New Mark Rehab And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Missouri.
- Location
- 11221 North Nashua Drive, Kansas City, Missouri 64155
- CMS Provider Number
- 265308
- Inspections on file
- 32
- Latest survey
- January 26, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at New Mark Rehab And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to maintain a safe, comfortable environment when both boilers malfunctioned, causing indoor temperatures to drop below the facility’s stated 71–81°F range. Several residents with conditions such as CHF, multiple sclerosis, dementia, chronic respiratory failure, and depression reported very cold rooms and described needing to wear coats, mittens, gloves, sweaters, and extra blankets indoors to stay warm. Some residents were offered moves to warmer rooms, but others were not offered relocation or extra blankets, despite the facility’s extreme weather policy requiring comfort measures during cold conditions. Observations confirmed cool rooms, non-functioning or inadequately heating room units, and residents bundled in outerwear and blankets while in bed or in their rooms.
A resident with multiple cardiac, cognitive, and functional diagnoses was moved from the facility to another SNF within the same company without a physician discharge order, required discharge notice, or completed discharge documentation in the medical record. The facility’s policy required advance written notice of transfer/discharge, including reasons, effective date, destination details, appeal rights, and Ombudsman information, to be provided to the resident and their representative, and for discharge planning and documentation to be maintained. Instead, staff communicated discharge plans with a family member who was not the resident’s DPOA, while the designated DPOA reported not being notified of the discharge, not receiving any discharge paperwork or notice, and not being contacted by or signing admission paperwork for the receiving facility. The DON stated that staff were expected to notify and obtain agreement from the DPOA or provide a 30‑day notice, and the Administrator acknowledged that no discharge notice was completed because staff believed the move to another SNF was a transfer rather than a discharge.
Licensed staff and the SSD failed to document critical clinical information and to administer or properly document medications as ordered. A resident with ESRD on hemodialysis, diabetes, CHF, atrial fibrillation, chronic infected wounds, and intact cognition had a critical potassium level reported from an outside clinic; the clinic ordered hospital transfer, the resident refused, and an NP ordered high-dose oral KCl and STAT labs, yet none of these events, refusals, code status changes, or missed dialysis/IV antibiotic treatments were documented in the clinical record. On a separate day, three other residents had multiple medications and nutritional supplements marked on the MAR with a code directing staff to see progress notes, but the notes did not explain why medications were not given, and some doses were not documented as administered at all. Staffing issues contributed when a CMT called off, an RN unfamiliar with LTC med passes attempted to cover while managing other clinical duties, and many scheduled medications were not administered or explained in the record.
A facility failed to report an alleged incident of sexual abuse between two residents to law enforcement and the state survey agency within the required timeframe, despite its own policy and federal regulations. The incident involved a resident with severe cognitive impairment and another resident with a history of inappropriate sexual behavior. Staff and family were aware of the allegation, but administration decided not to report it after reviewing camera footage and assessments, and the hospice agency was not notified by the facility.
A facility failed to follow its abuse prevention policy by not conducting a documented investigation or notifying authorities after an allegation that a resident with severe cognitive impairment was sexually abused by another resident with a history of inappropriate sexual behavior. Despite staff and family reports of the incident and the facility's own policy requirements, the Administrator determined the allegation was unsubstantiated without a formal investigation or external reporting.
A resident with a surgical wound and multiple health conditions had a wound vac dressing left unchanged for an extended period due to missing physician orders and unclear staff responsibilities. When the dressing was finally removed, it was severely adhered to the wound, causing significant bleeding and requiring hospital transfer. Staff interviews confirmed a lack of documentation and confusion about wound care procedures.
A resident with severe cognitive impairment and a history of wandering exited the secure memory care unit, was found in the parking lot with a head laceration, and required hospital evaluation. Staff were aware of the resident's exit-seeking behaviors but did not prevent the elopement, resulting in injury.
A resident with complex medical and behavioral needs was transferred to a hospital after an incident of aggression, but facility staff failed to provide the required written discharge notice, bed hold policy, and information on appeal rights to the resident or their representative. There was no evidence of involvement of the resident or representative in discharge planning, and communication among staff and with the hospital was lacking, resulting in confusion and harm to the resident.
A resident with a history of behavioral issues and neurocognitive disorders physically assaulted another resident with dementia, resulting in multiple injuries including facial scratches, bruising, and emotional distress. Staff discovered the incident after hearing screaming, and the facility's policies requiring intervention and abuse prevention were not effectively implemented to prevent the altercation.
During a recent survey, multiple food safety and hygiene protocol deficiencies were observed. Stored food items in the walk-in freezer and refrigerator were found undated and exposed to potential contamination. Additionally, air vents in the kitchen were visibly dirty, posing a risk of contaminating food with dust particles. The Dietary Director acknowledged the importance of proper labeling and dating but noted a lack of awareness among maintenance staff regarding vent cleanliness. Furthermore, a dietary staff member was observed not wearing a beard restraint while handling food, contrary to facility policy. The staff member cited discomfort as the reason for removing the restraint, indicating a gap in adherence to established hygiene guidelines. These deficiencies could potentially impact the health and safety of the 98 residents consuming food prepared in the facility's kitchen.
