Pinnacle Point Wellness & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverside, Missouri.
- Location
- 4700 Nw Cliffview Drive, Riverside, Missouri 64150
- CMS Provider Number
- 265379
- Inspections on file
- 26
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Pinnacle Point Wellness & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to accommodate the needs of a non-English speaking resident by not providing consistent communication aids, leaving the resident without engagement in their primary language. Additionally, another resident was not provided appropriate seating during meals, making self-feeding difficult. Staff were not adequately trained on using communication tools, and recommendations for alternative seating were not implemented.
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) to two residents at least two days before the end of their Medicare Part A stay. The NOMNC was issued and signed on the last day of coverage for both residents. Interviews revealed that the Business Office Manager and Administrator were unaware of the proper procedure and timeline for issuing the NOMNC, leading to non-compliance with CMS guidelines.
The facility failed to maintain acceptable noise levels and a clean, comfortable environment for its residents. A resident with cognitive loss was distressed by a continuously beeping door alarm, while another resident with anxiety and depression was disturbed by a loud clunking noise from a broken smoking cart wheel. The facility also had multiple unclean and damaged areas, with ineffective housekeeping and maintenance practices. The lack of a sound level policy and delayed corrective actions contributed to these deficiencies.
The facility failed to ensure residents were free from physical restraints, as evidenced by the improper use of a seat belt for a resident with severe cognitive impairment and locked wheelchair brakes for another resident with significant cognitive loss. The facility did not have necessary physician orders, assessments, or care plans for these restraints, leading to inappropriate restriction of residents' freedom of movement.
The facility did not conduct timely FCSR background checks for a Dietary Aide, an LPN, and a CNA before they interacted with residents, contrary to its Abuse Prevention Policy. The Human Resources Manager and Administrator acknowledged the oversight, which allowed these employees to have contact with residents without the required pre-screening.
The facility failed to complete accurate and timely MDS assessments for several residents. A resident was discharged without a discharge MDS, another had no MDS updates for months, a third passed away without a final MDS, and a fourth's MDS did not reflect dialysis treatment. Staff interviews revealed issues with obtaining RN signatures and unawareness of unsubmitted assessments.
The facility failed to develop comprehensive care plans for residents, neglecting to address critical areas such as BIPAP machine use, side rail usage, and significant weight loss. A resident's care plan did not include BIPAP use despite respiratory conditions, and side rails were used without documentation. Another resident's care plan lacked side rail documentation, despite their use for repositioning. Two residents experienced significant weight loss without care plan interventions. Staff interviews revealed a lack of awareness and updates in care plans.
Two residents in a facility, both dependent on staff for ADLs and always incontinent, did not receive necessary perineal care every two hours as required. Observations showed staff failed to reposition or assess the need for care over several hours, despite strong urine odors indicating neglect. Interviews with CNAs confirmed the lack of care, and care plans did not address routine incontinent care, leading to deficiencies in maintaining residents' personal hygiene.
The facility failed to address significant weight loss and provide adequate hydration for several residents. One resident experienced a 13.56% weight loss over six months without a care plan or interventions. Another resident lost 15.34% of their body weight over three months, with no specific interventions documented. Observations showed a lack of fluids and snacks, and inconsistent assistance during meals. Staff interviews revealed discrepancies in hydration procedures, contributing to these deficiencies.
The facility failed to assess bed rail entrapment risks for four residents, leading to the installation of side rails without proper evaluation or physician's orders. Residents had various medical conditions requiring careful consideration before using bed rails. The facility lacked a policy on entrapment, and entrapment evaluations were incomplete.
The facility failed to maintain a medication error rate below 5%, resulting in a 20% error rate. Errors included improper blood sugar testing procedures for multiple residents, incorrect application and removal of pain patches, and delayed meal service after insulin administration. These deficiencies affected the care of several residents, highlighting issues in medication management and adherence to physician orders.
Two residents experienced issues with the palatability and attractiveness of their meals. One resident with severe cognitive impairment struggled with dry rice, while another with moderate cognitive impairment and a history of stroke was served disliked rice and dry chicken. The facility lacked a policy for resident food preferences, and the Dietary Manager was unaware of complaints.
