Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Higginsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverbend Heights Health & Rehabilitation | 9.6 mi | ★★★★★ | 1 | 0 |
| Lutheran Nursing Home | 10.8 mi | ★★★★★ | 4 | 0 |
| Odessa Health Care Center | 13.3 mi | ★★★★★ | 34 | 0 |
| Apple Ridge Care Center | 15 mi | ★★★★★ | 5 | 0 |
| Shirkey Nursing And Rehabilitation Center | 17.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.