The facility failed to inform a resident and/or their representative of the risks and benefits of a physician-ordered antipsychotic medication. The resident, who had moderate cognitive impairment, was not aware of the purpose of the medication, and no consent was documented. The Unit Manager confirmed the lack of consent, and the facility did not provide a relevant policy.
The facility failed to maintain a clean and comfortable environment for a resident, who was observed to have a build-up of dirt and grime, dust, and ants in the room. Despite the resident's cognitive intactness, the room's condition remained poor over multiple observations. The Administrator was unaware of the ant issue, and the Activity Director acknowledged that spring cleaning had not started and there was no care plan addressing the resident's wishes and the need for room cleaning.
A resident with cognitive impairments bit another resident after the latter reached for a blanket, despite staff being aware of the aggressive behaviors and having interventions in place. The biting incident resulted in a bruise but no broken skin. Staff separated the residents and placed the aggressor on 15-minute checks.
The facility failed to report an injury of unknown origin and a resident-to-resident altercation to the SSA within the required timeframes. A resident with dementia was found with a bruise, and another resident was involved in an altercation, both of which were not reported promptly as per facility policy.
The facility failed to investigate an injury of unknown origin and a resident-to-resident altercation involving two residents. One resident was found with a bruise below her eye, and another was hit on the arm by another resident. No investigations were conducted as required by the facility's policy.
The facility failed to update the care plans for two residents. One resident with PTSD did not have a care plan addressing this condition, and another resident using a specialized wheelchair did not have this equipment included in their care plan. These oversights could lead to inappropriate care and services.
The facility failed to provide appropriate support for a resident's head and leg while in a wheelchair and delayed obtaining a dermatology appointment for another resident with excessive itching. These deficiencies were confirmed through observations, staff interviews, and record reviews.
A resident with a history of stroke and cerebral palsy did not receive appropriate services to maintain or improve her range of motion (ROM). Despite having functional limitations, the resident did not receive any restorative therapy or exercises, and the only intervention was the placement of a washcloth in her contracted hand. Staff confirmed that the resident had not been assessed for restorative exercises, and there was no designated nurse responsible for the restorative program.
The facility failed to properly store a resident's nebulizer tubing and pipe, leaving them uncovered on a bedside table. This oversight was confirmed by an LPN and placed the resident, who had COPD and required frequent nebulizer treatments, at risk for infection.
The facility failed to complete an AIMS assessment for a resident on antipsychotic medication and did not have a stop date or diagnosis for a PRN psychotropic medication for another resident. These oversights placed the residents at risk for unrecognized side effects and diminished quality of life.
The facility failed to remove an expired insulin pen from a medication cart, leading to its use on a resident with high blood sugar. The RN confirmed the pen was expired, and the DON stated that expired pens should be removed. The facility's policy and manufacturer's guidelines were not followed.
The facility failed to maintain the reach-in refrigerator in the kitchen, which had been leaking for at least six months, affecting 98 of the 99 residents who consume food from the kitchen. Despite being noted in the Maintenance Repair Log in August 2023, the issue was not repaired, and the maintenance staff was only notified about the leak recently.
Failure to Maintain Comfortable Indoor Temperatures During Heating System Malfunction
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, comfortable, and homelike environment when the heating system could not sustain comfortable temperatures for residents. The facility had a policy titled “Extreme Weather” dated 08/25/23, which stated that during extreme cold weather the facility would provide extra blankets to residents who desired them, obtain additional warm clothing for residents with insufficient warm clothing, provide additional warm beverages, and have staff assess residents for comfort and take additional measures as necessary. The policy also required the Maintenance Department to maintain a log of facility temperatures and document measures taken if temperatures fell below 71°F or above 81°F. Despite this policy, the heating system malfunctioned, and the facility did not consistently implement measures such as relocation or provision of extra blankets for all affected residents. One resident with lymphedema, repeated falls, asthma, depression, atrial fibrillation, and bilateral knee osteoarthritis, and with intact cognition per a BIMS score of 15, reported that it was very cold in the facility on a Sunday. This resident stated that the room was very cold, requiring extra blankets and a coat, and that staff later offered and completed a move to a warmer room on a different hall. The resident reported that no one had followed up about when they could return to the original room and that it was still too cold in the facility, requiring continued use of a coat and blanket while outside the room. Another resident with multiple sclerosis, dementia, cognitive communication deficit, and bipolar disorder, with moderately impaired cognition (BIMS score 12), reported that their room was very cold, that staff asked them to move rooms but they declined due to concern about leaving belongings unattended, and that they had to wear a coat, mittens, and an extra blanket to keep warm. Observation confirmed the room was very cool, the resident was in bed wearing a coat and mittens, and the in-room heating unit was not blowing air and had a blank control panel screen that did not respond to the on/off switch or temperature buttons. A third resident with polyneuropathy, type 2 diabetes mellitus, chronic respiratory failure, weakness, and major depressive disorder, and intact cognition (BIMS score 14), stated that it had gotten “pretty cold” in the room. This resident reported that staff did not offer another room to move to temporarily or offer additional