovered and not in a plastic bag, contrary to facility protocols. Staff interviews confirmed that oxygen supplies should be stored in labeled and dated bags to prevent contamination, but this was not followed, indicating a lapse in proper respiratory care procedures.
A resident admitted with a hip fracture and requiring pain management did not have a completed Pain Risk Assessment or an adequate Baseline Care Plan. The resident experienced varying pain levels and reported delays in receiving pain medication. Facility staff interviews revealed gaps in the admission process and documentation, contributing to the deficiency in care.
A resident with PTSD did not receive trauma-informed care or have a care plan addressing their condition, despite expressing a desire for therapy. Facility staff, including the DON, LPNs, and ADON, were unaware of the resident's PTSD diagnosis, and the MDS Coordinator failed to update the care plan to include necessary interventions.
A CMT without insulin administration certification administered insulin to two residents without following proper procedures, such as hand hygiene and needle priming. The facility's policies required certification for insulin administration, which the CMT lacked, and the DON was unaware of this deficiency.
The facility failed to ensure physicians documented their responses to pharmacist recommendations during monthly MRRs for two residents. One resident, with dementia and bipolar disorder, had missing physician responses for several months. Another resident, with brain degeneration and anxiety, also lacked physician responses to dose reduction recommendations. The DON expected timely physician responses, which were not documented.
The facility failed to provide routine and emergency dental care for two residents, resulting in a deficiency. One resident experienced a toothache for several days without receiving dental care, while another had not seen a dentist in over a year despite expressing a desire for a check-up. Staff interviews revealed a lack of awareness and understanding of the facility's policy and federal regulations regarding dental services, leading to inadequate care planning and communication.
A facility failed to properly monitor and document hospice care for a resident, resulting in missing hospice care plans and nurse visit summaries. Interviews with staff revealed a lack of coordination and communication regarding hospice documentation, with responsibilities unclear between facility and hospice staff. The DON and Hospice Nurse/Case Manager acknowledged the deficiencies, highlighting a lapse in ensuring the resident's hospice binder was updated with necessary information.
The facility failed to maintain an effective pest control program, as a screen was missing from the louvered vent in the basement boiler room. This allowed dead insects, bird droppings, and dried vegetation to accumulate in the area. The Maintenance Director confirmed the absence of the screen and noted past bird intrusions.
Failure to Document, Report, and Investigate Resident Fall With Possible Arm Injury
Penalty
Summary
The deficiency involves the facility’s failure to complete and document an incident report, make required notifications, and investigate a fall with possible injury for one resident. The resident was a new admission on hospice with multiple diagnoses including kidney disease, depression, anxiety disorder, atrial fibrillation, hypertension, and a history of knee surgery. Assessments documented that the resident was disoriented to person, place, and time, chair bound, dependent on staff for all ADLs, unable to bear weight, and required a full body mechanical lift for transfers. The resident had a high fall risk score, a history of falls prior to admission, and was receiving multiple pain and psychotropic medications. Behavior notes showed that shortly after admission the resident was restless, repeatedly trying to get out of bed and out of a recliner, and required staff to sit in the room to maintain safety. On the night in question, an agency LPN working night shift reported later (via follow-up contact) that the resident rolled out of a low bed onto a floor mat between midnight and 1:00 a.m. The resident was found lying partially on his/her back/side on the mat. The agency LPN stated that a head-to-toe assessment was completed, that no injuries or changes in range of motion were noted, and that the resident did not vocalize or show signs of pain. The LPN and an agency CNA attempted to use the full body mechanical lift but could not get it low enough, and instead physically lifted the resident back into bed. The LPN did not obtain or document vital signs after the fall, did not write a nursing note about the incident, did not complete an incident report, and did not notify the physician, hospice, responsible party, or facility leadership. The LPN acknowledged understanding that an incident report and notifications were required but stated that the unit was very busy and that these tasks were not completed during the shift. The following day, nursing documentation showed that when a day-shift LPN went to assess the resident, the resident appeared lethargic with low oxygen saturations and was noted to have his/her right wrist and hand bent at the wall, grimacing with movement of the arm, and later observed with swelling and bruising of the right wrist and elbow