Ozark Nursing And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ozark, Missouri.
- Location
- 1486 North Riverside Rd, Ozark, Missouri 65721
- CMS Provider Number
- 265753
- Inspections on file
- 28
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Ozark Nursing And Care Center during CMS and state inspections, most recent first.
A cognitively intact resident, dependent on staff for mobility and requiring a Hoyer lift with two-person assistance for transfers, fell from a manual Hoyer lift and sustained facial and head injuries, including a chin laceration and ongoing numbness in the lower face. During a transfer from wheelchair to bed, staff reported difficulty moving the lift, applied a strong push, and the lift tipped, causing the resident to fall from an elevated position. Facility policy required thorough assessment and investigation after falls, but observations and interviews showed inconsistent and unsafe Hoyer practices: staff pulled on the sling to move the lift, questioned correct strap use, positioned the sling above the resident’s head causing poor alignment, and lowered the resident without locking the wheels. Multiple CNAs, CMTs, an LPN, the ADON, and the administrator described expected standards (open legs, locked legs when raising/lowering, two staff with one operating and one guiding), yet at least one CNA reported no specific Hoyer training, staff expressed concerns that facility lifts were unstable or old, and the maintenance director had not yet completed the monthly safety check and had not been informed of any broken lifts. These findings demonstrate that the facility failed to ensure safe mechanical lift operation and adequate supervision, leading to the resident’s fall and injury.
A cognitively intact resident with multiple chronic conditions had a full set of scheduled morning oral medications prepared and signed out on the MAR by a CMT, who then asked an LPN to deliver them. The LPN placed the medications at the bedside at the resident’s request for milk, left to obtain the milk, returned with it, and then left the room without observing the medications being taken, despite facility policy prohibiting leaving medications at bedside without a physician’s order. Later, the resident reported the medications were missing, and a CNA notified the LPN; the resident subsequently found the pills in the bed. In interviews, the resident reported that staff do not stay to observe medication administration, and the CMT, LPN, ADON, and Administrator all confirmed that there was no order to leave medications at bedside and that medications should not have been left unattended, while the CMT had already documented administration on the MAR.
A resident with vascular dementia, diabetes, and moderate cognitive impairment alleged that a CMT hurt the resident’s hand during medication administration, with multiple staff hearing the resident say staff had hurt the hand and caused bruising. Although staff recognized that hitting or hurting a resident’s hand would constitute abuse, the accused CMT was allowed to continue working, including on the same hall, and was not suspended pending investigation. Required steps such as a complete resident assessment, detailed progress note documenting the allegation, notifications to the physician, family, and administration, and a thorough, documented investigation with submission to the state agency were not completed, and the facility could not provide a full investigation report when requested.
A resident with vascular dementia and moderate cognitive impairment alleged that a CMT hurt their hand during medication administration, became upset, and threw water at the staff member. Multiple staff, including an LPN and CNAs, heard or were told that the resident said staff hurt their hand or caused a bruise, and the allegation was reported internally to the ADON and Administrator. The LPN’s progress note documented the resident’s agitation and behavior but omitted the abuse allegation, and the ADON and Administrator assessed the resident’s bruising and obtained differing accounts from the resident about who caused the injury. Although staff acknowledged that hurting a resident’s hand would be abuse and that such allegations must be reported to the state within two hours, the facility did not report this allegation of possible abuse to the State Survey Agency as required by its own policy.
Surveyors found that the facility did not maintain proper documentation or timely destruction of discontinued and expired controlled medications. Numerous medications, including narcotics and other controlled substances, were stored in a locked file cabinet without required accountability sheets or destruction logs. Staff interviews revealed a lack of awareness and participation in the destruction process, and the DON admitted to not following policy due to missing documentation logs. The facility's own policy for dual-nurse destruction and prompt removal of medications was not followed.
A CNA physically and verbally abused a resident with dementia and Parkinson's by forcibly grabbing the resident's arms and cursing at them during an attempt to remove the resident from the dining room. The resident, who was confused and dependent on staff, resisted the CNA's actions, leading to an escalation where both parties exchanged profanities and the CNA used inappropriate physical force. Facility leadership confirmed the CNA's actions were abusive and not in line with policy.
The facility did not consistently post up-to-date daily nurse staffing information in a clear and accessible location. Observations showed outdated or missing staffing sheets, and record review confirmed several dates with no posted forms. Interviews with LPNs, the receptionist, and administrators revealed unclear responsibilities and oversight regarding the completion and posting of these forms, resulting in noncompliance with required staffing information postings.