blankets, and that they would have moved to sleep in a warmer room. The resident said the heating unit was working but did not blow very warm air, and that maintenance had checked it that morning without explaining what was done. Observation showed this resident wearing a coat, gloves, and blankets. A fourth resident with CHF, alcohol-induced persisting dementia, tachycardia, seizures, major depressive disorder, and GAD, and moderately impaired cognition (BIMS score 12), reported that the room was very cold overnight, that the heating unit felt like it was blowing cool air, and that they had to wear a sweater, coat, and gloves to stay warm. This resident stated that staff did not offer a move to a warmer room or extra blankets and that they would have moved temporarily if given the choice. A CMT reported working on the Sunday when the building became very cold, especially on one hall, due to a problem with the heating system. The CMT stated that some residents in affected rooms were offered moves to warmer rooms, two residents agreed to move, and two chose to stay, but the CMT did not know why all affected residents were not offered room changes. The Maintenance Director reported that one of the two boilers stopped working over the weekend and that while technicians were working on it, the second boiler also stopped working. The Maintenance Director acknowledged that temperatures in the facility became cool on that Sunday and again on the day of the survey, and noted that one resident room temperature had been 68°F that morning. The Maintenance Director stated they had been resetting individual heating units in resident rooms and that temperatures were returning to normal. The DON and Administrator both stated expectations that the facility temperature remain within 71–81°F, that residents should not need to wear mittens inside, and that residents should be relocated to warmer areas and offered extra blankets if rooms were too cold. Despite these stated expectations and the written policy, multiple residents experienced cold rooms, wore coats, gloves, and blankets indoors, and some were not offered relocation or additional blankets, demonstrating the failure to provide a safe and comfortable environment during the heating system failure.
Failure to Provide Required Discharge Notice and Documentation for a Resident Transferred to Another SNF
Penalty
Summary
The deficiency involves the facility’s failure to provide a required discharge notice, follow appropriate discharge procedures, and complete discharge documentation for a resident who was moved to another skilled nursing facility. The facility had a written Transfer and Discharge policy requiring that residents be transferred or discharged only under specific conditions, based on a physician order (unless leaving against medical advice), and that reasonable advance notice—typically 30 days—be given to the resident and their representative, with certain exceptions. The policy also required that a written notice of proposed transfer/discharge be provided to the resident and their representative, containing the reason for discharge, effective date, destination information, appeal rights, and Ombudsman contact information, and that a copy be sent to the State Long Term Care Ombudsman for facility-initiated discharges. Documentation related to discharge, including a discharge summary and post-discharge plan, was to be maintained in the medical record. The resident at issue was admitted from a hospital and later discharged to another skilled nursing facility within the same company. The resident had multiple diagnoses, including fluid overload, atrial fibrillation, cognitive communication deficit, repeated falls, lack of coordination, dementia with behavioral disturbance, heart disease, and urinary incontinence. An admission MDS showed adequate hearing, clear speech, ability to make self-understood and understand others, and a BIMS score of 10 indicating moderately impaired cognition, with no behaviors noted during that assessment. The comprehensive care plan included interventions for smoking-related lung function, ADLs, behaviors related to inappropriate sexual comments, communication, cardiac status, edema/fluid overload, cognition related to dementia, fall risk, mood problems related to new long-term care admission, nutrition, skin integrity, and bladder incontinence. The resident had a Durable Power of Attorney (DPOA) document naming a family member (Family Member A) as the Power of Attorney for financial, contractual, medical, legal, and personal matters. Despite these requirements and the identified DPOA, the facility did not obtain or document a physician order to discharge the resident to another skilled nursing facility, and the electronic medical record lacked a discharge notice, discharge summary, discharge care plan, or physician orders related to the discharge and admission to the receiving facility. Progress notes showed that on one date the Social Services Designee spoke with a family member who was not the DPOA to update them on the resident’s discharge progress, and later the Admissions Director documented that the resident would discharge to another skilled facility within the company on a specified day and time, with transport arranged, personal effects sent with the resident and family, and current documentation and discharge order to be sent. However, the DPOA (Family Member A) reported not being notified of the discharge, not receiving any discharge paperwork or discharge notice, and not being contacted by or signing admission paperwork for the receiving facility, and stated they would not have chosen that facility. The DON stated an expectation that staff notify the DPOA/representative, obtain approval or give a 30‑day notice, and ensure the accepting facility could meet the resident’s needs. The Administrator acknowledged that a discharge notice was not completed because staff believed the move to another skilled nursing facility was a transfer rather than a discharge, even though social services was responsible for discharge planning documentation and providing discharge notices as required by regulation. There was no indication in the record that, once the failure to provide a discharge notice was identified, the facility subsequently administered a discharge notice to the resident or the resident’s representative. The lack of required notice, absence of a physician discharge order, and missing discharge documentation in the medical record, combined with communication directed to a non‑DPOA family member instead of the designated DPOA, formed the basis of the deficiency identified by surveyors.
