Osage Beach Rehabilitation And Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Osage Beach, Missouri.
- Location
- 844 Passover Road, Osage Beach, Missouri 65065
- CMS Provider Number
- 265171
- Inspections on file
- 18
- Latest survey
- June 17, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Osage Beach Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
A resident who was totally dependent for transfers and required a mechanical lift with two-person assistance was transferred by a CNA alone, contrary to facility policy and manufacturer guidelines. During the transfer, the lift struck a wall-mounted TV, causing it to fall and injure the resident's head and arm. The resident, who is paraplegic and obese, reported the incident and expressed concern about single-staff transfers.
Staff did not notify a physician after a resident, who was cognitively intact and had Guillain-Barre syndrome with paraplegia, was struck on the arm and head by a falling television. Although the incident was reported internally, there was no documentation of physician notification as required by facility policy. Interviews confirmed that the RN did not realize the extent of the incident and failed to contact the physician, contrary to expectations set by the DON and administrator.
Facility staff failed to use barriers for glucometer supplies and did not wear gloves during insulin administration for several residents with diabetes, risking contamination. Interviews revealed a lack of awareness of infection control protocols. Additionally, the facility's water management program was incomplete, lacking specific control measures and corrective actions, with staff unfamiliar with the program's requirements.
Facility staff failed to document code status orders for a resident and had conflicting orders for another, leading to confusion about their medical intervention preferences. Additionally, three residents had medications prescribed without documented clinical conditions or symptoms, highlighting lapses in the facility's documentation process. The DON and Infection Preventionist acknowledged these issues, noting challenges with a new external company handling admission orders.
A facility failed to obtain informed consents and complete side rail assessments for five residents, leading to a deficiency in compliance with their policy on the proper use of side rails. Residents with varying cognitive and physical impairments were observed with bed rails in use without the necessary documentation. Interviews with staff revealed confusion and lack of clarity regarding responsibility for completing assessments and obtaining consents.
Facility staff failed to protect resident information by leaving computer screens open and unattended, exposing medication details for multiple residents. Despite awareness of HIPAA regulations, RNs repeatedly left screens visible in public areas, violating privacy policies.
Facility staff failed to accurately document MDS assessments for three residents, leading to deficiencies. A resident's PASRR Level II determination was not reflected in the MDS, and another resident's vision was inaccurately assessed. The MDS Coordinator, responsible for completing assessments, admitted to oversights and lack of awareness. The facility lacked a specific MDS policy, relying on CMS guidelines and the RAI manual.
The facility failed to prominently post the DHSS elder abuse and neglect hotline number, as required by policy. Observations showed the number was placed at the end of an unoccupied hall, not visible to residents or staff. Interviews revealed that neither the SSD nor the DON were aware of its improper placement, and residents were unaware of its location.
Facility staff failed to provide adequate hygiene care for three residents, who required substantial assistance with personal hygiene and bathing. Despite scheduled showers twice a week, observations noted greasy hair and unkempt appearances, with residents expressing dissatisfaction. Staff interviews revealed inconsistencies in documenting and communicating refusals, contributing to the deficiency.
A medication error occurred when an LPN, unfamiliar with residents, administered a roommate's medication to a resident, leading to hospitalization. The resident, with moderate cognitive impairment and various diagnoses, received medications not prescribed for them, resulting in low blood sugar and blood pressure. The error was discovered when the LPN noticed the resident did not have a catheter, prompting immediate medical intervention.
The facility did not conduct and document an annual facility-wide assessment to determine necessary resources for resident care during daily operations and emergencies. The assessment lacked required staffing information. The administrator acknowledged the incomplete assessment and stated staffing was based on census data. The facility had 73 residents.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
Facility staff failed to provide a proper mechanical lift transfer for a resident, resulting in an accident where a television was struck by the lift and fell, causing injury to the resident's head and arm. The facility's policy and the lift manufacturer's manual both require two staff members to assist with mechanical lift transfers, especially for residents with conditions such as obesity, contractures, or combativeness. The resident in question was assessed as cognitively intact, totally dependent for transfers, paraplegic, obese, and required a mechanical lift with two-person assistance for all transfers. Despite these requirements, a Certified Nursing Assistant (CNA) performed the transfer alone. During the transfer, the CNA raised the mechanical lift, which hit the television mounted on the wall, causing it to fall and strike the resident. The CNA acknowledged operating the lift alone and reported the incident to a Registered Nurse (RN), initially stating the television did not hit the resident, but later confirming it struck the resident's arm and head. The resident reported feeling a knot on the head and expressed concern that staff often use only one person for mechanical lift transfers, despite being paralyzed. Interviews and documentation confirmed that the facility's policy was not followed, leading to the accident and injury.