The facility did not report an allegation of staff-to-resident abuse to DHSS within the required two-hour timeframe after a CNA witnessed another CNA being rough with a resident who was highly dependent on staff. Additionally, the facility failed to report an allegation of misappropriation of personal items from a resident's room within the required twenty-four-hour period. Staff interviews revealed inconsistent knowledge of reporting requirements for abuse and misappropriation.
Staff failed to immediately remove a CNA from resident care after witnessing rough handling of a non-verbal resident with severe disabilities, allowing the CNA to continue working independently. In a separate case, a resident's repeated reports of missing personal items were not investigated by administration, despite facility policy requiring prompt action on such allegations.
The facility failed to ensure proper labeling and dating of food items in the kitchen, leading to potential contamination risks. Observations revealed undated or expired food items, including cottage cheese, mayonnaise, BBQ sauce, and various cheeses and cooked foods. The Dietary Manager confirmed these issues, and the Administrator emphasized the need for adherence to food safety policies to prevent foodborne illnesses among residents.
The facility failed to administer oxygen as ordered for a resident with COPD, setting the oxygen canister at four LPM instead of the prescribed two LPM. Additionally, oxygen supplies for two residents were not stored or dated properly, with apparatuses left undated and not in plastic bags. Staff interviews confirmed these practices were against facility policy.
A resident was found with an inhaler at their bedside without being assessed for self-administration, contrary to the facility's policy. The care plan did not include self-administration, and there was no physician's order. Staff confirmed the resident was not assessed for self-administration, highlighting a deficiency in medication management.
The facility failed to develop and implement care plans for two residents with nicotine dependence and tobacco use. Despite being cognitively intact, these residents did not have smoking addressed in their care plans, contrary to facility policy. Interviews with staff confirmed that smoking should be documented and care planned, but this was not done.
A resident with chronic pain due to multiple sclerosis and lower back pain did not receive effective pain management. The facility failed to keep lidocaine patches in stock, resulting in missed doses, and the resident reported that oxycodone was ineffective. A CMT did not document or reassess the resident's pain after administering oxycodone and failed to report the issue to the nurse. The DON was unaware of the resident's pain complaints.
The facility failed to ensure the DON did not serve as a charge nurse or CNA when the census exceeded 60. The DON worked in these roles on multiple occasions, with the census ranging from 68 to 73. Staff interviews confirmed the DON's additional duties, impacting her ability to complete her designated responsibilities.
The facility failed to provide showers as preferred for four residents due to staffing issues, leading to significant gaps between showers. Residents expressed dissatisfaction with the infrequency of showers, feeling unclean and desiring more regular assistance. Staff interviews confirmed that shower aides were often reassigned due to understaffing, resulting in inconsistent shower schedules and unmet resident needs.
The facility failed to provide adequate pressure ulcer care for three residents by not consistently assessing and documenting weekly skin assessments and wound tracking. A resident acquired a new pressure ulcer that was not documented, and two other residents had incomplete documentation of their skin conditions. The DON admitted to not measuring wounds during certain periods and was unaware of the lack of weekly assessments.
A resident in a special care unit was neglected for over 11 hours, leading to their death. The resident, who had dementia and required assistance, was found unresponsive under their bed with dried blood and emesis. The facility failed to ensure that staff conducted regular checks and walking rounds, as required by policy. Security footage confirmed no staff entered the resident's room during the night shift.
The facility did not maintain a current facility-wide assessment, necessary for determining resources to care for 71 residents during routine and emergency operations. The last review was in April 2023, and the 2024 update was not conducted. The Administrator, responsible for the assessment, acknowledged the oversight, and no policy was provided to guide the assessment process.
