Pearl's Ii Eden For Elders
Inspection history, citations, penalties and survey trends for this long-term care facility in Princeton, Missouri.
- Location
- 611 North College, Princeton, Missouri 64673
- CMS Provider Number
- 265796
- Inspections on file
- 18
- Latest survey
- August 7, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pearl's Ii Eden For Elders during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain sanitary conditions in the kitchen and food storage areas, despite policies requiring clean, contaminant-free storage and regular defrosting of freezers. Observations showed grease on floors, dirty and debris-covered windows in dry storage, refrigerators and freezers with dirt, food debris, unreadable thermometers, and thick ice buildup, as well as dusty pipes and cords hanging over prep tables and food-contact surfaces. Dishes were stored face up under dusty ceilings with visible dust inside, and equipment surfaces such as the steam table and shelves near the mixer were coated with dust, sticky residue, and food splatter. The DM, RD, and Administrator all stated they expected clean, sanitary conditions and confirmed that dietary staff and the DM were responsible for cleaning, while all refrigerators and freezers observed were used to store resident food for a census of 34 residents.
The facility has not had a full-time Director of Nursing (DON) for the past two years, despite a census of 40 residents. Efforts to fill the position through local advertisements and posters have been unsuccessful. The absence of a DON was confirmed through observations and interviews with the Administrator, Administrative Assistant, and MDS Coordinator, who all acknowledged the necessity of having a DON.
The facility failed to address grievances and recommendations from the resident council, affecting all residents involved. Residents were unaware of grievance procedures, lacked access to forms, and were not informed of resolutions. Meetings were led by staff without a council president, and concerns about showers, call light wait times, and other issues were not formally addressed.
The facility failed to develop and implement comprehensive care plans for four residents, leading to deficiencies in addressing specific needs such as side rail usage, shower preferences, PTSD, and weight loss. The care plans did not accurately reflect the residents' needs and preferences, and there was a lack of physician orders for side rails. The MDS/Care Plan Coordinator acknowledged the need for updates, highlighting a disconnect between documented care plans and actual resident needs.
The facility failed to provide necessary personal hygiene services to residents due to staffing shortages, resulting in missed showers for several residents. A resident with hemiplegia and other conditions did not receive showers as scheduled, feeling unclean as a result. Another resident, dependent on staff for mobility and hygiene, missed 17 out of 34 shower opportunities, going 31 days without a shower. A cognitively impaired resident missed 8 out of 25 showers, and another resident missed 3 out of 8 showers in July. Staff cited frequent call-ins and lack of a designated shower aide as reasons for the deficiency.
The facility failed to implement preventative skin risk measures for a resident with severe cognitive impairment, leading to a worsening stage II pressure ulcer due to inadequate repositioning and toileting. Additionally, another resident at risk for pressure ulcers did not have documented wound care treatments on four occasions, indicating a failure to follow physician orders. The facility was unable to provide a wound care policy, highlighting gaps in procedures for managing pressure ulcers.
The facility failed to assess and manage bed rail use for four residents, leading to potential safety risks. Residents had bed rails installed without proper assessment, informed consent, or care planning. Staff interviews revealed confusion and lack of communication regarding the necessity and use of side rails.
The facility experienced significant staffing shortages, resulting in delayed call light responses, missed showers, and unclean living conditions for residents. Residents reported waiting over 30 minutes for assistance, with some waiting over an hour. Missed showers were common, with one resident going 31 days without a shower. Observations noted unclean rooms with food crumbs and trash. Staff interviews confirmed the impact of staffing shortages on care quality.
The facility failed to ensure five nurse aides completed a state-approved competency evaluation program within four months of hire. Nurse Aides A, D, and E were not enrolled in a certification course, while Nurse Aides B and C completed the course but awaited testing. The facility's practice of waiting 30 days to evaluate new hires before enrolling them contributed to this deficiency.
A facility failed to maintain a medication error rate below five percent, resulting in a 30% error rate affecting three residents. Errors included improper administration of nasal spray, eye drops, and insulin. The RN did not follow manufacturer's guidelines, leading to incorrect administration techniques.
The facility failed to securely store medications, leaving them at the bedside for three residents and an unattended, unlocked medication cart. A resident with impaired cognition had an inhaler left on their bedside table without an order for self-administration. Another resident with cognitive impairment had a cream left on their bedside table, and a third resident with no cognitive impairment had medication cups with tablets on a table next to them. Additionally, a medication cart was left unlocked and unattended in the hallway.