Failure to Notify Physician After Resident Injury
Penalty
Summary
Facility staff failed to notify a physician in a timely manner after a television fell from the wall and struck a resident in the arm and head. The resident was assessed as cognitively intact and had a history of Guillain-Barre syndrome and paraplegia. According to the facility's policies, staff are required to notify the physician and document the content of the discussion following any change in patient status or accident. However, nurse notes indicated that although the incident was reported by a CNA, there was no documentation that the physician was notified of the change in condition. Interviews with staff revealed that the RN on duty did not realize the resident had been struck by the television and therefore did not contact the physician. Both the DON and the administrator stated that their expectation is for staff to notify the physician of any accidents, particularly those involving the head, and to document the notification. Despite these expectations and policies, the required physician notification did not occur in this incident.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility staff failed to adhere to infection prevention protocols by not using barriers for glucometer supplies and not wearing gloves during insulin administration. This was observed in seven residents who were sampled, all of whom had a diagnosis of diabetes. Registered Nurses were seen placing glucometers directly on dining room tables without barriers, which could lead to contamination. Additionally, some nurses did not wear gloves while administering insulin, increasing the risk of exposure to blood and bodily fluids. Interviews with the staff revealed a lack of awareness and understanding of the infection control protocols. One RN acknowledged the risk of contamination but could not explain why gloves were not worn. Another RN did not see an issue with placing the glucometer on the table, despite acknowledging the potential for contamination. The Director of Nursing and the facility administrator also recognized the risks but were unsure about the necessity of wearing gloves during insulin administration. The facility also failed to develop and implement comprehensive policies for the inspection, testing, and maintenance of its water systems to prevent the growth of waterborne pathogens like Legionella. The facility's water management program lacked specific control measures, acceptable ranges, and corrective actions. The maintenance director was unfamiliar with the program's control measures and did not document water quality test results or take corrective actions. The administrator admitted to a lack of knowledge about the water management program and could not locate specific control measures or corrective actions in the plan.
Documentation Failures in Code Status and Medication Indications
Penalty
Summary
The facility staff failed to meet professional standards of care by not documenting code status orders for residents, which is crucial for determining the level of medical intervention a resident wishes to receive. Specifically, Resident #9 did not have a documented order for code status, despite being moderately cognitively impaired and expressing a preference for full code status. The Director of Nursing (DON) and Clinical Coordinator acknowledged the oversight, noting that the admitting nurse is responsible for verifying and entering the code status order, while the Health Information staff audits these orders. However, the Health Information staff admitted to not checking code status orders for residents who have been at the facility for a while, leading to the oversight. Resident #37 had conflicting orders for code status, with both DNR and full code status documented on different dates. The DON confirmed that a resident should not have two different orders for code status and attributed the error to the admitting nurse's responsibility to verify and enter the correct order. The Health Information staff is supposed to audit these orders, but the discrepancy was not caught, leading to confusion about the resident's code status. Additionally, the facility failed to document clinical conditions or symptoms for the use of medications for Residents #75, #79, and #80. Resident #75 was on an antibiotic without a documented indication for use, Resident #79 was prescribed an antipsychotic medication without a documented clinical condition, and Resident #80 was on a blood pressure medication without documentation of the condition it was treating. The Infection Preventionist/Clinical Coordinator and the DON acknowledged the lapses, noting that the facility had recently started using an external company for entering admission orders, which had not been going smoothly. The pharmacist also had not reviewed the medications for new admissions in a timely manner, contributing to the lack of documentation for medication indications.
Failure to Obtain Consents and Assessments for Bed Rail Use
Penalty
Summary
The facility failed to obtain informed consents and complete side rail assessments for five residents, leading to a deficiency in compliance with their own policy on the proper use of side rails. The policy requires an assessment to determine the resident's symptoms, risk of entrapment, and reason for using side rails, as well as obtaining consent from the resident or their legal representative. However, the facility did not have signed consents or completed assessments for the use of bed rails for the residents in question. Resident #18, who has severe cognitive impairment and requires substantial assistance for mobility, was observed multiple times with bed rails in the upright position without a signed consent or assessment in their electronic medical record. Similarly, Resident #43, who is cognitively intact, was also observed with a bed rail in the upright position without the necessary documentation. Residents #64, #76, and #77, all with varying degrees of cognitive and physical impairments, were also found to have bed rails in use without the required consents and assessments. Interviews with facility staff, including the MDS/Care Plan Coordinator, RN, and DON, revealed a lack of clarity and responsibility regarding who should complete the initial and ongoing side rail assessments and obtain informed consents. The MDS Coordinator admitted to missing some residents during audits, and there was confusion among staff about the process and oversight for ensuring compliance with the facility's policy. The administrator also expressed uncertainty about the procedures for bed rail assessments and consents, indicating a systemic issue in the facility's management of side rail use.