Improper Hoyer Lift Operation and Inadequate Supervision Resulting in Resident Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision and assistance with mechanical lifts, resulting in a resident falling from a Hoyer lift and sustaining injuries. The facility’s own fall protocol required immediate physical and neurological assessment, investigation of the incident, physician and responsible party notification, and completion of a fall incident report after any unintentional change in position to the floor. Resident #2, cognitively intact and dependent on staff for toileting, dressing, and mobility, had a care plan requiring use of a Hoyer lift with assistance from two staff for transfers. Despite this, the resident reported that during a transfer from wheelchair to bed using a manual Hoyer lift, the lift became difficult to move across the floor, staff gave it a strong push, and the lift tipped over, landing on the resident. Record review of the facility’s event report documented that two staff applied the Hoyer straps, raised the resident, and moved the lift toward the bed. As the resident’s body neared the edge of the bed, the lift tipped to the left, causing the resident to fall from the highest position, striking the chin and back of the head and sustaining a laceration that required sutures to the chin. The resident later exhibited bruising around both eyes and a healed scar from the bottom lip to the underside of the chin, and reported ongoing decreased sensation and numbness in the lower half of the face, affecting eating and talking. The administrator, who was called to the room immediately after the incident, did not observe any evidence that the lift was broken or malfunctioning and concluded that the lift simply tipped over during use. Interviews with staff revealed inconsistent and unsafe practices in operating Hoyer lifts and a lack of specific training. One CNA present during the incident stated that no one was operating the lift when it tipped; instead, both CNAs were on either side of the resident pulling on the sling to move the lift, at which point it flipped over. Another CNA present stated that on the day of the incident, one CNA was operating and moving the lift toward the bed while the other CNA was on the opposite side of the bed and not guiding the resident or lift. Multiple staff, including CNAs, CMTs, an LPN, the ADON, and the administrator, described the expected standard that Hoyer lift legs must be open, two staff must be present, one staff should operate the lift while the other guides and positions the resident, and the legs should be locked when raising or lowering the resident. However, one CNA reported not receiving specific Hoyer training, and another CNA and other staff expressed concerns that the facility’s manual Hoyer lifts seemed unstable or old, though the maintenance director stated he had not been informed of any broken lifts and had not yet completed the monthly safety check. Observation of a later transfer using a hospice-owned Hoyer showed staff questioning strap color and whether to attach the middle strap, the sling positioned above the resident’s head causing leaning and a crooked neck, and the operator lowering the resident without locking the wheels, further demonstrating improper and inconsistent use of mechanical lifts. Additional interviews showed that staff had differing understandings of whether pulling on the sling could cause a lift to tip, with some acknowledging that pulling on the sling could create a balance concern and cause an accident, while another CNA did not believe that pulling on the sling without someone operating the lift could cause tipping. The medical director reported he did not recall being notified of the incident at the time, though his notes reflected that the facility had reported the lift as broken, and he confirmed awareness of the resident’s ongoing lack of sensation in the lower portion of the face. The maintenance director stated that maintenance was responsible for inspections and repairs of facility-owned Hoyer lifts and that lifts with reported issues would be tagged out of service, but he had not yet performed the monthly safety check and had not received any staff reports of broken lifts. Overall, the observations, interviews, and record review showed that staff were not consistently trained or following safe operating procedures for mechanical lifts, and that the facility failed to ensure safe operation of the Hoyer lift and adequate supervision during transfers, resulting in the resident’s fall and injury.
Medications Left at Bedside and Inaccurate MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate documentation and safe administration of medications. Facility policy stated that nurses must use acceptable nursing practices when administering medications, never leave medications in a resident’s room without a physician’s order to leave them at bedside, and remain with the resident until medications are taken or remove them if refused. Despite this, staff left a full morning medication pass at a cognitively intact resident’s bedside without a physician’s order and documented the medications as administered on the MAR by a staff member who did not actually give them. The resident involved had multiple diagnoses, including COPD, Parkinson’s disease, type II diabetes mellitus, borderline personality disorder, PTSD, ADHD, bipolar disorder, hypertension, and bladder dysfunction, and had active orders for several scheduled oral medications during the morning med pass, including pantoprazole, Mag 64, ondansetron, a multivitamin, Lipitor, bethanechol, aspirin, and amlodipine. On the date of the incident, a CMT signed these medications out on the MAR but asked an LPN to deliver them. The LPN entered the resident’s room, woke the resident, and informed the resident that the medications were present. When the resident requested milk and stated he or she would take the medications if milk was provided, the LPN left the medications at the bedside, obtained milk, returned, placed a straw in the milk carton, and then left the room without observing the resident take the medications. Later that morning, the resident reported that the morning medications were missing and requested to speak with the Administrator. A CNA responded to the call light and was told by the resident that medications had been delivered while the resident was awake, that the resident then fell asleep, and that upon waking for breakfast the medications were missing. The LPN was notified of the alleged missing medications. A subsequent progress note documented that the resident later located the pills next to him or her and apologized to the LPN. In interviews, the resident stated that staff do not stay to observe medication administration despite being asked, and that on the day in question the LPN initially claimed the medications had been taken until the resident later found them in the bed. The CMT, LPN, ADON, and Administrator all acknowledged in interviews that medications should not be left at the bedside without a physician’s order and that the resident did not have such an order, confirming that facility policy was not followed and that the staff member who signed the MAR was not the one who actually delivered and observed administration of the medications.