The facility exhibited multiple deficiencies in food safety and sanitation, including improper food labeling, inadequate hand hygiene, and insufficient sanitation practices. Staff failed to follow policies on food storage and preparation, leading to potential cross-contamination. Additionally, the facility's stove was not fully operational, affecting meal preparation.
The facility failed to implement proper infection prevention and control measures, affecting several residents. Staff did not use Enhanced Barrier Precautions for residents with COVID-19 or open wounds, and there were lapses in hand hygiene and PPE use. Additionally, laundry handling did not comply with facility policy, and staff were inadequately trained on infection control procedures.
A facility failed to manage a deceased resident's personal funds properly, resulting in unauthorized bank fees being charged due to an account balance below the bank's threshold. The facility could not provide a resident trust and banking policy, and a check issued with deducted fees was never cashed. The Administrator did not expect such charges on a resident's account.
A resident reported missing $1,300 from their purse, which was not protected by the facility. Despite the facility's policy to prevent misappropriation, staff were unaware of the resident's money and did not conduct thorough interviews or report the incident to law enforcement. The resident's family confirmed the money's existence, but the facility's investigation was insufficient.
A resident reported missing $1,300 from their purse, but the facility failed to notify law enforcement or the state survey agency as required by their policies. The resident, with intact cognitive skills, noticed the money missing and informed the staff. Despite the facility's policy mandating immediate reporting of such incidents, the Administrator admitted to not contacting the police or state agency, resulting in a deficiency.
A resident reported missing $1,300 from their purse, but the facility failed to follow its policy to investigate the allegation. The Administrator did not conduct interviews or notify law enforcement, and no police report was filed. Social Services confirmed the possibility of the missing money with the resident's daughter, but the investigation was incomplete, leading to a deficiency in handling the situation.
A resident's care plan was not updated to reflect an above-the-knee amputation, despite significant changes in their condition. The resident had a history of venous insufficiency ulcers, which led to the amputation. Facility staff acknowledged that care plans should be updated with significant changes, but the process was not followed.
A resident with a physician-ordered mechanical soft diet was served a regular hamburger, posing a choking risk. Despite the resident's cognitive impairment and dietary needs, staff failed to adhere to the prescribed diet. Interviews revealed a lack of awareness and adherence to dietary orders, with the facility's policy on diet order accuracy not being effectively implemented.
A facility failed to provide Trauma Informed Care for a resident with PTSD, as their care plan did not address the diagnosis or include triggers and interventions. Staff interviews revealed a lack of awareness and training on PTSD, and no Trauma Informed Care Assessment was completed. The facility also lacked a policy for trauma informed care.
A significant medication error occurred when an RN failed to prime an insulin pen before administering insulin to a resident with diabetes. The RN did not follow the necessary steps to ensure accurate dosing, such as priming the pen and leaving the needle in the skin for the recommended duration. The facility lacked a policy for insulin administration, contributing to the error.
Unsanitary Kitchen and Food Storage Conditions
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain the kitchen in a clean and sanitary condition in accordance with its own food storage and kitchen cleaning policies. The facility’s policies required food to be stored in clean, dry areas free of contaminants, with appropriate methods to ensure food safety, and called for regular defrosting of freezers as part of general and deep cleaning. During an observation of the kitchen, surveyors noted grease on the floor around the stove, an open dry storage room window covered with dirt, dust, and debris, and a freezer with dirt and debris on the door compartments and shelves, as well as a thick sheet of ice on the bottom. A subsequent observation showed that the dry storage room window remained open and dirty, and that multiple refrigerators and freezers used to store resident food contained dirt, food debris, and ice buildup. Further observations showed that dishes and food-contact items were stored in a manner that allowed contamination. Multiple blue bowls and white saucers were stored face up on a dish storage rack beneath a dusty ceiling, with visible dust inside the dishes. The freezer next to the dish storage rack had dirt and debris on the shelves and sides, and its bottom shelf still had a sheet of ice. Two metal pipes covered with dust and dirt hung over a prep table holding a food processor and microwave, and the top of the steam table and a shelf above the mixer were covered with thick dust and a sticky substance. An electrical cord covered in dust hung above a prep table containing silverware and glasses, and the wall behind the mixer had food splatter and dust. The Dietary Manager, Registered Dietitian, and Administrator each stated they expected the kitchen, including refrigerators and freezers, to be clean and sanitary, with freezers defrosted at least every six months (per DM and RD) or monthly (per Administrator), and dishes stored to prevent contamination, and confirmed that dietary staff and the Dietary Manager were responsible for cleaning and sanitation. The facility census at the time was 34 residents, and all kitchen refrigerators and freezers, including one in the back dining room, were used to store resident food.