Failure to Document Critical Clinical Events and Administer Medications as Ordered
Penalty
Summary
The deficiency involves failures by licensed nursing staff and the social services designee (SSD) to document critical changes in a resident’s condition and treatment, as well as failures by nursing staff to administer and/or document medications as ordered for multiple residents. One resident with intact cognition, end-stage renal disease on hemodialysis three times weekly, insulin-dependent diabetes, chronic infected wounds with osteomyelitis, prior lower extremity amputation, atrial fibrillation, and congestive heart failure had a critical potassium level reported from an outpatient clinic. The clinic physician ordered that the resident be sent to the emergency room for treatment. RN A was notified of the critical lab and the order to send the resident to the hospital, spoke with the resident who refused transfer, and then contacted the facility nurse practitioner, who ordered an immediate 80 mEq dose of oral potassium and a STAT repeat potassium level. None of these events, including the resident’s refusal of hospital transfer, the new treatment plan, the STAT lab order, or the subsequent STAT lab results and provider notification, were documented in the resident’s clinical record. For this same resident, the SSD completed a change in code status to Do Not Resuscitate (DNR) but did not document this interaction or other extensive contacts with the resident in the clinical record, instead keeping notes in a separate notebook. The SSD recalled the resident expressing a wish to change to DNR status after discussions with dialysis nurses, and a new DNR was completed, but there was no corresponding documentation in the facility chart. Additionally, there was no documentation that the dialysis clinic or physician were notified when the resident refused a scheduled hemodialysis treatment, which also included IV antibiotic therapy, nor was the missed dialysis/antibiotic treatment documented as such. Nursing progress notes around the time of the critical potassium result and subsequent events contained only limited entries (e.g., repositioning, offering water, and the time the resident was found without respirations and pulse), with no record of the critical lab, treatment decisions, refusals, or communication with outside providers. The deficiency also includes failures to administer and/or document medications as ordered for three other residents. For one resident with multiple cardiac and nutritional medications, the MAR showed that on a specific date all ordered medications and supplements were marked with a code "9" (indicating to see progress notes), but the progress notes contained no explanation for why the medications were not administered. For another resident with numerous psychotropic, cardiac, pain, GI, and nutritional orders, the MAR likewise showed all medications and supplements coded "9" on a specific date, with no corresponding documentation in the progress notes explaining the omissions; in addition, gabapentin, buspirone, and Med Pass were not documented as administered at scheduled times. A third resident had ordered diltiazem three times daily and a nutritional supplement four times daily; on a specific date, both were coded "9" on the MAR, and a progress note explicitly stated that neither the medication nor the supplement had been administered. Staff interviews further clarified the circumstances leading to the missed medications. The staffing coordinator reported that on the day in question a Certified Medication Technician (CMT) called in for the 100 halls, and despite attempts to find in-house or agency coverage, no replacement was obtained until 2:00 p.m. RN B, who had never previously passed medications in LTC, was instructed to begin passing medications while coverage was sought. RN B reported difficulty with medication administration, including not knowing which medications required crushing or mixing with food, and being simultaneously responsible for a resident with a medical emergency, wound care, and monitoring residents for falls or altercations. RN B acknowledged that some medications were passed but not all, and that when the CMT arrived at 2:00 p.m., the CMT declined to administer the overdue medications and told RN B to document them as not administered. RN B stated that if medications were not passed, he or she should have documented in the progress notes why they were not administered, but this was not done.
Failure to Timely Report Alleged Sexual Abuse to Authorities
Penalty
Summary
The facility failed to follow its own abuse prevention policy and federal and state regulations by not reporting an alleged incident of sexual abuse involving a resident to law enforcement and the state survey agency within the required two-hour timeframe. The policy clearly mandates immediate reporting of suspected abuse, including sexual abuse, to the appropriate authorities, but this was not done in this case. The incident involved one resident allegedly attempting to put their hands down another resident's pants in a common area, as witnessed by staff and other residents. The resident who was the alleged victim had significant cognitive impairment, including diagnoses of senile degeneration of the brain, dementia with agitation, and major depressive disorder. The resident required assistance with activities of daily living and exhibited behaviors such as yelling and agitation. The alleged perpetrator also had cognitive deficits and a history of making inappropriate sexual comments, and was placed on one-to-one supervision following the incident. Despite these factors and the facility's policy, the incident was not reported to the state survey agency, law enforcement, or the hospice agency caring for the resident. Interviews revealed that staff were aware of the incident and that the family of the alleged victim was notified. However, the facility's administration determined, after reviewing camera footage and conducting assessments, that the incident did not occur as initially reported and therefore did not report it to authorities. The hospice agency only became aware of the incident after being informed by the resident's family, not by the facility. The failure to report the allegation as required constitutes the deficiency.