The facility was found to have multiple maintenance issues, including dust, debris, and mold-like substances in various areas, chipped paint, and rusted frames. Interviews revealed unclear responsibilities between housekeeping and maintenance staff, and no written plan for repairs. The administrator expected the building to be clean and in good repair.
The facility failed to maintain an effective pest control program, leading to the presence of gnats, flies, and wasps in resident rooms, dining areas, and hallways. Observations revealed multiple instances of pests, including flies landing on a resident and crawling on their bed. The facility lacked a pest control policy, and pest control services were limited to outside fly control. The Administrator acknowledged the issue and stated that pest control would be notified.
A resident with dementia and anxiety was treated without dignity when a CNA shook their shirt despite requests to stop, and an LPN restricted their movement by yelling at them for self-propelling their wheelchair. The facility's actions disregarded the resident's rights to a dignified existence and self-determination.
A resident with bilateral sensorineural hearing loss did not receive assistance from the facility in obtaining a hearing aid. The care plan lacked documentation of the resident's hearing needs, and there was confusion among staff about responsibilities. The Social Services Director and transportation person did not document or follow up effectively, leading to delays in obtaining the hearing aid.
A significant medication error occurred when a resident did not receive a meal within the required time after receiving fast-acting insulin. The resident's blood sugar was checked, and 4 units of Humalog insulin were administered, but the meal was delayed by nearly an hour, contrary to the manufacturer's guidelines. The LPN assumed the resident had gone to the dining room, but the resident remained in their room and expressed hunger. The DON confirmed that the insulin should be given no earlier than 10 minutes before a meal.
The facility failed to complete performance reviews of CNAs at least once every 12 months and did not provide regular in-service education based on the outcome of the reviews. A review of 52 CNA personnel files revealed this deficiency, and the Executive Director admitted to not having the necessary competency evaluations.
The facility failed to ensure proper food safety and hygiene practices, including unsealed food in the freezer, dirty containers, dusty shelving, and a dietary cook not performing hand hygiene while handling food and equipment.
The facility failed to have a written transfer agreement with a hospital to ensure timely hospital admission and information exchange for residents. The Executive Director was unaware of the Federal requirement and believed it was not necessary in Missouri. She had never seen a written transfer agreement at the facility and stated she would begin the process of obtaining one.
The facility failed to implement and maintain their infection prevention and control program, resulting in a lack of documentation and tracking of infections. The Infection Preventionist, new to the position, acknowledged the deficiencies, and the Corporate Nurse confirmed the need for improvement towards compliance with IPCP regulations.
The facility failed to ensure residents who smoked were assessed and supervised according to their needs. Several residents were observed smoking unsupervised outside designated areas, and the facility did not have a system to identify and monitor residents' smoking needs. Additionally, care plans and smoking evaluation tools were incomplete or missing for some residents.
The facility failed to ensure timely administration and availability of prescribed medications for eight residents, resulting in a medication error rate of 49.15%. Issues included assumptions about resident refusals, delays in administration, and failure to reorder medications on time.
The facility failed to implement and maintain their IPCP program to monitor and evaluate antibiotic use for their 115 residents. The Infection Preventionist admitted to not having implemented the program and could not provide documentation for ongoing review. The Corporate Nurse confirmed awareness of the issue and stated the goal was to improve the program towards compliance.
The facility failed to notify the Ombudsman of two unplanned, facility-initiated hospital discharges for a resident with multiple medical conditions. The Social Services Director did not include the resident in the monthly discharge lists for November 2023 and March 2024, resulting in a lack of required notification.
The facility failed to ensure accurate completion of MDS assessments for two residents under PASARR and for one resident under the Antipsychotic Medication section. The inaccuracies were due to the MDS Coordinator completing assessments without always having access to the paper charts, leading to incorrect documentation of PASARR evaluations and antipsychotic medication use.
The facility failed to develop a comprehensive care plan for a resident with chronic wounds and edema, despite having orders for Lasix and Bumex. Staff interviews confirmed that the care plan should have been updated to include these conditions.