Failure to Investigate Abuse Allegation and Remove Accused Staff From Duty
Penalty
Summary
The deficiency involves the facility’s failure to immediately and fully investigate an allegation of staff-to-resident abuse and to protect the resident and other residents during the investigation. The facility’s own Abuse and Neglect Policy required that all reports of resident abuse be thoroughly investigated by administration or designees, that accused employees be placed on leave at the time of the allegation, that the resident and reporter be protected from retaliation, and that findings be documented and reported to the state agency. The policy also required review of documentation and evidence, interviews with the reporter, the resident, staff who had contact with the resident, and at least ten other residents cared for by the accused employee, as well as complete documentation of the investigation and submission of a follow-up report to the state within five working days. Despite these requirements, the facility did not initiate or complete a full, documented investigation and did not remove the accused staff member from duty when an allegation of abuse was made. The resident involved had vascular dementia with moderate cognitive impairment, diabetes mellitus, and hypertension, and required staff assistance with transfers and mobility. The resident frequently rejected care. On the date of the incident, a CMT entered the resident’s room to administer medications, check blood sugar, and give insulin. The CMT reported that the resident became irate after administration, claimed injury to the hand, and began swatting and throwing water. The CMT stated that the resident accused the CMT of hurting the resident’s hand and that this was reported to an LPN and the ADON. The LPN’s written statement indicated the resident was yelling that the CMT had hurt the resident’s hand and that the LPN observed a couple of light bruises on both hands, described as usual, with no new injury noted. Another CNA reported hearing the resident hollering and the resident saying staff hurt the resident’s hand. A different CNA reported that the resident pointed to the CMT and said, “He gave me that bruise,” and this was immediately reported to the ADON and LPN. Despite these direct allegations that staff had hurt the resident’s hand and caused bruising, the accused CMT continued to work after the allegation, including on the same unit and the following day, and was not suspended pending investigation. Facility staffing records confirmed the CMT worked after the allegation. The LPN documented in a progress note that the resident became upset, threw water on the CMT, and was educated about staff being there to help, but did not document the resident’s allegation of possible abuse, any assessment of the resident, or notifications to the physician, family, or administration. The electronic medical record contained no entries related to an abuse assessment or further information about the allegation. The ADON reported assessing the resident and noting old bruising on both hands that did not appear suspicious, but this assessment was not documented in the medical record as a formal skin assessment. The Administrator acknowledged that the CMT was not suspended, that the CMT continued to work on the resident’s hall, and that a progress report with resident statement, notifications, and assessment should have been completed. The facility did not provide a full completed investigation upon request, and state records showed no investigation had been submitted. Subsequent observation documented multiple bruises on both of the resident’s hands, and the resident reported obtaining the bruising when staff helped the resident out of bed. Multiple staff, including the CMT, LPNs, RN, and other CNAs, stated that hitting or hurting a resident’s hand or causing a bruise would be considered abuse and that an allegation of abuse should trigger resident assessment, documentation, and notifications. The ADON and Administrator both described expectations that allegations of abuse be reported promptly to administration and the state, that residents be assessed for bruises or marks, and that progress notes include what happened, assessments, and notifications. However, in this case, those steps were not carried out as required. The facility failed to initiate an immediate, thorough, and documented investigation, failed to suspend the accused employee at the time of the allegation, allowed the accused staff member to continue working independently, and failed to submit an investigation report to the state agency, resulting in noncompliance with the facility’s abuse policy and regulatory requirements for responding to alleged abuse.