Failure to Appoint a Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis for the past two years, despite having a census of 40 residents. The facility did not provide a policy regarding the DON position. Observations during the survey confirmed the absence of a DON. Interviews with the Administrator and Administrative Assistant revealed that the facility had not had a DON for a couple of years, and efforts to fill the position through advertisements in the local paper and posters had not been successful. The Minimum Data Set (MDS) Coordinator and Administrator acknowledged that the facility should have a DON.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to honor the residents' right to organize and participate in resident/family groups by not considering the views of the resident council and not acting promptly upon grievances and recommendations made by the group. The facility did not demonstrate their response or provide a rationale for such responses, nor did they maintain documentation of attempts to resolve concerns or communicate follow-up actions to the council. This affected all residents serving on the resident council and potentially other residents in the facility, which had a census of 40. During interviews, resident council participants expressed that they were unaware of how to complete a grievance, lacked access to grievance forms, and did not know where to submit them. They also did not know they could hold meetings without staff present. Concerns were raised about showers not being given, long wait times for call lights, and slow responses from the facility on planned solutions. The review of resident council minutes from March to May 2024 showed no old business was documented or reviewed, no council president was assigned, and meetings were led by staff members. New business items such as lack of showers, crowded living areas, and other issues were noted, but no formal responses were provided to the council. Interviews with Activity Directors and the Administrator revealed that grievances or recommendations from meetings were forwarded to the Administrator but there was uncertainty about how residents were notified of resolutions. Meetings were advertised through various means, but families were not notified, and there was a lack of understanding about the resident council president's role. The Administrator expected residents to be satisfied with explanations for unmet concerns due to staffing issues and assumed residents knew how to file grievances, although they could not do so anonymously.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in addressing specific care needs. For Resident #3, the care plan did not include the use of side rails, which the resident used for repositioning, nor did it address the resident's shower preferences, which were not consistently met due to staffing issues. Despite the resident's cognitive intactness and physical limitations, the care plan inaccurately described the resident as independent with physical limitations and did not reflect the resident's actual needs and preferences. Resident #19, who was severely cognitively impaired and dependent on a walker, had a care plan that failed to include the use of side rails, which were observed in use. The resident's care plan inaccurately stated that the resident could transfer independently, despite requiring substantial assistance. The MDS Coordinator acknowledged that side rails should have been included in the care plan, and there was a lack of physician orders for the side rails, indicating a disconnect between the resident's needs and the documented care plan. For Resident #6, the care plan did not address the diagnosis of PTSD, including potential triggers and interventions, despite the resident having intact cognition and a history of mental health conditions. Additionally, Resident #21's care plan did not address significant weight loss, which was documented over several months. The resident, who was severely cognitively impaired and dependent on staff for eating, reported a lack of appetite. The MDS/Care Plan Coordinator confirmed that the care plans should have addressed both the weight loss and PTSD diagnosis, highlighting a failure to update care plans with significant changes in residents' conditions.