The facility failed to administer physician-ordered glaucoma eye drops as prescribed for a resident. The resident's MAR for April 2024 showed multiple instances of missing documentation, indicating that the medications may not have been given. The interim DON confirmed that the lack of documentation meant the facility could not prove the medications were administered.
A resident with chronic pain did not receive prescribed Hydrocodone for over a week due to the facility's failure to reorder the medication. Staff did not adequately assess the resident's pain or offer alternative pain management, and the Interim Director of Nursing was unaware of the issue until it was reported.
The facility failed to maintain a qualified administrator from mid-February to early March 2024. Administrator A, who had not yet obtained a license, assumed the role without being listed as a current Missouri Licensed Administrator. The application for a Temporary Emergency License was incomplete and delayed, resulting in a gap in qualified administrative oversight.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to provide adequate accommodations for a non-English speaking resident, identified as Resident #104, who primarily spoke Spanish. Despite the resident's care plan indicating the use of a communication board and Google Translate for communication, observations revealed that these tools were not consistently utilized. The resident was often left without engagement or entertainment in their primary language, and staff frequently communicated with the resident in English, which the resident did not understand. Interviews with staff indicated a lack of awareness and training on using communication aids, and the resident's family had to frequently assist with communication and care. Additionally, the facility did not provide appropriate seating accommodations for another resident, identified as Resident #26, during meal times. This resident, who had significant cognitive loss and was dependent on a wheelchair, was observed sitting at a dining table that was too high, causing difficulty in self-feeding. The resident's wheelchair was not appropriately fitted, leading to challenges in reaching the table and resulting in the resident eating with their fingers. Despite recommendations from the therapy department for alternative seating arrangements, such as using an over-bed table, these were not implemented. The facility's failure to accommodate these residents' needs and preferences highlights a lack of adherence to the residents' rights to dignified existence and communication. The absence of a policy on accommodating residents' needs further exacerbated the issue, as staff were not adequately trained or informed on how to effectively communicate and provide care for residents with language barriers or specific physical needs.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) form CMS-10123 to Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay. This deficiency affected two residents, as evidenced by the review of their medical records. Resident #1's record indicated that the NOMNC was issued and signed on the same day that Medicare Part A benefits were ending, failing to meet the required two-day notice period. Similarly, Resident #93's record showed the NOMNC was also issued and signed on the last day of coverage, not adhering to the mandated timeline. Interviews conducted with the Business Office Manager and the Administrator revealed a lack of awareness and understanding regarding the proper procedure for issuing the NOMNC. The Business Office Manager was unaware that the residents did not receive the notice within the required timeframe, while the Administrator could not recall the specific time frame for issuing the NOMNC and was unsure who was responsible for providing the form to residents. This lack of knowledge and procedural oversight contributed to the facility's failure to comply with the CMS guidelines for notifying residents about the end of their Medicare coverage.
Facility Fails to Maintain Acceptable Noise Levels and Clean Environment
Penalty
Summary
The facility failed to maintain acceptable noise levels and a clean, comfortable environment for its residents, as observed in the cases of two residents. Resident #35, who has significant cognitive loss and uses a wheelchair, was observed in distress due to a continuously beeping door alarm in the Special Care Unit dining room. The alarm was caused by a propped-open patio door, and the resident was seen covering their ear and displaying a distressed expression. Additionally, Resident #77, who has intact cognitive skills but suffers from anxiety and depression, reported being disturbed by a loud clunking noise from a broken smoking cart wheel, which had been an issue for over a month and affected their sleep. The facility also failed to maintain a sanitary and orderly environment, as evidenced by multiple observations of unclean and damaged areas throughout the facility. These included stained carpets, dusty light fixtures, chipped paint, and mold-like substances in air conditioning units. The facility's housekeeping and maintenance policies were not effectively implemented, as indicated by the presence of debris, unpainted drywall patches, and broken equipment. Interviews with staff revealed a lack of communication and follow-up on maintenance issues, contributing to the ongoing deficiencies. Furthermore, the facility did not have a policy on sound levels, which may have contributed to the noise-related issues experienced by the residents. The maintenance director acknowledged awareness of some of the problems, such as the broken smoking cart wheel, but corrective actions were delayed. The Director of Nursing expressed expectations for a clean and comfortable environment, yet the facility's practices did not align with these expectations, resulting in a failure to uphold residents' rights to a safe and homelike environment.