Failure to Timely Report Resident’s Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of staff-to-resident abuse to the State Survey Agency (DHSS) within the required two-hour timeframe, as required by facility policy and state law. The facility’s Abuse and Neglect Policy states that suspected abuse must be reported immediately to administration and to the state licensing agency within two hours for allegations of abuse or those resulting in serious bodily injury. On the date in question, a resident with vascular dementia, diabetes mellitus, and hypertension, who had moderate cognitive impairment and frequently rejected care, alleged that a certified medication tech (CMT) hurt his/her hand during medication administration, including a blood sugar check and insulin injection. According to staff statements, the CMT entered the resident’s room to administer medications, check blood sugar, and give insulin. The resident became irate, claimed injury to his/her hand, and began swatting and throwing water at the CMT. The CMT reported to an LPN that the resident accused him/her of hurting the resident’s hand, and the LPN and ADON were informed of the accusation. The LPN documented in a progress note that the resident became upset, threw water, and yelled at staff, but did not document the resident’s allegation that staff caused injury to the hand. Multiple staff, including a CNA, reported hearing the resident hollering and the resident stating that staff hurt his/her hand or gave him/her a bruise, and one CNA reported that the resident pointed at the CMT and said, “He gave me that bruise.” Staff interviewed acknowledged that hitting or hurting a resident’s hand would be considered abuse and that such allegations should be reported to the state within two hours. The ADON and Administrator were made aware of the situation. The ADON stated that his/her understanding was that the resident said the CMT hurt his/her finger during a finger stick, which the resident reportedly says often, and that he/she noted old bruising on the resident’s hands but no new bruising. The Administrator reported being notified that someone hurt the resident’s hand and, upon questioning the resident, was told that a man who got the resident out of bed grabbed the resident’s hand too tightly, while the resident denied that the employee giving medications hurt him/her. The Administrator also noted bruising on the resident’s hands and stomach, which he/she believed related to lab draws and insulin injections. Despite these allegations and assessments, DHSS records showed the facility did not report the allegation of possible abuse on that date, and the Administrator later acknowledged that he/she should have reported and followed policy regarding the initial abuse report. Further observation and interview with the resident showed multiple bruises on both hands, including circular reddish-purple and purple bruises of various sizes, and the resident reported obtaining the bruises when staff helped him/her out of bed. Staff interviews consistently reflected knowledge that abuse allegations must be reported promptly to administration and to the state within two hours. However, the allegation that staff hurt the resident’s hand and caused bruising was not reported to DHSS within the required timeframe, constituting the failure to ensure all allegations of possible abuse were timely reported to the State Survey Agency as required by facility policy and regulation.
Failure to Timely Destroy and Document Discontinued Controlled Medications
Penalty
Summary
The facility failed to maintain an ongoing monitoring process for the documentation, destruction, and accountability of expired or unusable medications, particularly controlled substances. Surveyors observed that a locked file cabinet in the DON/ADON's office contained numerous discontinued and expired medications for approximately 34 residents, including controlled substances such as morphine, lorazepam, temazepam, fentanyl, tramadol, pregabalin, and haloperidol. Many of these medications lacked the required individual narcotic accountability sheets, and some had been retained for several months after residents had expired or been discharged. The facility's own policy required prompt removal and destruction of such medications, with documentation by two licensed nurses, but this was not followed. Interviews with staff, including the ADON, LPNs, the physician, the pharmacist, the DON, and the administrator, revealed a lack of awareness and responsibility regarding the destruction of discontinued medications. The ADON, new to the position, was unaware of the quantity of medications stored and had not participated in any destruction process. LPNs reported that discontinued medications were given to the DON for destruction but had not witnessed any destruction events. The DON admitted to not having destroyed any medications with the ADON and was unable to locate the Drug Destruction Log, resulting in medications being stored indefinitely in the file cabinet. The DON and administrator both acknowledged that the number of discontinued medications on hand was unacceptable and not in line with facility policy. The facility did not provide a logbook documenting the destruction of controlled substances, as required by policy. Observations and interviews confirmed that medications were not destroyed within the expected 30-day timeframe, and there was no evidence of the required dual-nurse destruction process or proper documentation. The physician and pharmacist both stated that medications should be destroyed promptly to prevent diversion, and the facility's failure to do so was attributed to high staff turnover and lack of clear responsibility.
Staff-to-Resident Physical and Verbal Abuse in Dining Room
Penalty
Summary
A certified nurse aide (CNA) physically and verbally abused a resident by grabbing the resident's arm and wrist and cursing at the resident during an incident in the dining room. The resident, who had diagnoses including cancer, nutritional deficiency, dementia with agitation, depression, and Parkinson's disease, was observed to be confused, an elopement risk, and dependent on staff for most activities of daily living. On the day of the incident, the resident was agitated, exit-seeking, and had set off emergency exit door alarms. Staff attempts to redirect the resident were unsuccessful, and the resident struck the CNA in the face during the altercation. Facility video footage and staff interviews confirmed that the CNA repeatedly attempted to physically remove the resident from the dining room by pushing the wheelchair, jerking it, and lifting the front to prevent the resident from stopping movement with their feet. The CNA also pushed the resident's arms abruptly and grabbed at the resident's hands and arms in an attempt to control the resident's movements. During the incident, both the resident and the CNA exchanged profanities, with the CNA responding to the resident's verbal outburst with a curse. The CNA did not seek assistance or attempt to de-escalate the situation by leaving and reapproaching. Interviews with facility leadership and staff acknowledged that the CNA's actions constituted both physical and verbal abuse, as defined by the facility's abuse and neglect policy. The CNA admitted that cursing at or physically redirecting a resident would be considered abuse. Leadership staff, including the ADON and DON, reviewed the incident and agreed that the CNA's handling of the situation was inappropriate and abusive, noting that the resident was permitted to be in the dining room and should not have been forcibly removed.