and the arm in an awkward position. Hospice documentation on the same day described the resident as restless and moaning, with the right arm bent at a 90-degree angle, the wrist hanging off the side of the bed, swelling from elbow to fingertips, coolness to touch, and weak pulse, with an estimated pain score of 9 on a non-verbal pain scale. Hospice recorded that facility staff reported the resident had rolled out of bed early that morning and that hospice had not been notified at the time of the fall. Review of the medical record showed no nursing note on the day of the fall, no documentation of the fall event, no incident report, no recorded vital signs or neurological checks related to the fall, and no documented notifications to the physician, hospice, or responsible party. There was also no documented facility investigation or root cause analysis of the injury after the agency LPN later acknowledged that the resident had fallen from bed. Additional interviews and a coroner’s report confirmed that the fall from bed onto the floor mat was not reported to facility administration, the physician, hospice, or the family at the time it occurred, and that there was no contemporaneous documentation in the resident’s record describing the circumstances of the fall or any immediate assessment. The family member stated that the facility never notified him/her of the fall or the apparent arm injury and that he/she learned of the suspected injury from hospice. Hospice staff stated that hospice should have been notified as soon as the resident fell and that they were not informed until the following day when the resident was already exhibiting increased pain and arm deformity. The facility’s fall policy described expectations for assessment and care planning but did not specify who must be notified or how falls should be documented, and the record review confirmed that required documentation and notifications related to this resident’s fall and possible injury were not completed.
Failure to Inform Resident of Transportation Charges at Admission
Penalty
Summary
The facility failed to inform a resident of transportation costs as required in the admission agreement. The resident, who was admitted with multiple fractures and was under a Medicare-covered stay, was billed for transportation services on several occasions. However, neither the resident nor the family member was aware of these charges, and the family member stated they would not have used the facility's transportation if they had known about the cost. A review of the facility's policies and admission documents showed that transportation was listed as an extra charge, and residents or their representatives were supposed to be informed of such charges through the admission agreement and accompanying handbook. Despite this, the facility was unable to locate a signed admission agreement for the resident in question, either in the electronic medical record or the paper chart. Staff interviews revealed uncertainty about the timeframe for completing admission agreements and acknowledged that the process was behind schedule. The Social Services Designee, responsible for completing admission agreements, believed the agreement should have been completed and signed by the resident, but could not account for its absence. The Assistant Director of Nursing recalled discussing transportation fees with the resident but did not document the conversation, and there was no signed acknowledgment that the resident or representative had been educated about the transportation fee. As a result, the resident incurred charges for services without documented prior notification or consent.
Inadequate RN Coverage in Facility
Penalty
Summary
The facility failed to provide sufficient proof of Registered Nurse (RN) coverage for eight consecutive hours a day during the Fiscal Year Quarter Two 2024, as required by regulations. The Payroll Based Journal (PBJ) data revealed that there were 26 days within the quarter where the facility did not have RN coverage, affecting all 53 residents. The facility's policy stated that RN services should be utilized for at least eight consecutive hours per day, seven days a week, and that accurate staffing data should be submitted through the CMS PBJ system. The review of various documents, including Daily Staffing Rosters and Payroll Detail Sheets, showed inconsistencies and lack of RN coverage on specific dates in January, February, and March 2024. For instance, on several days, the MDS Coordinator, who is also an RN, was present in the building for less than the required eight hours, and on other days, there was no RN coverage at all. Interviews with staff, including the Director of Nursing (DON), Certified Nursing Assistant (CNA), Licensed Practical Nurse (LPN), and the MDS Coordinator, confirmed the lack of consistent RN coverage and highlighted issues with recording RN hours, especially for salaried employees like the DON. The Administrator believed the PBJ data report accurately reflected the facility's RN coverage, despite the discrepancies noted. The facility had experienced turnover in staffing coordinators, which may have contributed to the inconsistencies in marking RN coverage on the Daily Staffing Roster. The deficiency in RN coverage had the potential to affect all residents within the facility, as it did not meet the regulatory requirements for RN staffing.