Improper Use of Restraints in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints, as evidenced by the improper use of a seat belt for one resident and locked wheelchair brakes for another. Resident #11, who has severe cognitive impairment and is dependent on staff for all activities of daily living, was observed with a seat belt fastened across their lap, which they could not release independently. The facility did not have a physician's order, assessment, or care plan for the use of the seat belt, and staff were unaware of the resident's ability to release it. Interviews with staff and administration confirmed that the seat belt should not have been in use without proper evaluation and documentation. Resident #84, who has significant cognitive loss and uses a wheelchair for mobility, was observed with locked wheelchair brakes, preventing them from moving freely. The resident expressed distress and discomfort, indicating they did not want the brakes locked. Staff interviews revealed that the brakes were locked to keep the resident in place, despite the understanding that locked brakes constitute a restraint if the resident cannot unlock them independently. The resident's care plan did not address the use of locked wheelchair brakes, and staff acknowledged that the brakes should not have been locked without the resident's ability to release them. The facility's failure to obtain necessary physician orders, conduct assessments, and update care plans for the use of restraints resulted in the improper use of a seat belt and locked wheelchair brakes for these residents. The facility's policies and the Missouri Resident Rights emphasize the right of residents to be free from restraints, yet these incidents demonstrate a lack of adherence to these guidelines, leading to the inappropriate restriction of residents' freedom of movement.
Failure to Conduct Timely Background Checks
Penalty
Summary
The facility failed to adhere to its Abuse Prevention Policy by not conducting timely background checks through the Family Care Safety Registry (FCSR) for three employees before they had contact with residents. The policy, dated October 2022, mandates pre-screening of potential employees for a history of abusive behavior. However, the personnel files of a Dietary Aide, an LPN, and a CNA revealed that their FCSR checks were conducted after their hire dates, allowing them to interact with residents without the necessary background screening. Interviews with the Human Resources Manager and the Administrator confirmed that the FCSR checks should have been completed before any employee had contact with residents, highlighting a lapse in the facility's hiring process.
Inaccurate and Untimely MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately and timely for four residents. Resident #72 was discharged to another long-term care facility, but no discharge MDS was completed or submitted. Resident #84 had an admission MDS completed, but no subsequent MDS assessments were completed or submitted for several months. Resident #33 had an admission and a Prospective Payment System (PPS) MDS completed, but no MDS assessments were completed or submitted in the months leading up to their death, and no discharge assessment was completed post-mortem. Resident #39's quarterly MDS failed to reflect their dialysis treatment, despite physician orders and care plans indicating the necessity of dialysis. Interviews with facility staff revealed systemic issues contributing to these deficiencies. The MDS Coordinator acknowledged difficulties in obtaining Registered Nurse signatures, leading to delayed MDS submissions. The Coordinator was unaware of any unsubmitted discharge MDS assessments and could not explain the lack of a current MDS for Resident #84. The Director of Nursing and the Administrator both expressed expectations for timely and accurate MDS submissions, yet these expectations were not met, resulting in incomplete and inaccurate resident assessments.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in addressing critical care areas. For Resident #39, the care plan did not include the use of a bilevel positive airway pressure (BIPAP) machine, despite the resident's respiratory conditions and the resident's expressed desire for its use at night. Additionally, the care plan did not address the use of side rails, which the resident used for repositioning in bed. Observations and interviews revealed that the BIPAP machine was not consistently applied, and the side rails were not documented in the care plan, despite being used by the resident. Resident #113's care plan also lacked documentation regarding the use of side rails, which were present on the resident's bed. The resident had involuntary movements and used the side rails to assist with repositioning, yet this was not reflected in the care plan. Staff interviews indicated a lack of awareness about the reason for the side rails, and the side rail evaluation did not support their use, highlighting a disconnect between the resident's needs and the care plan. For Residents #26 and #84, the facility failed to address significant weight loss in their care plans. Both residents experienced substantial weight loss over several months, yet their care plans did not include interventions to address or mitigate this issue. The MDS coordinator and the Director of Nursing acknowledged the expectation for care plans to include such interventions, but the care plans remained incomplete, indicating a failure to update and implement necessary care strategies for these residents.