Staffing Shortages Lead to Missed Showers for Residents
Penalty
Summary
The facility failed to ensure that dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene. This deficiency was observed in four of the twelve sampled residents, who did not receive their scheduled showers. The facility did not have a policy for showers, and staffing shortages were cited as a primary reason for the failure to provide adequate care. Resident #6, who required substantial to maximum assistance for ADLs due to hemiplegia and other medical conditions, did not receive showers twice weekly as per their care plan. The resident expressed feeling dirty when showers were missed. Staff interviews revealed that the lack of a designated shower aide and frequent staff call-ins contributed to the inconsistency in providing showers. Resident #3, who was dependent on nursing staff for mobility and personal hygiene, missed 17 out of 34 scheduled shower opportunities over several months. The resident went 31 days without a shower, expressing dissatisfaction with the lack of care. Similarly, Resident #19, who was severely cognitively impaired, missed 8 out of 25 shower opportunities, going 18 days without a shower. Resident #37, who was cognitively impaired and required substantial assistance, missed 3 out of 8 shower opportunities in July, going 10 days without a shower. Staff interviews consistently highlighted staffing shortages as a barrier to completing scheduled showers.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure preventative skin risk measures were in place for a resident with severe cognitive impairment, who required assistance with mobility and was incontinent. The resident was identified as having a stage II pressure ulcer and was supposed to be frequently repositioned and have skin assessments conducted weekly. However, observations showed the resident remained in a wheelchair for extended periods without being repositioned or toileted, leading to a worsening of the pressure ulcer. Staff interviews revealed a lack of adherence to repositioning schedules and inadequate use of pressure-reducing devices. Another resident, who was at risk for pressure ulcers and required assistance with mobility, did not have documented wound care treatments on four occasions as per physician orders. The resident's treatment record lacked documentation for specific dates, indicating a failure to follow and document prescribed wound care treatments. Interviews with staff confirmed that treatments should be documented when completed, highlighting a lapse in following physician orders and maintaining accurate records. The facility was unable to provide a wound care policy when requested, indicating a potential gap in established procedures for managing and preventing pressure ulcers. The lack of documentation and adherence to care plans and physician orders contributed to the deficiencies observed in the care of these residents, affecting their overall skin integrity and health outcomes.
Failure to Assess and Manage Bed Rail Use
Penalty
Summary
The facility failed to properly assess and manage the use of bed rails for four residents, leading to potential safety risks. For Resident #3, the facility did not assess the risk of entrapment or obtain informed consent before installing bed rails, despite the resident's cognitive intactness and physical limitations. The resident used the side rails for repositioning, but there was no care plan in place for their use, and the facility did not provide a policy on entrapment or side rails. Resident #19, who was severely cognitively impaired, had a side rail installed without a physician's order or care plan. The resident was not able to verbalize the reason for the side rail, and staff interviews revealed confusion about its necessity. Similarly, Resident #1, who was also severely cognitively impaired, had side rails installed without proper assessment or care planning, despite being independent in some mobility aspects. Resident #192, with moderately impaired cognition, had side rails installed without a physician's order or proper assessment. The resident was unaware of the reason for the side rails, and staff interviews indicated a lack of understanding and communication regarding their use. The facility's failure to conduct entrapment assessments and ensure proper documentation and communication contributed to these deficiencies.
Staffing Shortages Lead to Delayed Care and Unclean Conditions
Penalty
Summary
The facility failed to maintain adequate staffing levels to meet the needs of its residents, resulting in delayed response times to call lights, missed showers, and unclean living conditions. Several residents reported waiting extended periods for assistance, with call light response times frequently exceeding 30 minutes and, in some cases, over an hour. This delay in response was corroborated by call light logs and interviews with residents and their family members. The lack of timely assistance led to residents feeling neglected and, in some instances, experiencing accidents due to the inability to reach the bathroom in time. In addition to delayed call light responses, the facility did not provide the required number of showers for some residents. For example, one resident missed 17 out of 34 scheduled shower opportunities, going as long as 31 days without a shower. Another resident missed 8 out of 25 scheduled showers, with a gap of 18 days between showers. Interviews with staff revealed that the facility's staffing shortages often resulted in the shower aide being reassigned to other duties, further contributing to the missed showers. The facility also failed to maintain resident rooms in a clean and sanitary manner. Observations noted food crumbs, sticky spots, and trash scattered across the floors and furniture in several residents' rooms. Housekeeping staff reported difficulties in maintaining cleanliness due to the residents' presence in the rooms and the facility's staffing challenges. Interviews with staff and residents highlighted the ongoing issues with cleanliness and the impact of staffing shortages on the facility's ability to provide a clean and safe environment for its residents.