Failure to Investigate and Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy and did not ensure that an alleged incident of sexual abuse involving a resident was properly investigated. According to the facility's policy, all allegations of abuse, including sexual abuse, must be promptly and thoroughly investigated, with appropriate notifications made to authorities and documentation of all investigative steps. However, when an allegation was made that one resident put their hands down another resident's pants in a common area, the facility did not conduct a documented investigation as required by policy. The Administrator relied on a review of camera footage, which was later stated to be unavailable, and determined the allegation was unsubstantiated without further inquiry or reporting to the state survey agency or law enforcement. The resident involved in the alleged incident had significant cognitive impairment, as evidenced by a BIMS score of zero and diagnoses including dementia with agitation, senile degeneration of the brain, and major depressive disorder. The resident was also receiving hospice services and required assistance with activities of daily living. The alleged perpetrator had a history of making inappropriate sexual comments and was placed on one-to-one supervision following the incident. Despite these factors and the facility's policy requiring investigation and reporting, the Administrator did not initiate a formal investigation or notify external authorities. Interviews with staff and the resident's family revealed inconsistencies in the facility's response. The family was informed by nursing staff that the incident had been witnessed by others and that an assessment found no injuries or signs of distress. However, the Administrator later stated there was no camera footage and that the incident did not warrant reporting or further investigation. The lack of a documented investigation and failure to follow established protocols resulted in a deficiency related to the facility's handling of abuse allegations.
Failure to Obtain and Follow Wound Vac Dressing Orders Resulting in Harm
Penalty
Summary
The facility failed to ensure that appropriate wound dressing orders were obtained and followed for a resident with a left below-the-knee amputation and multiple comorbidities, including Parkinson's Disease and peripheral vascular disease. The resident had a negative pressure wound therapy (wound vac) applied to the surgical site, but there were no documented physician orders for wound vac changes between September 9 and September 16. During this period, the wound vac dressing remained in place for ten days without being changed, contrary to standard practice and the facility's own wound management policy, which requires treatment per physician order and regular skin assessments. When staff attempted to change the wound vac dressing, they found the sponge severely adhered to the wound, resulting in significant bleeding and pain for the resident. The lack of documentation regarding dressing changes and absence of a wound nurse contributed to confusion among staff about wound care responsibilities and supply ordering. The incident led to the resident being transferred to the hospital due to excessive bleeding. Interviews with clinical staff and providers confirmed that the dressing was not changed as expected and that there were no clear orders or documentation guiding wound care during the period in question.
Failure to Prevent Elopement and Injury in Cognitively Impaired Resident
Penalty
Summary
A resident with a history of traumatic brain injury, subdural hemorrhage, dementia with behavioral disturbances, and other significant medical conditions eloped from the facility's secure memory care unit. The resident was known to have severely impaired cognition, required substantial assistance with activities of daily living, and had a documented risk for elopement and wandering. On the day of the incident, the resident was observed to be agitated, demanding to go home, and was last seen at the nurse's station before propelling a wheelchair down the hallway, transferring out of the wheelchair, and exiting through a door that sounded an alarm. Shortly after, the resident was found in the facility parking lot by visitors, sitting on the ground with a laceration to the forehead. Staff responded, brought the resident back inside, and the resident was subsequently sent to the emergency room for evaluation due to the head injury and history of anticoagulant use. The resident returned later with sutures to the forehead and additional bruising, but imaging was negative for further injury. Interviews with staff and practitioners confirmed that the resident was known for frequent wandering and exit-seeking behaviors, and staff were expected to monitor the resident and respond to door alarms. The deficiency occurred due to the facility's failure to provide adequate supervision and prevent the resident from eloping, despite the resident's known risks and behaviors. The resident was able to leave the secure unit, exit the building, and sustain an injury before being found and assisted by staff.
Failure to Provide Required Discharge Notice and Documentation
Penalty
Summary
A deficiency occurred when facility staff failed to provide an appropriate discharge for a resident with complex medical and behavioral needs. The resident, who had diagnoses including congestive heart failure, neurocognitive disorder with Lewy bodies, repeated falls, dementia, and was on hospice care, was transferred to a hospital following an incident of severe agitation and aggression. Staff attempted de-escalation techniques, but after the resident struck a staff member and exhibited exit-seeking behavior, the DON called 911 for a hospital transfer. The family was notified of the transfer for medical evaluation, but there was no clear communication that the resident would not be accepted back to the facility. The facility did not provide the required written notice of discharge, which should have included the date and location of discharge, a statement of appeal rights, and contact information for the State Long Term Care Ombudsman. Documentation of the bed hold policy was not found in the electronic records, and the family confirmed they did not receive a copy of the bed hold policy, notice of proposed transfer/discharge, or information regarding appeal rights. The resident's DPOA was not notified of the transfer or discharge, and there was no evidence of the resident or representative's involvement in the development of a discharge plan addressing the resident's needs. Interviews with facility staff revealed confusion and lack of coordination regarding the discharge process. The Social Services Director had little involvement and was notified after the transfer occurred, while the Admissions Coordinator was unaware that the resident would not return to the facility. The DON and LPN involved in the transfer did not communicate the final discharge decision to the family or DPOA. The hospital staff were also not informed that the resident would not be returning, and the hospital was not equipped to provide long-term care. As a result, the resident experienced confusion, physical and psychosocial harm due to the lack of appropriate planning and notification.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident physically assaulted another, resulting in multiple injuries. Specifically, a resident with a history of behavioral problems, including hitting and pulling peers' hair, and diagnoses such as frontal temporal neurocognitive disorder, dementia, depression, and Pick's disease, hit and restrained another resident. The assaulted resident, who had Alzheimer's disease and dementia, sustained a scratch to the left cheek, redness to the right eye, an abrasion to the right eyebrow, and redness and bruises to the right forearm and bicep. The incident occurred in a resident room and was discovered by staff after hearing screaming; staff did not witness the altercation but found the injured resident visibly shaken and crying. The care plan for the resident who initiated the altercation noted a behavior problem and directed staff to intervene as necessary to protect others, but the incident still occurred. Both residents involved had significant cognitive impairments, and the resident who was assaulted had a history of trauma and poor safety awareness. The facility's Abuse Prevention and Prohibition Program outlined a zero-tolerance policy for abuse and required staff to prevent abuse and monitor resident behaviors that could lead to conflict. Despite these policies, the altercation resulted in physical harm, and the injuries were confirmed by the DON and Administrator as fitting the definition of physical abuse according to facility policy.