Failure to Protect Resident Information
Penalty
Summary
Facility staff failed to protect residents' personal information by leaving computer screens open and unattended in public areas, exposing medication information for six residents. Observations revealed that Registered Nurse (RN) A left screens open with visible medication information for three residents in Hallway A, while RN B did the same for two residents on the insulin cart. RN C also left screens open with resident information visible in the dining room. These actions occurred despite the facility's policy to comply with the HIPAA Privacy Rule and maintain the confidentiality of Protected Health Information (PHI). Interviews with the involved RNs and the Director of Nursing (DON) confirmed awareness of the risk of exposing resident information and the importance of minimizing screens when unattended. The administrator also acknowledged the need to close screens to protect privacy. Despite this awareness, the repeated failure to secure computer screens resulted in the exposure of sensitive resident information, violating the facility's privacy policy and HIPAA regulations.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility staff failed to document accurate Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the federally mandated assessment process. For Resident #9, the MDS inaccurately reflected the resident's PASRR Level II determination, which indicated a serious mental illness related to Bipolar I Disorder. The MDS Coordinator admitted to an oversight and lack of awareness of the resident's PASRR Level II determination. Similarly, Resident #41's MDS did not accurately reflect the resident's PASRR Level II status, despite having diagnoses of Major Depression Disorder and PTSD. The MDS Coordinator was unaware of the resident's Level II status, resulting in an inaccurate assessment. Additionally, Resident #43's MDS inaccurately assessed the resident's vision as adequate, despite the resident's self-reported blindness and inability to watch TV. The Director of Nursing (DON) acknowledged the inaccuracies in the MDS assessments and noted that the MDS Coordinator, who had been in the role for about seven months, was responsible for completing the assessments without any double-checking for accuracy. The facility lacked a specific MDS policy and relied on CMS guidelines and the RAI manual for guidance, which contributed to the inaccuracies in the assessments.
Failure to Prominently Post DHSS Hotline Number
Penalty
Summary
The facility failed to post the Department of Health and Senior Services (DHSS) elder abuse and neglect hotline number in a location that was accessible and visible to residents, their representatives, visitors, and staff. The facility's policy, revised on 02/01/2023, required that the names, addresses, and telephone numbers of pertinent state client advocate groups be prominently posted. However, observations on multiple occasions revealed that the hotline number was posted at the end of an unoccupied hall, rather than in a prominent location. Interviews with the Social Service Designee (SSD) and the Director of Nursing (DON) confirmed that they were unaware the number was not posted in the front area of the facility, as required. Interviews with residents indicated that they were not aware of the hotline number's location, and some had never heard it discussed. The Administrator stated that the SSD was responsible for ensuring the information was posted, but acknowledged that it was currently located near the DON's office rather than in a more visible area. This oversight resulted in residents and staff being unaware of the hotline number's location, which is a critical resource for reporting abuse and neglect.
Inadequate Hygiene Care for Residents
Penalty
Summary
The facility staff failed to provide adequate hygiene care for three residents, as observed and documented in the report. Resident #5 was assessed to require substantial assistance with personal hygiene and bathing, with a scheduled shower twice a week. However, records showed inconsistent documentation of showers, and observations noted the resident with greasy hair, indicating a lack of proper hygiene care. The Clinical Coordinator confirmed that the resident did not refuse showers, yet the scheduled care was not consistently provided. Resident #24 also required substantial assistance with personal hygiene and was scheduled for showers twice a week. Despite this, the resident was observed with long nails and greasy hair, and expressed dissatisfaction with the infrequency of showers. The Clinical Coordinator mentioned occasional refusals but was unsure of any pattern, and the documentation did not reflect consistent care or refusals. Resident #80, admitted with severe cognitive impairment, required supervision for personal hygiene and was scheduled for showers twice a week. The resident was observed with unkempt hair and expressed concerns about not receiving a shower since admission. The Clinical Coordinator was unaware of any refusals, and the documentation showed only one shower and one refusal. Interviews with staff revealed inconsistencies in documenting and communicating refusals, contributing to the deficiency in providing adequate hygiene care.
Medication Error Leads to Hospitalization
Penalty
Summary
Facility staff failed to ensure residents remained free from significant medication errors when a Licensed Practical Nurse (LPN) administered the wrong medication to a resident. The error occurred when the LPN, unfamiliar with the residents, addressed a resident by the name of their roommate, and the resident responded, leading the LPN to administer medications intended for the roommate. The medications included Lantus insulin, hydralazine, metformin, and gabapentin, which were not prescribed for the resident. The error was discovered when the LPN noticed the resident did not have a catheter, which was expected for the roommate. The resident, who was moderately cognitively impaired and had diagnoses including anemia, gastric reflux disease, benign prostatic hyperplasia, and anxiety, experienced an adverse reaction. The resident's blood sugar dropped to 70, and their blood pressure trended downwards, necessitating hospitalization. The incident was reported to the physician, and the resident was monitored with blood sugar checks and given snacks to counteract the insulin effects. The error was attributed to the LPN's unfamiliarity with the residents and a mix-up in the medication administration record (MAR) that flipped the bed assignments.
Failure to Conduct Annual Facility-Wide Assessment
Penalty
Summary
The facility staff failed to conduct and document an annual facility-wide assessment to determine the necessary resources for competent resident care during both day-to-day operations and emergencies. The assessment, covering the period from September 2022 through August 2023, lacked required information on staffing for these operations. During an interview, the administrator acknowledged the absence of a complete facility assessment and admitted awareness of the annual requirement, stating that staffing decisions were made based on census data. The facility had a census of 73 residents at the time of the report.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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