Failure to Ensure Timely Certification of Nurse Aides
Penalty
Summary
The facility failed to ensure that five nurse aides completed a competency evaluation program approved by the state within four months of hire. The facility's census was 40, and the deficiency was identified through interviews and record reviews. Nurse Aide A was hired on April 24, 2024, but was not enrolled in a state-approved certification program. During an interview, Nurse Aide A confirmed that they had not yet enrolled in a Certified Nurses Aide (CNA) course, despite being aware of the requirement. Similarly, Nurse Aides B, C, D, and E were not registered as CNAs in the state registry, although Nurse Aides B and C had completed the certification course and were awaiting testing. The facility's administrative assistant revealed that the facility typically waited 30 days after hiring a nurse aide to assess their performance before enrolling them in a certification course. This evaluation included reviewing the quality of work and attendance. However, this practice resulted in Nurse Aides A, D, and E not being enrolled in the certification course within the required timeframe. The administrator acknowledged that nurse aides should be certified within four months of hire, indicating a lapse in the facility's adherence to regulatory requirements.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 30% error rate. This deficiency affected three residents out of a sample of 12, with the facility census being 40. The facility did not provide policies for medication administration, including nasal sprays, eye drops, or insulin administration. For Resident #30, the registered nurse (RN) did not follow the manufacturer's guidelines for administering Flonase nasal spray. The nurse failed to have the resident blow their nose and did not close one side of the nostril before administering the spray. The nurse acknowledged the oversight during an interview, admitting that the manufacturer's instructions should have been followed. Resident #6 received Systane Balance Solution eye drops, but the RN allowed the dropper tip to touch the resident's eyelashes and did not apply lacrimal pressure as required. The nurse admitted to not following the correct procedure. For Resident #22, the RN did not prime the insulin pen before administering insulin and failed to leave the needle in the skin for the recommended time. The nurse acknowledged these errors during an interview.
Medication Storage Deficiencies in LTC Facility
Penalty
Summary
The facility failed to store medications securely, resulting in medications being left at the bedside for three residents and an unattended, unlocked medication cart. Resident #15, who had moderately impaired cognition and required assistance with various activities, was observed with a Combivent inhaler left on the bedside table without an order for self-administration. The resident's care plan did not include an assessment for self-administration, and staff confirmed that the resident did not self-administer medications. Resident #192, also with moderately impaired cognition and dependent on staff for assistance, had Clobestasol Propionate cream left on the bedside table. There was no assessment for self-administration, and staff confirmed that the resident did not self-administer medications. The MDS Coordinator mentioned that medications were left in rooms for residents with COVID-19, which was the case for Resident #192. Resident #27, who had no cognitive impairment, was found with a stack of medication cups containing various tablets on a table next to them. The resident did not remember when they received the medication. Additionally, a medication cart was observed unlocked and unattended in the hallway, which was acknowledged by RN B as a mistake. The facility lacked a policy on medication storage, and the administrator stated that medications should never be left at the bedside or carts left unlocked and unattended.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies in food labeling, storage, preparation, and sanitation practices. Observations revealed that food items in the refrigerator were not properly labeled or dated, including opened containers of milk, chocolate syrup, and bread. The Dietary Manager and staff demonstrated a lack of understanding of the facility's policies, with inconsistent practices regarding the dating and discarding of leftovers. Additionally, the facility did not follow standardized recipes or production charts, leading to inconsistencies in meal preparation, particularly for pureed meals. Hand hygiene and glove use were also found to be inadequate, with staff failing to wash hands between tasks and improperly using gloves. Observations showed staff touching various surfaces and residents without changing gloves or washing hands, which could lead to cross-contamination. The facility's policies on handwashing and glove use were not consistently followed, and staff were not adequately trained on these procedures. The facility's sanitation practices were insufficient, with improper testing of the dishwasher for sanitation levels and inadequate cleaning of food preparation surfaces. The use of inappropriate cleaning solutions, such as mixing dish soap with Comet cleaner, was observed, and staff were not aware of the correct procedures for sanitizing surfaces. Additionally, the facility's stove was not fully operational, impacting the ability to prepare meals effectively. The Dietary Manager and Administrator acknowledged the stove's issues but had not resolved them due to financial constraints.
Infection Control and PPE Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, affecting five residents out of the 12 sampled. Resident #142, who tested positive for COVID-19 and required intermittent urinary catheterization, was not placed on Enhanced Barrier Precautions (EBP). The care plan did not address the resident's care needs after testing positive for COVID-19, and staff were observed not using proper precautions when providing care. Similarly, Resident #17, who had a stage II pressure ulcer, was not placed on EBP, and staff failed to sanitize their hands or use personal protective equipment (PPE) appropriately when providing care. The facility also failed to ensure proper handling of soiled laundry and adherence to hand hygiene guidelines. Laundry Aide A was observed transporting uncovered carts of clean laundry, contrary to facility policy, and was not adequately trained on the need to cover laundry inside the building. Additionally, staff members, including CNAs and RNs, were observed not following hand hygiene protocols, such as washing hands after glove removal or before administering medications. This was evident in the handling of medications for Residents #30, #6, and #37, where staff used bare hands to handle medications, violating standard precautions. Furthermore, the facility did not ensure that staff were adequately trained on infection control procedures, particularly in the context of COVID-19 precautions. Staff members, including CNAs and housekeepers, were observed entering COVID isolation rooms without proper PPE, such as N95 masks, and failing to sanitize between resident interactions. Interviews with staff revealed a lack of training and understanding of infection control measures, contributing to the deficiencies observed during the survey.