Failure to Provide Timely Incontinent Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary services for dependent residents who were unable to perform activities of daily living, specifically in providing perineal care at least every two hours. This deficiency affected two residents, both of whom were always incontinent of bowel and bladder and dependent on staff for all ADLs. Observations showed that staff did not reposition or assess the need for incontinent care for these residents over several hours, despite the facility's policy requiring routine perineal care after each incontinent episode. Resident #11, with severe cognitive impairment and diagnoses including cerebral palsy and quadriplegia, was observed lying in bed without being repositioned or provided incontinent care for over three hours. Interviews with CNAs revealed that they had not provided the necessary care since arriving at work, acknowledging that the resident should be repositioned and provided care every two hours. The resident's care plan did not address incontinence or incontinent care, contributing to the oversight. Similarly, Resident #19, with moderate cognitive impairment and diagnoses including Guillain-Barre syndrome, was observed in a room with a strong smell of urine, indicating a lack of timely incontinent care. Staff interviews confirmed that the resident had not been repositioned or provided perineal care since the start of their shift. The care plan for this resident also failed to address routine incontinent care, leading to the deficiency in maintaining the resident's personal hygiene.
Inadequate Hydration and Weight Loss Management
Penalty
Summary
The facility failed to adequately address significant weight loss and provide sufficient hydration for several residents. Resident #26 experienced a 13.56% weight loss over six months, with no care plan or interventions documented to address this issue. Observations revealed that the resident was not consistently provided with fluids or assistance during meals, contributing to inadequate hydration and nutrition. Despite a physician's order for an appetite stimulant, there was no evidence of consistent follow-up or notification of the physician regarding the resident's weight loss. Resident #84 also suffered from significant weight loss, losing 15.34% of their body weight over three months. The resident's care plan did not include specific interventions to address this weight loss, and observations showed a lack of fluids and snacks available to the resident. Staff did not consistently assist the resident during meals, and there was no documentation of efforts to encourage or monitor the resident's food and fluid intake. Additional residents, including #35, #57, and #4, were observed to have inadequate hydration, with inconsistent documentation of fluid intake and a lack of fluids available at bedside. Staff interviews revealed a lack of consistent procedures for providing fluids and snacks, with discrepancies in the reported times and frequency of hydration cart rounds. The facility's failure to adhere to its hydration policy and lack of individualized care plans for weight loss and hydration contributed to these deficiencies.
Failure to Assess Bed Rail Entrapment Risks
Penalty
Summary
The facility staff failed to properly assess residents for the risk of entrapment from bed rails before their installation. This deficiency was observed in four out of 21 sampled residents. The facility did not have a policy on entrapment, and there were no physician's orders for the use of side rails for these residents. The residents involved had various medical conditions, including cognitive impairments, mobility issues, and other health diagnoses, which necessitated careful consideration before the use of bed rails. For Resident #39, the facility did not complete a full entrapment assessment, and the bed's dimensions were not appropriately measured against FDA recommendations. Despite the resident's request for side rails to assist with repositioning, there was no documented physician's order for their use. Similarly, Resident #113 had side rails installed without a proper assessment or physician's order, and the entrapment evaluation was incomplete. The resident's involuntary movements were noted, but the side rail committee had recommended against their use. Resident #54 also had side rails installed without a physician's order, and the entrapment evaluation was not fully documented. The resident used the side rails for mobility assistance, but this was not care planned. Lastly, Resident #104 had side rails without a completed side rail evaluation form or physician's order. The entrapment evaluation was incomplete, and staff were unsure of the necessity of the side rails. The facility's maintenance director was tasked with completing entrapment evaluations, but there was a lack of clarity and consistency in the process.