Food Safety and Hygiene Protocol Deficiencies Identified
Penalty
Summary
The facility failed to ensure compliance with food safety standards during a survey conducted on 04/08/24. Observations revealed multiple instances of stored food items being undated and exposed to potential contamination in the walk-in freezer and refrigerator. Additionally, air vents in the kitchen were visibly dirty, posing a risk of contaminating food with dust particles. The Dietary Director acknowledged the importance of proper labeling and dating of food items but noted a lack of awareness among maintenance staff regarding the cleanliness of the vents. Furthermore, during the same survey, a dietary staff member was observed not wearing a beard restraint while handling food on the serving line, contrary to facility policy requiring staff to wear appropriate hair restraints at all times. The staff member admitted to removing the restraint due to discomfort, highlighting a gap in adherence to established guidelines for preventing hair contamination in food preparation areas. These deficiencies in food storage practices and staff compliance with hygiene protocols could potentially impact the health and safety of the 98 residents consuming food prepared in the facility's kitchen.
Failure to Inform Resident of Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was informed of the risks and benefits of a physician-ordered antipsychotic medication. Specifically, Resident 78, who was admitted with Alzheimer's disease and major depressive disorder, was prescribed Abilify 5 mg at bedtime. The resident's electronic medical record did not document that the resident or her representative was informed of the risks and benefits prior to initiating the new medication order. This oversight was confirmed during an interview with the Unit Manager, who acknowledged that no consent was obtained for the use of the medication. Resident 78 had a Brief Interview of Mental Status score indicating moderate cognitive impairment and was administered the antipsychotic medication daily. During an interview, the resident stated she was not aware of what Abilify was for, despite being administered the medication. The facility did not provide a policy regarding the documentation of informed consent for medication use, highlighting a significant lapse in ensuring residents are fully informed about their treatments.
Failure to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for Resident 67, who was observed to have a heavy build-up of dirt and grime in the sliding door track, dirt and dust under the bed, and small black ants in the room. Despite the resident's cognitive intactness, as indicated by a BIMS score of 15 out of 15, the room's condition remained poor over multiple observations. The resident and a family member both noted the presence of ants and the need for better cleaning. The facility's Administrator was unaware of the ant issue, and the Activity Director, who oversees housekeeping, acknowledged that spring cleaning had not yet started and there was no care plan addressing the resident's wishes and the need for room cleaning. During interviews, the Administrator mentioned that exterminators visit every other week and weekly in late spring and summer. The Activity Director stated that they had not begun spring cleaning tasks such as steam cleaning and moving furniture. The lack of a care plan to balance the resident's preferences with the need for cleanliness contributed to the ongoing issue. The facility's failure to address the cleanliness and pest control in Resident 67's room led to the deficiency noted in the report.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. Resident 96, who has diagnoses including frontotemporal neurocognitive disorder, dementia, impulse disorder, and delusional disorder, bit Resident 51 on the arm after Resident 51 reached for a blanket that Resident 96 was using. Both residents have significant cognitive impairments, with their respective care plans noting aggressive and socially inappropriate behaviors. Despite interventions to monitor and manage these behaviors, the incident occurred, resulting in a bruise on Resident 51's arm, although the skin was not broken. Interviews with staff revealed that Resident 96 was known to be uncooperative with care, often becoming combative when staff attempted to take something away from her. Staff had been using strategies such as offering sweets and drinks to redirect her, but these were not always effective. On the day of the incident, Resident 96 was lying on a couch in the common area, a place she preferred to stay during the day. When Resident 51 reached for the blanket, Resident 96 reacted by biting her. Staff immediately separated the residents and placed Resident 96 on 15-minute checks. Further interviews indicated that staff were aware of Resident 96's unpredictable behavior and had been trying to keep a close eye on her. The Director of Nursing mentioned that Resident 96 had been sent out for psychiatric evaluation following the incident. The facility's policy on abuse and neglect emphasizes the residents' right to be free from all forms of abuse and outlines procedures for reporting and addressing such incidents. However, the measures in place were insufficient to prevent the incident from occurring, highlighting a deficiency in protecting residents from abuse by other residents.