Unauthorized Bank Fees Charged to Deceased Resident's Account
Penalty
Summary
The facility failed to properly manage and account for a deceased resident's personal funds, resulting in unauthorized bank fees being charged to the resident's account. Specifically, the facility charged a deceased resident's account with bank service fees of five dollars per month over a period, totaling twenty dollars, without reimbursement to the resident's guardian or responsible party. The issue arose because the account balance fell below the bank's threshold of two thousand dollars, leading to service charges. The facility was unable to provide a resident trust and banking policy when requested. Interviews with the Administrative Assistant and the Administrator revealed that a check was mailed on behalf of the closed resident's account, which included the deduction of the unauthorized bank fees, and the check was never cashed. The Administrator stated that they would not expect a resident's personal funds account to incur bank fees.
Failure to Protect Resident's Property
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property when a resident reported missing $1,300. The resident, who had intact cognitive skills and required assistance with certain activities, reported the missing money to a Certified Nurse Aide and a Registered Nurse. The resident stated that the money was kept in an envelope in their purse, and they were unsure when it went missing. The facility's policy requires reporting and investigating such incidents, but the facility did not provide a copy of the resident's care plan. The facility's investigation involved a handwritten statement by a Registered Nurse and a typed statement by the Administrator. The resident's family was informed, and Social Services searched the resident's room but could not locate the missing money. The resident's daughter confirmed that the resident received a monthly check, which was cashed and kept in the resident's purse. Despite the facility's policy to protect residents from misappropriation, the staff was unaware of the resident's money or the presence of a safe in the room. Interviews with the resident, Social Services, and the Administrator revealed that the facility did not conduct individual staff interviews or contact the police to file a report. The Administrator acknowledged the lack of interviews and the failure to report the incident to law enforcement. The facility's inaction and lack of thorough investigation contributed to the deficiency in protecting the resident's property.
Failure to Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to report an allegation of misappropriation of funds for a resident who reported missing $1,300. Despite the resident's report, the facility did not notify law enforcement or the state survey agency as required by their policies. The facility's policy mandates that any alleged violations involving misappropriation of property be reported immediately to the appropriate authorities, including the state licensing agency and local law enforcement. However, the Administrator admitted to not notifying the police or the state survey agency, stating that she did not consider contacting law enforcement. The resident involved, identified as having intact cognitive skills, reported the missing money to the staff. The resident had approximately $1,500 in a purse and noticed the money was missing around mid-July. The resident's family was aware of the money and was informed of its disappearance. The facility's social services department searched the resident's room, but the money was not found. The resident was advised not to keep money in the room, and staff were reminded to be vigilant. The facility's policies, revised in 2017, clearly outline the procedures for reporting such incidents, including the requirement to notify various agencies and individuals within specific time frames. Despite these guidelines, the Administrator failed to follow the protocol, resulting in a deficiency in the facility's handling of the situation. The lack of immediate reporting to the appropriate authorities constitutes a breach of the facility's established procedures for managing allegations of misappropriation.
Failure to Investigate Misappropriation Allegation
Penalty
Summary
The facility failed to follow its policy and investigate an allegation of misappropriation when a resident reported missing $1,300. The resident, who had intact cognitive skills and required assistance with daily activities, reported the missing money to a Certified Nurse Aide and a Registered Nurse. The resident stated that the money was kept in an envelope in their purse, and upon checking, the envelopes were missing. The facility's policy requires the Administrator to assign an investigation to an appropriate individual and keep the resident informed of the progress, but this was not done. The Administrator did not conduct a thorough investigation as required by the facility's policy. Although the Administrator and Social Services were informed of the missing money, no police report was filed, and the state survey agency was not notified. The Administrator did not interview staff members or witnesses, nor did they notify the Ombudsman. The Administrator admitted to not seeing the need to interview each individual person and did not consider notifying law enforcement. Social Services attempted to verify the resident's claim by speaking with the resident's daughter, who confirmed the possibility of the resident having such an amount of money. Despite this, the investigation was not completed according to the facility's policy, as no statements from staff were collected, and the investigation's findings were not documented. The lack of a proper investigation and failure to report the incident to the appropriate authorities constituted a deficiency in the facility's handling of the situation.