Medication Administration Errors and Delays in Insulin Management
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 20% error rate. This was observed through various incidents involving five residents. For instance, Resident #4, who has diabetes mellitus and chronic obstructive pulmonary disease, had their blood sugar checked without allowing the alcohol wipe to air dry, contrary to proper procedure. Similarly, Resident #15's blood sugar was checked after only a four-second air dry, and Resident #43's blood sugar was checked after a six-second air dry, both of which were insufficient according to the facility's standards. Resident #91 experienced issues with the application and removal of Salonpas patches. The patches were not removed at the scheduled time, and the MAR inaccurately indicated that they had been removed. This oversight was confirmed when the nurse found the patches still on the resident the following morning, despite documentation stating otherwise. The resident reported shoulder pain and expressed that the patches were supposed to be removed at night. Resident #103, who requires insulin for diabetes management, did not receive their meal within the recommended time frame after insulin administration. The resident's blood sugar was checked, and insulin was administered according to the sliding scale, but the meal was delayed by approximately an hour. This delay was contrary to the manufacturer's guidelines for Humalog insulin, which should be administered no earlier than 10 minutes before a meal. The LPN involved assumed the resident had gone to the dining room, leading to the oversight.
Failure to Provide Palatable and Attractive Food
Penalty
Summary
The facility failed to provide food that was palatable and attractive, affecting two residents. Resident #85, who had severe cognitive impairment and required assistance with eating, was observed struggling with dry rice that was served in the form of an ice cream scoop. The resident expressed that the food was very dry. The care plan for Resident #85 indicated the need to obtain and update food preferences and serve the diet as ordered, but there was no policy provided for resident food preferences. Resident #52, with moderate cognitive impairment and a history of stroke and dementia, was observed having difficulty eating dry chicken and was served rice despite disliking it. The meal ticket indicated a preference against rice, yet it was still served. The Dietary Manager was unaware of any current food complaints, and the Administrator expected food to be served palatably. The facility census was 103, and the deficient practice was noted during observations and interviews.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain the physical environment in good repair, as observed in various areas including the Special Care Unit, dining/activity room, nurse's station, and entrance areas. Specific issues included dead bugs, dust, and debris in light fixtures, scratched and chipped paint on doors, scuffed and stained floor tiles, and black mold-like substance on PTAC units. Additionally, there were cobwebs, rusted and chipped window frames, and cracked tiles in several locations. These deficiencies were noted to potentially affect all residents, with a census of 103. Interviews with housekeeping and maintenance staff revealed a lack of clarity and coordination in responsibilities for cleaning and repairs. Housekeeping staff indicated that maintenance was responsible for high dusting and cleaning lights, while the maintenance director stated that housekeeping should handle these tasks. The maintenance director also acknowledged awareness of rusted door frames and the need for patching and painting but noted that no contractor had been contacted for repairs. Furthermore, there was no written plan for the repair and upkeep of the building, and the administrator expressed an expectation for the building to be clean and in good repair.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats, flies, and wasps in various areas, including resident rooms, dining rooms, and hallways. Observations on multiple occasions revealed gnats in a specific room, flies in the dining room, and both flies and gnats in another room, where a fly strip with dead flies was also noted. A resident reported frequent fly infestations in their room, with flies landing on them and crawling on their bed. Additionally, wasps were observed on the wall of the Special Care Unit's nursery room, and another room had multiple flies crawling on a resident and their bed. The facility did not provide a pest control policy, and the review of pest service invoices indicated that the pest control program was limited to outside fly control services conducted monthly from July to September. During an interview, the Administrator acknowledged the existence of a pest control program but noted that fly strips should not be present in resident rooms and stated that pest control would be notified of the concerns.