Failure to Report Injury and Altercation Timely
Penalty
Summary
The facility failed to report an injury of unknown origin and a resident-to-resident altercation to the State Survey Agency (SSA) within the required timeframes. Resident 96, who has diagnoses including frontotemporal neurocognitive disorder, dementia, impulse disorder, and delusional disorder, was found with a bruise below her left eye on 10/24/23. The Licensed Practical Nurse (LPN) who discovered the bruise did not remember reporting it to the Director of Nursing (DON) or completing a report. The DON also did not recall the incident and confirmed it was not reported to the SSA as required. Additionally, an altercation occurred on 03/20/24 where Resident 96 was hit by another resident. This incident was reported to the unit manager but not to the DON until the following morning. The DON was unaware that such incidents needed to be reported within two hours if they did not result in major injury. The incident was eventually reported to the SSA on 03/22/24. The facility's policy mandates reporting all incidents of potential abuse, neglect, exploitation, or potential crimes against residents within prescribed timeframes, but this was not adhered to in these cases.
Failure to Investigate Injury and Altercation
Penalty
Summary
The facility failed to conduct thorough investigations for an injury of unknown origin and a resident-to-resident altercation involving two residents. Resident 96, who has diagnoses including frontotemporal neurocognitive disorder, dementia, impulse disorder, and delusional disorder, was found with a small purplish bruise below her left eye while sitting in the TV area. The resident was unable to explain how the bruise occurred and denied pain. The Licensed Practical Nurse (LPN) who discovered the bruise did not remember reporting it to the Director of Nursing (DON) or completing a report. The DON confirmed that no investigation was conducted to determine the cause of the bruise. Resident 51, diagnosed with Alzheimer's and dementia, was involved in an altercation where another resident was observed hitting her on the right arm. The incident was reported to the unit manager by an LPN, but the DON confirmed that no investigation or witness statements were collected. The facility's policy mandates thorough investigations for all allegations, observations, or suspected cases of abuse, neglect, misappropriation of property, exploitation, or injuries of unknown sources, which was not followed in these cases.
Failure to Update Care Plans for PTSD and Specialized Wheelchair
Penalty
Summary
The facility failed to revise the care plan for two residents, leading to deficiencies in their care. Resident 66, who was admitted with a diagnosis of PTSD, did not have an updated care plan addressing this condition. Despite showing symptoms of depression and expressing feelings of tiredness and lack of interest in activities, the care plan for Resident 66 did not include any interventions related to PTSD. The Social Services Director was unaware of the PTSD diagnosis and had not written a care plan for it, indicating a lapse in communication and documentation within the facility's care planning process. Resident 55, who has Alzheimer's disease and dementia, was observed using a specialized wheelchair provided by hospice for four to six months. However, the care plan for Resident 55 was not updated to reflect the use of this specialized wheelchair. The Unit Manager confirmed that the care plan had not been revised to include this critical piece of equipment. This oversight in updating the care plan could lead to inappropriate care and services for Resident 55, who is dependent on staff for all activities of daily living and has severe cognitive impairment.
Failure to Provide Appropriate Care and Timely Medical Appointments
Penalty
Summary
The facility failed to ensure that two residents received care and treatment in accordance with professional standards of practice. Resident 55, who has Alzheimer's disease and is severely cognitively impaired, was observed in a specialized wheelchair without proper support. The headrest was angled away from her head, and her left leg was dangling without the support of a leg pedal. Staff interviews revealed that the headrest and leg pedal were not consistently utilized, and there was confusion about whose responsibility it was to ensure these supports were in place. The Rehabilitation Director confirmed that the headrest and leg pedal should be used at all times when the resident is in the wheelchair. Resident 67, who is cognitively intact and has a history of Guillain-Barre syndrome and pruritus, complained of excessive itching and believed she was being bitten by bugs. Despite her requests to see a dermatologist, no appointment was made. Observations and interviews revealed that the resident had reddened and scabbed areas on her skin, and her complaints were documented in the medical record. However, the Assistant Director of Nursing and the Social Service Director were unaware of her request for a dermatology appointment, and no orders for such an appointment were obtained. The facility's failure to provide appropriate support for Resident 55's head and leg while in the wheelchair and the delay in obtaining a dermatology appointment for Resident 67 highlight deficiencies in adhering to professional standards of care. These lapses were confirmed through observations, staff interviews, and record reviews, indicating a need for improved communication and adherence to care plans within the facility.