Failure to Update Care Plan After Resident's Amputation
Penalty
Summary
The facility failed to revise the comprehensive person-centered care plan for a resident who had undergone an above-the-knee amputation of the left leg. Despite the significant change in the resident's condition, the care plan was not updated to reflect this amputation. The resident's annual minimum data set (MDS) indicated various dependencies and medical conditions, including venous insufficiency and surgical wounds. However, the care plan, last revised several months prior, did not include the amputation, which was a significant oversight given the resident's medical history and current condition. Interviews with facility staff, including the MDS Coordinator and the Administrator, revealed that care plans should be updated every ninety days and with significant changes, such as an amputation. The facility utilized a contract consolidator for care plan updates, but communication and timely updates were lacking. The resident expressed that the facility struggled to heal his/her venous insufficiency ulcers, which ultimately led to the amputation. The failure to update the care plan was a clear deficiency in the facility's care planning process.
Failure to Adhere to Physician-Ordered Diet
Penalty
Summary
The facility failed to ensure an environment free of accident hazards when a resident was not served a physician-ordered mechanical soft diet and was instead given a regular hamburger on a bun. This incident placed the resident at risk for choking hazards. The resident, who was severely cognitively impaired and had a mechanically altered diet, was observed eating a hamburger from a fast-food restaurant after returning from an out-of-facility doctor appointment. The dietary manager noted that the resident was motivated to leave the facility by receiving a fast-food meal after appointments. The resident's care plan indicated a need for a mechanical soft diet due to oral/dental health problems and GERD, with specific instructions to avoid certain foods. Despite this, the resident was served a regular hamburger, which was inconsistent with the physician's orders. Interviews with facility staff, including the MDS Coordinator, CNAs, and the Registered Dietician, revealed a lack of awareness and adherence to the prescribed diet. The MDS Coordinator and Registered Dietician both expressed that the mechanical soft diet should have been followed, and the resident should not have been served a regular hamburger. The facility's policy required regular checks for diet order accuracy, but the incident suggests a failure in this process. The MDS Coordinator mentioned that the facility had been serving the resident regular meals for years without observing any swallowing issues. The Administrator acknowledged the resident's motivation to attend appointments was linked to receiving hamburgers and fries, indicating a possible oversight in prioritizing dietary needs over motivational strategies.
Failure to Provide Trauma Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide Trauma Informed Care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident's quarterly Minimum Data Set (MDS) indicated intact cognitive skills, hemiplegia, depression, bipolar disorder, anxiety, psychotic disorder, and PTSD. However, the resident's care plan did not address the PTSD diagnosis, including potential triggers and interventions. Additionally, there was no Trauma Informed Care Assessment completed for the resident, and the facility lacked a policy for trauma informed care. Interviews with facility staff, including registered nurses, certified nurse aides, and the MDS/Care Plan Coordinator, revealed a lack of awareness and training regarding PTSD. Staff members were unsure if any residents had a PTSD diagnosis and had not received training on managing PTSD or identifying triggers. The Social Services staff was aware of the resident's brain injury and PTSD diagnosis, but this information was not effectively communicated or incorporated into the resident's care plan. The deficiency was further highlighted by the absence of any documented behaviors related to PTSD in the resident's records.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure a safe and effective medication administration system, resulting in a significant medication error involving a resident. The error occurred when a registered nurse (RN) did not prime an insulin pen before administering insulin to a resident with diabetes mellitus. The resident's physician's order sheet and medication administration record indicated the use of an Insulin Lispro insulin pen, with specific instructions for dosage before meals and per sliding scale based on blood sugar levels. However, during an observation, the RN attached the needle to the insulin pen but did not prime it, which is a necessary step to remove air from the needle and cartridge and ensure accurate dosing. The RN administered six units of insulin to the resident, whose blood sugar was 195, without priming the pen or leaving the needle in the skin for the recommended duration. During interviews, the RN acknowledged the mistake, stating that the pen should have been primed with two units and that the needle should have been left in the skin for five seconds. The MDS/Care Plan Coordinator confirmed that staff should prime the insulin pen and leave it in the skin for three to five seconds. The facility did not provide a policy for the administration of insulin or medications, contributing to the deficiency.
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Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