Failure to Consistently Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to consistently post current daily nurse staffing information in a clear and readable format in a prominent location accessible to residents and visitors. Observations over several days revealed that the staffing sheets posted near the front entrance were outdated, with some sheets dating back several weeks, and at times the clipboard intended for posting was empty. Review of records showed multiple dates where no staffing forms were available, indicating gaps in compliance with posting requirements. Interviews with staff, including LPNs, the receptionist, and administrators, revealed confusion and lack of clarity regarding responsibility for completing, posting, and checking the daily nurse staffing forms. While it was generally understood that the night shift nurse was to complete the form at midnight and the DON or administrator was responsible for ensuring completion, the receptionist was not aware that checking the forms was part of their duties. This lack of clear assignment and oversight led to the failure to post current staffing information as required.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. A Certified Nursing Assistant (CNA) witnessed another CNA being rough and aggressive with a resident who had severe intellectual disabilities, epilepsy, and spastic quadriplegic cerebral palsy, and was dependent on staff for all activities of daily living. The incident was reported by the witnessing CNA to the receptionist and then to the nurse, but not immediately. The nurse subsequently notified the former Administrator, who suspended the accused CNA and initiated an investigation. However, the facility did not document reporting the abuse allegation to DHSS until over two hours after the CNA became aware of the potential abuse. Additionally, the facility failed to report an allegation of misappropriation of resident property within the required twenty-four-hour timeframe. A resident, who was cognitively intact and required assistance with activities of daily living, reported multiple personal items missing from their room, including lip balm, sharpies, and stuffed animals. The grievance was reported to the DON, Administrator, and management staff, but was not reported to DHSS as required. The Social Services Designee (SSD) and Administrator confirmed that the report of missing items should have been considered misappropriation and reported to DHSS, but this did not occur. Interviews with staff revealed inconsistent understanding of the required reporting timeframes for abuse and misappropriation. While most staff stated that abuse should be reported to the charge nurse immediately and to DHSS within two hours, there was confusion regarding the timeframe for reporting misappropriation. Some staff were unaware of the specific requirements, and the SSD admitted not knowing how long the facility had to report allegations of misappropriation. The former Administrator acknowledged responsibility for ensuring staff were aware of abuse and neglect policies.
Failure to Protect Residents and Investigate Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to respond appropriately to allegations of abuse and misappropriation involving two residents. In the first incident, a certified nursing assistant (CNA) was observed by another CNA to be handling a non-verbal resident with severe intellectual disabilities and spastic quadriplegic cerebral palsy in a rough and aggressive manner, including yanking the resident's legs and rolling the resident forcefully during care. Despite witnessing this behavior, the reporting CNA did not immediately intervene or report the incident, and the accused CNA continued to provide care to residents independently for several hours before being sent home. The facility's own policy required immediate suspension of any employee accused of abuse and prompt initiation of an investigation, but these steps were not followed in a timely manner, leaving residents unprotected during the interim. The second incident involved a resident with a history of respiratory infection, diabetes, and chronic cough, who reported multiple personal items missing from their room, including lip balm, sharpies, and stuffed animals. The resident stated that these concerns had been reported to the former administrator over the previous two to three months, but no follow-up or investigation was conducted. The grievance was documented, but since the resident did not witness the items being taken or know who was responsible, the matter was not reported to outside agencies, and there was no evidence that an internal investigation was initiated as required by facility policy. Interviews with staff revealed a general understanding of the need to protect residents and initiate investigations in cases of abuse or misappropriation. However, in practice, the required procedures were not consistently followed. The accused CNA was not immediately removed from resident care after the abuse was witnessed, and the allegation of misappropriation was not investigated by the administrator or director of nursing. These failures resulted in the facility not protecting residents from potential harm and not addressing allegations of theft in accordance with established policies.
Improper Food Labeling and Storage in Kitchen
Penalty
Summary
The facility failed to ensure that all food stored in the main kitchen was free from possible contamination due to improper labeling and dating of food items. During an observation, several food items in the reach-in refrigerator were found to be either undated or past their use-by dates. These included an opened container of cottage cheese with no date, a gallon of mayonnaise and BBQ sauce with used dates, and various other items such as shredded meat, cheeses, and cooked foods that were either undated or improperly stored. The Dietary Manager confirmed these observations and acknowledged that the items should have been dated correctly with an open date and a use-by date, and that leftovers should only be kept for three days. Further inspection of the walk-in refrigerator revealed a crate of 36 undated thawed Mighty Shakes, which according to the manufacturer's instructions, should be consumed within 10 days after thawing. The Administrator expressed that the expectation was for the dietary staff to follow the policy for labeling and disposing of food appropriately to ensure the residents are served safe and quality food. The failure to adhere to these standards had the potential to increase the prevalence and spread of foodborne illnesses and infections among all 68 facility residents.