Failure to Provide Appropriate ROM Services
Penalty
Summary
The facility failed to ensure that a resident with a history of stroke and cerebral palsy received appropriate services to maintain or improve her range of motion (ROM). The resident, who was cognitively intact, had functional limitations in ROM on one side for both the upper and lower extremities. Despite this, the resident did not receive any restorative therapy or exercises to prevent a decline in her contractures. The only intervention documented was the placement of a washcloth in her contracted right hand, which was insufficient to address her needs. Interviews with the resident and staff revealed that the resident did not receive any exercises for her hand and foot, and there was no restorative program in place for her. The Assistant Director of Nursing (ADON) and the MDS Coordinator both confirmed that the resident had not been assessed for restorative exercises, and there was no designated nurse responsible for the restorative program. The facility's policy indicated that residents with potential for decline should be referred to the restorative nurse aid (RNA) program, but this was not done for the resident in question.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to ensure that a resident received respiratory care consistent with professional standards of practice. Specifically, the facility did not place the resident's nebulizer tubing and pipe into a covered bag to minimize the spread of pathogens. This deficiency was observed during a survey, where the nebulizer machine and its components were found on the bedside table without a barrier or bag. The resident, who had been admitted with diagnoses including heart failure and chronic obstructive pulmonary disease (COPD), was at risk for infection due to this oversight. The resident's medical records indicated a need for nebulizer treatments four times a day and the use of oxygen at night. Despite these requirements, the facility did not follow proper storage protocols for the respiratory equipment. An interview with an LPN confirmed that nebulizer masks and pipes should be bagged when not in use, but this was not done for the resident in question. The facility was unable to provide a policy for storing respiratory equipment when requested by the surveyors.
Failure to Complete AIMS Assessment and Properly Document PRN Psychotropic Medication
Penalty
Summary
The facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident (R78) who was administered antipsychotic medication, Abilify, for Alzheimer's disease, dementia, and major depressive disorder. The AIMS assessment was not performed upon initiating the medication but was delayed by 57 days. The facility's policy required AIMS assessments at admission, readmission, and quarterly if the resident has orders for psychotropic medication. The Unit Manager confirmed that the AIMS assessment was not done at the time the medication was started and could not provide an assessment for the previous quarter before the survey team exited. This failure placed the resident at risk for unrecognized side effects and a diminished quality of life. Additionally, the facility failed to have a stop date and diagnosis for the use of an as-needed (PRN) psychotropic medication, Lorazepam, for another resident (R59) who had a history of stroke and diabetes and was severely impaired in cognition. The Physician Order for Lorazepam was open-ended without a discontinue date and lacked a diagnosis for its use. The Licensed Practical Nurse (LPN) and Consultant Pharmacist were unaware of the need for an end date and proper diagnosis for the medication. The facility's policy required that each resident's drug regimen be free from unnecessary drugs, and PRN orders for psychotropic medications should be limited and necessary. This oversight placed the resident at risk for unrecognized side effects and a diminished quality of life.
Failure to Remove Expired Insulin Pen
Penalty
Summary
The facility failed to ensure an insulin pen was removed from one medication cart after 28 days for one of 18 Kwik pens that were observed for open date and expiration date. During an observation with a Registered Nurse (RN), it was revealed that the Kwik pen for a resident had an open date that was smudged and not legible. The RN confirmed that the Kwik pen was expired and had been used to administer insulin to the resident when their blood sugar was 375. The Director of Nursing (DON) confirmed that the expectation was for expired insulin pens to be removed from the cart and not used. Review of the physician orders in the electronic medical record (EMR) indicated that the resident was to receive four units of Humalog Kwik Pen U-100 insulin if their blood sugar was greater than 300. The manufacturer's guidelines state that opened Humalog prefilled pens must be discarded 28 days after first use. The facility's policy on medication storage also mandates that no outdated or deteriorated drugs be retained for use. Despite these guidelines, the expired insulin pen was not removed, leading to the deficiency.
Failure to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to ensure the reach-in refrigerator in the kitchen was properly maintained, which had the potential to affect 98 of the 99 residents who consume food from the kitchen. During a tour of the kitchen, it was observed that the refrigerator had a leak resulting in about an inch of water at the bottom, which was almost reaching the rim of a cookie sheet with condiments on it. Several boxes of Jello were visibly wet from the leak, and the water extended onto the floor when the doors were opened. The issue persisted the following day, with a thick slice of cheese wrapped in saran wrap observed submerged in the water. Dietary staff confirmed that the refrigerator had been leaking for at least six months, sometimes causing water to leak onto the floor. The maintenance staff, who had been employed since February 19, 2024, stated that logbooks were kept at each nursing station for items needing attention and were checked daily. However, the maintenance staff was only notified about the refrigerator leak on the day of the interview. The administrator, acting as the maintenance director, confirmed that they had been without a Maintenance Director for a few weeks and were only notified about the leak the previous day. A review of the Maintenance Repair Log revealed that the issue was noted on August 10, 2023, but there was no indication that it had been repaired. The dietary director mentioned that the state had visited in August 2023 and indicated that the refrigerator should be fixed, but it was left as a concern without a violation, leading to the repair notice being written in the log.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