Deficiencies in Kitchen Cleanliness and Food Safety
Penalty
Summary
The facility failed to maintain proper cleanliness and food safety standards in the kitchen, as observed during a survey. There was a significant buildup of grease on the baffle vents and around the deep fat fryer, indicating a lack of regular cleaning. Additionally, several food packages, including zucchini sticks, breaded okra, chicken tenders, and frozen meat patties, were found unsealed and unlabeled with the date they were opened, which is against food safety protocols. The floor behind the fryer was also not maintained, with a heavy buildup of grease, and there were red and brownish stains under a shelf holding meat. The dietary staff acknowledged these issues, noting that a solution to clean the stains had been ordered but not yet received. Further observations revealed that two cutting boards were not in a cleanable condition, and the food processor was not properly washed between uses, as it was only rinsed instead of undergoing a three-step cleaning process. This improper cleaning was noted when the processor was used for different foods, such as eggs and sausage. Additionally, the milk in the dining room was found to be at 51.4 F, above the recommended temperature, and was not stored on ice. The Dietary Director admitted to not conducting in-services regarding the cutting boards and was unaware that the dietary staff were responsible for cleaning the baffle vents, assuming it was done by an external company.
Failure to Submit Required Staffing Data to PBJ
Penalty
Summary
The facility failed to submit the required staffing data to the Payroll Based Journal (PBJ) for two of the last four quarters, specifically Fiscal Year Quarter Three 2023 and Fiscal Year Quarter Four 2024. This failure had the potential to affect all 53 residents of the facility. The facility's policy mandates the electronic submission of complete and accurate direct care staffing information to CMS on a quarterly basis. However, the facility did not adhere to this policy, resulting in the deficiency. Interviews with facility staff revealed confusion and miscommunication regarding the responsibility for submitting the PBJ data. The MDS Coordinator and the Assistant Director of Nursing were unclear about who was responsible for the submission, with each suggesting different staff members. The Administrator acknowledged responsibility for the submissions but indicated that the previous management company had restricted his ability to submit the data, suggesting it was the responsibility of someone higher up. This lack of clarity and communication contributed to the failure to submit the required staffing data.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection control practices during incontinence care for a resident on Enhanced Barrier Precautions (EBP) due to an open wound on the coccyx. Certified Nursing Assistants (CNAs) did not wear gowns while providing care, despite signage indicating the need for EBP. The CNAs were unaware of the resident's EBP status and the presence of an open wound, leading to inadequate protection against potential infection transmission. Additionally, the facility did not maintain adequate hand hygiene during medication administration for multiple residents. An LPN failed to perform hand hygiene before and after administering medications, including nasal spray and insulin, and did not sanitize hands after picking up a pen from the floor. This lack of hand hygiene was observed across several medication passes, indicating a systemic issue with infection control practices. The facility also failed to screen employees for tuberculosis (TB) in a timely manner, with several staff members lacking documentation of TB screening upon hire. The Human Resource Director acknowledged errors in the TB screening process under previous management, resulting in incomplete or delayed screenings. This oversight in employee health screening further compromised the facility's infection control measures.
Failure to Monitor Long-Term Antibiotic Use
Penalty
Summary
The facility failed to implement an effective Infection Control Surveillance process for monitoring and tracking long-term antibiotic usage, specifically for a resident who was on an antibiotic as a preventative measure for chronic urinary tract infections (UTIs). The facility's Infection Prevention and Control Program and Antibiotic Stewardship Program Policy outlined the need for monitoring antibiotic use, including tracking antibiotic starts, adherence to evidence-based criteria, and reviewing resistance patterns. However, the facility did not have a system in place to track or monitor long-term antibiotic use, which was evident in the case of Resident #17, who was on Macrobid for long-term use without proper documentation or tracking. Resident #17, who had a history of UTIs, was moderately cognitively impaired and had memory problems. The resident was prescribed Macrobid for candidiasis, but the diagnosis was incorrect, as Macrobid is not indicated for fungal infections. The resident's medical records lacked documentation of a Situation-Background-Assessment-Recommendation (SBAR) or McGreer Criteria related to the antibiotic use. Interviews with facility staff, including the Infection Control Preventionist (ICP), Licensed Practical Nurse (LPN), and Assistant Director of Nursing (ADON), revealed that there was no monthly review or reassessment of long-term antibiotic use, and the facility did not track such usage as part of their infection control surveillance. The Director of Nursing (DON) confirmed that the ICP was responsible for the Infection Control Surveillance and monitoring of the antibiotic stewardship program but did not track long-term antibiotic use. The facility's surveillance only documented new antibiotic usage and infections monthly. The resident was on Macrobid upon admission for long-term preventative management of UTIs due to colonized bacteria, but the facility did not include this in their monitoring. The DON also noted that a diagnosis of fungal infection was not an acceptable use for Macrobid, and the pharmacy's monthly drug regimen review was expected to ensure correct use and diagnosis for all medications.