Failure to Administer and Store Oxygen Supplies Appropriately
Penalty
Summary
The facility failed to provide respiratory care per standard practice for three residents. For one resident, the staff did not administer oxygen as ordered. The resident, who had a diagnosis of chronic obstructive pulmonary disease (COPD) and was at risk for ineffective breathing patterns, was observed using a nasal cannula with the oxygen canister set at four liters per minute (LPM) instead of the prescribed two LPM. This discrepancy was noted over several days, and the Licensed Practical Nurse (LPN) acknowledged signing off on the Medication Administration Record (MAR) without verifying the actual oxygen flow rate. Additionally, the facility did not ensure proper storage and dating of oxygen supplies for two other residents. One resident's updraft apparatus was observed undated and not stored in a plastic bag, contrary to the facility's policy. Another resident's nasal cannula was found draped over a table without a date on the tubing. Both residents had diagnoses related to respiratory issues, including COPD and chronic respiratory failure with hypoxia. Interviews with staff confirmed that oxygen supplies should be stored in a bag and dated, which was not adhered to in these cases.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside for a resident who had not been assessed to self-administer medications. Specifically, a resident was observed on multiple occasions with an inhaler lying on the bedside table next to their recliner. The resident's care plan did not include self-administration of medications, and there was no physician's order for self-administration. The facility's policy requires that residents must be alert, oriented, and have a physician's order to self-administer medications, which must be kept in a locked box or drawer. During interviews, an LPN and the Director of Nursing confirmed that the resident had not been assessed to self-administer medications and that the inhaler should not have been in the resident's room. The Nurse Practitioner also stated that no medications should be at a resident's bedside unless they have been assessed to self-administer. This oversight indicates a failure to adhere to the facility's medication administration policy, resulting in a deficiency.
Failure to Care Plan Smoking for Residents
Penalty
Summary
The facility failed to develop and implement a complete care plan for two residents who were identified as smokers. Resident #12, admitted on January 31, 2024, with a diagnosis of nicotine dependence, did not have a care plan addressing their smoking habits. The resident was cognitively intact and reported only smoking when a family member visited. The family member confirmed visiting three times a week to assist the resident with smoking, as the resident could not light or dispose of cigarettes independently. Despite these details, the care plan dated March 21, 2024, did not include any provisions for managing the resident's nicotine dependence or smoking. Similarly, Resident #62, who was admitted with a diagnosis of tobacco use, also lacked a care plan addressing smoking. The resident's significant change MDS indicated no cognitive impairment, yet the care plan dated May 16, 2024, did not include smoking management. Interviews with the Director of Nursing and the MDS Coordinator revealed that smoking should be documented and care planned, but this was not done for Resident #62. The facility's policy required smoking to be discussed during care plan meetings and included in the care plan upon admission, but this was not adhered to for these residents.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident with chronic pain due to multiple sclerosis and lower back pain. The resident had a care plan that required staff to address pain complaints promptly and administer PRN medication for breakthrough pain. However, the facility did not keep the resident's lidocaine patches in stock, resulting in missed doses on three consecutive days. Additionally, the resident reported that the administered oxycodone was no longer effective, but this was not documented or reported to the nurse on duty. During an observation, the resident expressed severe back pain to a Certified Medication Technician (CMT), who acknowledged the lack of lidocaine patches and failed to report the resident's ongoing pain to the nurse. The CMT admitted to not reassessing the resident's pain after administering oxycodone and not documenting the administration on the Medication Administration Report (MAR). The Director of Nursing was unaware of the resident's pain complaints and emphasized the importance of addressing pain promptly and involving the physician if current measures were insufficient.
DON Serving as Charge Nurse and CNA Despite High Census
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) did not serve as a charge nurse or certified nurse aide (CNA) when the facility census was greater than 60. The facility census was recorded as 68, and on multiple occasions, the DON worked in roles other than her designated position. Specifically, on August 9, 2024, the DON worked as a charge nurse during the evening shift when the census was 72. On August 13, 16, 19, and 23, 2024, the DON worked as a CNA or Licensed Practical Nurse (LPN) during various shifts, with the facility census ranging from 71 to 73. Interviews with facility staff, including the DON, LPN A, and the Minimum Data Set (MDS) Coordinator, confirmed that the DON frequently worked on the floor as a charge nurse or CNA due to staffing needs. The MDS Coordinator noted that the administration staff, including the DON, often worked as nursing staff, which made it difficult for the DON to complete her designated duties. The DON herself acknowledged being behind on her responsibilities due to covering shifts on the floor. The facility did not provide a policy outlining the responsibilities of the DON position, and the Administrator was aware of the DON's additional duties.