Resident Dignity and Respect Deficiency
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by the actions of staff towards a resident with significant cognitive impairment. The resident, who had a diagnosis of dementia and anxiety, was observed sitting in the hallway when a Certified Nurse Aide (CNA) grabbed and shook the resident's shirt despite the resident's repeated requests to stop. The CNA continued this behavior, dismissing the resident's protests as playful interaction. This incident was witnessed by surveyors and highlighted a lack of respect for the resident's right to a dignified existence. Additionally, the resident was subjected to disrespectful treatment by a Licensed Practical Nurse (LPN) who yelled at the resident for self-propelling their wheelchair in the hallway. The LPN repeatedly called the resident back to the nurses' station, restricting their movement within the secured care unit. The resident expressed dissatisfaction with being confined to certain areas, indicating a disregard for their right to self-determination. Interviews with the Director of Nursing and the Administrator confirmed that such actions were inappropriate and not aligned with the facility's expectations for resident care.
Failure to Assist Resident in Obtaining Hearing Aid
Penalty
Summary
The facility failed to assist a resident, identified as Resident #82, in obtaining a hearing aid, despite the resident's diagnosis of bilateral sensorineural hearing loss. The resident's care plan did not address the hearing issues or the need for a hearing aid, and there was a lack of documentation regarding the process of obtaining the hearing aid. The resident had undergone a hearing test at a local hospital but had not received the hearing aid, and there was no communication with Social Services about the issue. Interviews with facility staff revealed a lack of clarity and responsibility in the process of obtaining the hearing aid. The Social Services Director indicated that the transportation person was responsible for scheduling appointments and following up, but did not document any information in the resident's chart. The transportation person confirmed they were waiting for Medicaid approval and did not have access to charting, while the Director of Nursing stated that Social Services should document the process. The Administrator expected the Social Services Director to play a larger role in obtaining the hearing aid, rather than leaving it to transportation.
Significant Medication Error Due to Delayed Meal After Insulin Administration
Penalty
Summary
The facility failed to ensure a safe and effective medication administration system, resulting in a significant medication error involving a resident who did not receive a meal within the required time after receiving fast-acting insulin. The facility's policy for medication administration requires that medications be administered as prescribed and in accordance with professional standards. However, the policy did not specify the time frame for providing a meal after administering insulin. The manufacturer's guidelines for Humalog insulin indicate that it should be administered 15 minutes before a meal. In this case, the resident's blood sugar was checked, and 4 units of Humalog insulin were administered at 11:54 A.M. The resident did not receive a meal until 12:52 P.M., nearly an hour after the insulin was given, contrary to the manufacturer's guidelines. Observations showed that the resident remained in their room without being checked on by staff after receiving insulin. The LPN responsible for administering the insulin assumed the resident had gone to the dining room to eat. However, the resident stayed in their room and expressed hunger at 12:42 P.M. The Director of Nursing confirmed that the physician's orders should be followed and that Humalog should be given no earlier than 10 minutes before a meal. The delay in providing the meal after insulin administration was identified as a significant medication error, as the resident should not have waited 45 minutes to an hour to eat after receiving fast-acting insulin.
Failure to Complete CNA Performance Reviews and Provide In-Service Education
Penalty
Summary
The facility failed to complete a performance review of nurse aides at least once every 12 months and did not provide regular in-service education based on the outcome of the review. This deficiency was identified through interviews, record reviews, and a review of the facility's policy. The facility's policy, dated 07/01/03, mandates that all new employees, including CNAs, must undergo orientation within the first 40 hours of employment and complete specific training topics annually. However, a review of 52 CNA personnel files revealed that the facility did not adhere to this policy, as no performance reviews or competency evaluations were completed for the CNAs within the required 12-month period. During an interview, the Executive Director admitted that she did not have the CNAs' competency evaluations and could not provide the necessary documentation. This lack of adherence to the facility's policy and federal regulations resulted in the facility failing to ensure that CNAs received the required performance reviews and in-service education, which are critical for maintaining the quality of care provided to residents.
Failure to Ensure Proper Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen, which had the potential to affect all residents consuming food from the kitchen. During an observation, it was noted that the freezer contained an open bag of hamburgers, eight plastic containers ready for use were dirty with dried food particles, and two metal shelving units with dust collected on them. Additionally, during a tray line observation, a dietary cook handled food and equipment without performing hand hygiene. The cook unplugged a hot box with bare hands, transported it through hallways, and continued to serve food after picking up utensils and a pen from the floor without washing hands. Interviews with the dietary cook and the dietary manager revealed a lack of awareness and adherence to proper hand hygiene and sanitization practices. The dietary manager acknowledged the need to stay within regulations and maintain a clean kitchen, while the administrator emphasized the importance of sanitizing and washing hands when processing and handling food. These observations and interviews indicate a failure to follow the facility's policy on sanitizing equipment and food contact surfaces, posing a risk to the health and safety of the residents.