Deficiency in CNA In-Service Training Documentation
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of in-service education annually, which was to include training on abuse, neglect, and dementia care. This deficiency was identified through interviews and record reviews, revealing that documentation for five CNAs employed for over 12 months was not available. The facility's policy mandated that all employees complete required training within designated time frames, and it was the responsibility of each employee to attend these trainings. However, the facility did not monitor or document the education received by CNAs, potentially affecting all 53 residents. The facility had been using Relias, a provider of workplace education and training, for monthly in-service education until the company filed for bankruptcy in December 2023. The facility continued to use Relias services until March 2024, when they were denied access to training records due to unpaid bills. Consequently, the facility began conducting in-person in-service training. However, the records showed that not all CNAs attended these sessions, and there was a lack of clarity among staff regarding who was responsible for maintaining training records and ensuring completion of the required in-service hours. Interviews with various staff members, including the Administrator, LPN, and ADON, highlighted confusion and miscommunication regarding the responsibility for tracking and ensuring the completion of in-service training. The Administrator and department heads were believed to be responsible for this task, but the lack of access to Relias records and the transition to in-person training contributed to the failure in meeting the training requirements. This deficiency had the potential to impact the quality of care provided to residents, particularly those with dementia and other cognitive impairments.
Failure to Deliver Quarterly Financial Statements to Guardian
Penalty
Summary
The facility failed to prepare and deliver quarterly financial statements to the Public Administrator, who was the guardian for four residents with funds managed by the facility. This deficiency was identified through interviews and record reviews, revealing that the Business Office Manager (BOM), hired in April 2023, was not trained in preparing and sending these statements. During interviews, the BOM admitted to the lack of training, and the Administrator acknowledged being unaware of this issue, despite expecting the BOM to fulfill this responsibility. The facility's census at the time was 53 residents.
Failure to Conduct Timely Background Checks and Registry Verification
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the timely completion of criminal background checks (CBC) and verification of the Nurse Aide Registry for new employees. This deficiency was identified during a review of four employee records, revealing that the facility did not conduct CBCs or check the Nurse Aide Registry in accordance with state requirements before hiring. Specifically, Cook A's CBC was requested and received over a month after hire, CMT B's CBC was delayed by several months, and Dietary Aide A's CBC was not completed until weeks after hire. Additionally, the Nurse Aide Registry check for CNA F was not conducted upon hire. During an interview, the Human Resource Manager acknowledged the lapses, attributing some of the issues to practices under the former company, which did not complete criminal background screenings correctly or timely. The manager also noted ongoing audits of employee files to correct mistakes and fill in missing information. However, specific reasons for the delays in CBCs for CMT B and Dietary Aide A were not provided, and the Nurse Aide Registry report for CNA F could not be located.
Facility Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with an observed error rate of 18.52%. This was due to several incidents involving improper medication administration. Certified Medication Technician (CMT) A administered insulin to two residents without priming the insulin pen needles, contrary to the manufacturer's instructions and facility policy. This oversight could lead to incorrect dosing, as priming is necessary to ensure the pen is functioning correctly and to remove air from the needle and cartridge. Additionally, Licensed Practical Nurse (LPN) D made errors during medication administration for two residents. For one resident, LPN D administered a nasal spray incorrectly by not agitating the solution, not occluding the opposite nostril, and not instructing the resident to inhale properly. This led to multiple doses being administered in an attempt to ensure the medication was received. For another resident, LPN D omitted a prescribed medication, Famotidine, from the medication pass without taking appropriate steps to address the omission, such as contacting the pharmacy or documenting the issue adequately. Further errors were noted when LPN D dropped a medication, Atenolol, during administration and failed to provide it to the resident. The nurse did not follow up with the necessary procedures to replace the dropped medication or monitor the resident's blood pressure adequately after the omission. These actions and inactions contributed to the facility's high medication error rate, affecting the quality of care provided to the residents.