Failure to Provide Resident Showers Due to Staffing Issues
Penalty
Summary
The facility failed to uphold residents' rights to self-determination by not providing showers as preferred for four residents out of a sample of 14. The facility's policy outlined a specific shower schedule, but records showed significant gaps between showers for the residents. For instance, one resident received showers with intervals ranging from 7 to 14 days, despite expressing a preference for more frequent showers. Another resident, who was cognitively intact, required assistance with bathing but experienced similar delays, receiving showers with intervals of up to 20 days. Interviews with residents revealed dissatisfaction with the frequency of showers, with some residents feeling unclean and expressing a desire for more regular assistance. The Director of Nursing acknowledged that the residents should have received showers more frequently than they did. The facility's failure to adhere to the shower schedule and provide adequate assistance was attributed to staffing issues, as confirmed by multiple staff members during interviews. Staff interviews highlighted a pattern of understaffing, with shower aides being reassigned to other duties due to staff shortages. This led to inconsistent shower schedules and unmet resident needs. The Director of Nursing and the Administrator both recognized the issue, noting that there was no designated staff for showers and that residents were not receiving showers as frequently as expected. The deficiency was primarily due to inadequate staffing, which prevented the facility from fulfilling its obligation to support resident choice and self-determination in personal care routines.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for three residents. The staff did not consistently assess and document complete, thorough, and accurate weekly skin assessments, nor did they complete weekly wound tracking for the residents with pressure ulcers. The facility's policy required weekly skin assessments and documentation by the charge nurse, including size, description, color, odor, and any change in skin condition, but these were not adhered to. For Resident #1, the facility did not document the presence of a new pressure ulcer acquired on 07/29/24, nor did they provide a description or measurements of the ulcer in the weekly skin assessments. The resident's progress notes and medication records from 07/29/24 through 09/08/24 showed a lack of documentation regarding the pressure ulcer. The DON admitted to not measuring the resident's wounds from 07/29/24 through 08/26/24 and was unaware of the lack of weekly skin assessments. Resident #2 was readmitted with moisture-associated skin damage (MASD) on 07/07/24, but staff failed to provide a description, measurements, or location of the MASD in subsequent assessments. The resident's progress notes and weekly skin assessments lacked detailed documentation of the skin condition. Similarly, for Resident #3, the facility did not document a description or follow-up on a previously identified wound. The DON acknowledged not measuring the resident's wound during specific periods and expected the nurses to complete weekly assessments, which were not done.
Neglect of Resident in Special Care Unit
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in the resident being left unchecked for over 11 hours in a locked special care unit. The resident, who had multiple diagnoses including dementia and was dependent on staff for daily activities, was found unresponsive under their bed with dried blood and emesis present. The resident was subsequently sent to the hospital and later passed away. The facility lacked a system to ensure that nursing staff monitored the care provided by aides and that aides performed walking rounds as per facility policy. The facility's policy required CNAs to conduct walking rounds at the beginning and end of each shift and to check on bedridden residents every two hours. However, the CNA responsible for the resident admitted to failing to check on the resident after putting them to bed and even charted on the resident without verifying their condition. The CNA was distracted by personal issues and did not perform the required checks throughout the night. Additionally, the CNA who relieved the primary CNA for a break did not check on the resident or any others during their coverage. Interviews with various staff members, including LPNs and RNs, revealed that the resident was not checked on during the night shift, and the facility's security footage confirmed that no staff entered the resident's room from the time they were put to bed until they were found unresponsive. The facility's failure to ensure regular checks and monitoring of the resident's condition led to the neglect and subsequent death of the resident.
Failure to Maintain Current Facility Assessment
Penalty
Summary
The facility failed to maintain a current and accurate facility-wide assessment, which is necessary to determine the resources required to care for residents competently during both routine operations and emergencies. The facility's census was 71, and the last documented review of the facility assessment was completed in April 2023. The Administrator acknowledged that the annual update for 2024 was not conducted, despite being responsible for reviewing and completing the assessment. It was noted that department heads and the physician should be involved in the assessment process, which should have been reviewed and updated in April 2024. Additionally, the facility did not provide a policy regarding the facility assessment, indicating a lack of procedural guidance for maintaining the assessment's accuracy and currency.
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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