Deficiencies in Food Palatability and Temperature Control
Penalty
Summary
The facility failed to ensure that pureed eggs were palatable and that hot foods on room trays were delivered at a safe and appetizing temperature. The pureed eggs were prepared with fewer eggs and cold milk, resulting in a bland taste, as confirmed by both a state surveyor and the Dietary Director (DD). The DD admitted that the recipe for pureed eggs was recently added to the recipe book and had not been tasted in its pureed form before being served. The Consultant Registered Dietitian was not consulted about the flavor of the pureed eggs and had not reviewed the recipe recently. Additionally, the facility did not maintain the required temperature for hot foods on room trays, with a test tray showing sausage at 101.3 F, below the recommended 120 F. The DD acknowledged that the dietary staff had not been checking the temperatures of room tray items and that some residents had previously complained about cold food. Interviews with residents confirmed that meals, particularly breakfast, were often delivered cold, affecting their dining experience.
Failure to Invite Resident to Care Plan Meeting
Penalty
Summary
The facility failed to invite a resident to their quarterly care plan meeting, which is a requirement for person-centered care planning. The resident, who was moderately cognitively impaired and had multiple diagnoses including Generalized Anxiety Disorder, Congestive Heart Failure, Diabetes Mellitus, Major Depressive Disorder, PTSD, and COPD, was not invited to the care plan meeting held on 6/20/24. The resident expressed a desire to be involved in their care planning process but reported not receiving invitations to these meetings. The facility's policy on comprehensive care plans did not include specific procedures for inviting residents to their care plan meetings. Interviews with facility staff, including the Director of Nursing, Social Services Designee, Certified Nursing Assistant, Licensed Practical Nurse, MDS Coordinator, and Assistant Director of Nursing, revealed a lack of clarity and consistency regarding the process for inviting residents to care plan meetings. The Social Services Designee, who was responsible for inviting residents, believed that verbal invitations were sufficient and was unaware of the requirement for written invitations. Other staff members were unsure of the invitation process and who was responsible for it, indicating a systemic issue in ensuring resident participation in care planning.
Incomplete Baseline Care Plans for Residents with Significant Health Conditions
Penalty
Summary
The facility failed to ensure that the baseline care plans for two residents, both with significant health conditions, were adequately developed and implemented within 48 hours of admission. Resident #154 was admitted with multiple health issues, including a cholecystostomy drain that required monitoring and draining every two hours. However, the baseline care plan did not document the presence of the cholecystostomy drain or any interventions related to it, despite physician orders and observations indicating its necessity. The resident was observed with a cholecystostomy tube collection bag, and the resident reported receiving pain medication through a gastrostomy tube, yet these details were not reflected in the care plan. Resident #155 was admitted with a left hip fracture and was receiving rehabilitation services. The baseline care plan failed to document the resident's surgical site or any interventions for monitoring it, despite the resident's admission assessment indicating a dressing on the left hip. Physician orders included pain management medications, but there was no mention of treatment for the surgical site. Observations confirmed the resident's condition and the need for rehabilitation, yet the baseline care plan did not reflect these critical aspects of care. Interviews with facility staff, including an LPN and the Director of Nursing, revealed that the baseline care plans should have included specialized care needs such as surgical sites and pain management. The staff acknowledged that the baseline care plans were incomplete and did not incorporate all necessary information from the initial nursing assessments. This oversight resulted in a deficiency in the facility's ability to provide effective and person-centered care for the residents involved.
Improper LAL Mattress Settings for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that the low air loss (LAL) mattress settings for a resident with pressure ulcers were set according to the physician's orders based on the resident's weight. The resident, who was severely cognitively impaired and had both Stage II and Stage III pressure ulcers, had a physician's order for a LAL mattress with settings to be adjusted according to their weight. However, observations revealed that the mattress was set at 450 pounds, significantly higher than the resident's actual weight of approximately 160 pounds. Interviews with staff, including CNAs and LPNs, indicated a lack of awareness and understanding of the correct settings for the LAL mattress. CNAs believed that the settings were managed by maintenance staff, while LPNs acknowledged that the settings should be based on the resident's weight. Despite this, the mattress remained incorrectly set, and nursing staff failed to document or adjust the settings appropriately during their shifts. The Assistant Director of Nursing and the Director of Nursing confirmed that the mattress settings were incorrect and acknowledged the potential risks associated with improper settings, such as affecting the resident's wound healing process. The deficiency was identified through observations and interviews, highlighting a failure in the facility's protocol to monitor and adjust the LAL mattress settings as per the physician's orders and the resident's current weight.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage and handling of respiratory equipment for a resident diagnosed with chronic obstructive pulmonary disease (COPD) and heart failure. The resident, who was alert and oriented, used intermittent oxygen therapy and other respiratory treatments. Observations revealed that the resident's oxygen concentrator was placed next to their bed with the nasal cannula and tubing coiled around it, uncovered, and without a plastic bag or covering. Although the nebulizer machine's face mask was covered with a plastic bag, the nasal cannula and tubing were not stored properly, leading to potential cross-contamination. Interviews with facility staff, including a CNA, LPN, and the Director of Nursing, confirmed that oxygen supplies such as nasal cannulas, tubing, and face masks should be stored in a plastic bag when not in use to prevent contamination. The staff acknowledged that the oxygen supplies should be labeled, dated, and changed out weekly, with the responsibility of monitoring resting on the nursing staff. Despite these protocols, the resident's oxygen supplies were not stored according to the facility's standards, indicating a lapse in adherence to proper respiratory care procedures.
Deficiency in Pain Management for Resident Post-Surgery
Penalty
Summary
The facility failed to accurately assess and manage pain for a resident who required such services, leading to a deficiency in care. The resident, who was admitted with a history of osteoporosis, lower back pain, left hip pain, a left hip fracture, and a history of falling, did not have a completed Pain Risk Assessment. The resident's Baseline Care Plan also lacked essential healthcare information regarding pain management, despite the resident being admitted after surgical repair of a hip fracture and having orders for narcotic pain medication. Observations and interviews revealed inconsistencies in the resident's pain assessment and management. The resident's pain levels varied significantly, with scores ranging from zero to nine on a scale where nine is the highest level of pain. Despite these fluctuations, the resident's Baseline Care Plan did not reflect the need for pain management, and the resident reported having to request pain medication, sometimes experiencing delays in receiving it. The facility's policy required a pain assessment tool appropriate for the resident's cognitive status, but this was not adequately implemented. Interviews with facility staff, including an LPN and the Director of Nursing, highlighted gaps in the admission process and documentation. The initial admission assessment failed to document the resident's specialized care needs, such as the hip fracture and repair, and did not include a comprehensive pain assessment. The facility's policy required all risk assessments, including pain, to be completed within 24 hours of admission, but this was not done for the resident in question, contributing to the deficiency in pain management.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, who also had Generalized Anxiety Disorder and Major Depressive Disorder, did not have a care plan addressing their PTSD or trauma-informed care. Despite the facility's policy requiring trauma-informed and culturally competent care plans, the resident's care plan lacked any interventions related to their PTSD diagnosis. Interviews with the resident revealed that they felt their PTSD affected them and expressed a desire to see a therapist, which had not been provided by the facility. The resident reported feeling lonely and had previously relied on family for mental support, but most of their family was no longer available. The resident had communicated their wish to see a therapist to a Certified Nursing Assistant (CNA), but no action was taken. Staff interviews indicated a lack of awareness regarding the resident's PTSD diagnosis and the absence of any specific interventions or triggers in the care plan. The Director of Nursing (DON), Licensed Practical Nurses (LPNs), and the Assistant Director of Nursing (ADON) were all unaware of the resident's PTSD diagnosis. The MDS Coordinator, responsible for updating care plans, also failed to include the PTSD diagnosis in the care plan, resulting in the resident not receiving necessary psychiatric or mental health services.
Uncertified Insulin Administration by CMT
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate skills and competencies to safely administer insulin, as evidenced by a Certified Medication Technician (CMT) who was not certified to administer insulin injections, administering insulin to two residents. The facility's policy required medications to be administered by staff legally authorized to do so, and the CMT job description did not include insulin administration. Despite this, CMT A administered insulin to two residents without performing necessary hand hygiene or priming the insulin pen needle, which is required to ensure the correct dosage. During observations, CMT A was seen administering insulin without following proper procedures, such as priming the needle and performing hand hygiene before and after administration. Interviews revealed that CMT A was not certified to administer insulin, and the Director of Nursing was unaware of this lack of certification. The facility's policies and the Missouri Nurse Aide Registry confirmed that CMTs must have proper certification to administer insulin, which CMT A did not possess.
Failure to Document Physician Responses to Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that attending physicians documented their review and response to irregularities identified by the consulting pharmacist during monthly Medication Regimen Reviews (MRRs) for two residents. Resident #8, who had diagnoses including dementia with behavioral disturbance, bipolar disorder, depression, and anxiety, was receiving antipsychotic, anticoagulant, and diuretic medications. The resident's care plan indicated risks related to these medications, and the pharmacist had made recommendations on several occasions. However, the medical record showed only one documented response from the physician, with missing MRR reports for other months where recommendations were made. Similarly, Resident #32, with diagnoses including degeneration of the brain, dementia with behavioral disturbance, anxiety, and depression, was receiving antianxiety and antidepressant medications. The pharmacist made recommendations for dose reductions on multiple occasions, but the medical record showed a lack of physician response for some of these recommendations. The Director of Nursing acknowledged that physicians were expected to respond to MRRs within two to three weeks and that staff should have followed up to ensure responses were documented, which did not occur in these cases.
Deficiency in Providing Routine and Emergency Dental Care
Penalty
Summary
The facility failed to provide routine and emergency dental care for two residents, leading to a deficiency in dental services. Resident #6, who was cognitively intact, experienced a toothache for several days without receiving dental care. Despite being aware of the resident's pain, the staff only administered pain medication and did not offer or arrange for a dental appointment. The resident had not seen a dentist since before admission to the facility, and there was no documentation of dental services in the medical record. Resident #1, also cognitively intact, expressed a desire for a dental check-up, having not seen a dentist in over a year. However, there was no documentation of any dental services provided during their stay at the facility. Interviews with staff revealed a lack of awareness and understanding of the facility's policy and federal regulations regarding dental services. The staff, including the Director of Nursing, were unaware of the residents' dental needs and had not taken steps to address them. The facility's policy stated that dental needs should be identified and addressed in each resident's care plan, but this was not done for either resident. Interviews with various staff members, including CNAs, LPNs, and the Social Services Designee, highlighted confusion about the process for arranging dental care and a lack of communication regarding the residents' dental needs. The MDS Coordinator and Assistant Director of Nursing were also unaware of the requirements for including dental preferences in care plans, contributing to the deficiency in providing necessary dental services.
Deficiency in Hospice Care Documentation and Monitoring
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of hospice care services for a resident receiving hospice care. The resident, who was cognitively intact and able to communicate needs, was admitted to hospice services with a physician order and had been recertified for hospice care. However, the resident's care plan did not include a hospice care plan in the electronic medical record, and there was a lack of documentation for hospice nurse visits on specific dates. Interviews with facility staff, including LPNs, the Assistant Director of Nursing (ADON), and Medical Records Staff, revealed a lack of coordination and communication regarding hospice documentation. The hospice staff were expected to document visits in the resident's hospice binder, but the facility staff did not monitor or review the binder. The Medical Records Staff were responsible for filing hospice documentation but were unaware of missing certifications and care plans. The Director of Nursing (DON) and the Hospice Nurse/Case Manager acknowledged the deficiencies in documentation and coordination of care. The DON expected hospice documentation to be current and placed in the resident's hospice binder or scanned into the medical record. The Hospice Nurse/Case Manager was not aware of the missing documentation until the week of the survey, indicating a lapse in ensuring the resident's hospice binder was updated with necessary information.
Pest Control Deficiency in Boiler Room
Penalty
Summary
The facility failed to implement a pest control program effectively, as evidenced by the absence of a screen over the louvered vent in the basement boiler room. This deficiency was observed during a survey conducted with the Maintenance Director, where dead insects, bird droppings, and dried vegetation were found in the boiler room area. The Maintenance Director acknowledged that birds had previously entered the boiler room and confirmed the lack of a screen over the vent.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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