Lack of Written Transfer Agreement with Hospital
Penalty
Summary
The facility failed to ensure a written transfer agreement with a hospital was in effect to assure residents of timely hospital admission when medically appropriate and necessary information would be exchanged between providers. On 04/18/24, the written transfer agreement(s) with the community hospital(s) was requested from the Executive Director, but no written transfer agreement was provided. During an interview on 04/19/24, the Executive Director stated that the facility did not have a written transfer agreement, believing it was not a requirement in Missouri and that the community understood residents would be treated at the hospital without one. The Executive Director was unaware of the Federal requirement for a written transfer agreement and had never seen one at the facility since she had been working there for a few months. She stated she would immediately begin the process of obtaining a written transfer agreement with the community hospital.
Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement and maintain their established infection prevention and control program (IPCP) for surveillance, tracking, trending, and administration of corrective actions to prevent and control the spread of identified infections. The facility's policy for IPCP included completing a monthly infection control surveillance log with detailed information about each infection case, such as the resident's identifying information, infection onset date, diagnostic test outcomes, infection site, culture results, and resolution date. However, this surveillance action was not implemented, leading to a lack of documentation and tracking of infections within the facility, which had a census of 115 residents. During an interview, the Infection Preventionist (IP) stated she had completed her certification process recently and had been in the position for one month. She was unaware of the previous IP or if the facility had employed one in the past several months. The IP acknowledged the lack of documentation for tracking and trending infections and was trying to improve the process. The Corporate Nurse also confirmed awareness of the documentation deficiencies and stated that the goal was to improve the program towards compliance with IPCP regulations, policies, and procedures.
Failure to Supervise Smoking Residents
Penalty
Summary
The facility failed to ensure residents who smoked were assessed and that supervision was provided in accordance with their assessed needs. Residents were observed smoking unsupervised outside of designated areas. The facility did not have a system in place to individually identify and determine if residents needed staff to maintain their smoking materials, care plan such needs, and implement a monitoring system for five of 22 residents who smoked. Additionally, the facility failed to develop a care plan for one of the residents who smoked. One resident, R11, was readmitted with diagnoses including chronic obstructive pulmonary disease and had a BIMS score indicating moderate cognitive impairment. The resident's care plan did not reflect that they were a smoker, and the smoking evaluation tool was incomplete. Another resident, R81, who was cognitively intact, was observed smoking outside the designated area without supervision. The smoking evaluation tool for R81 was also incomplete, and the resident admitted to obtaining cigarettes and a lighter from another person in the facility. Other residents, including R17, R5, and R87, were also observed smoking without proper supervision and outside designated areas. R17, who was cognitively intact, kept smoking materials in their scooter basket and expressed dissatisfaction with the lack of supervision. R5, who had a traumatic brain injury and was cognitively intact, kept cigarettes in a lockbox in their room and smoked outside the building unsupervised. R87, who had chronic obstructive pulmonary disease and moderate cognitive impairment, was observed smoking and admitted to having access to cigarettes despite the facility's policy. The facility's staff admitted to forgetting to document necessary information in the smoking evaluation tools, and the Executive Director confirmed that residents should be supervised while smoking in designated areas.
Medication Administration Failures
Penalty
Summary
The facility failed to ensure prescribed medications were administered at the prescribed time and were available for administration for eight of 13 residents. This resulted in 29 medication errors out of 59 opportunities, leading to a medication error rate of 49.15%. The facility's policy mandates that medications be administered in accordance with written orders of attending physicians and within a specific time frame, which was not adhered to in these cases. For instance, one resident did not receive a prescribed patch because the LPN assumed the resident would refuse it, while another resident received their medication late due to the LPN's delay. Additionally, a resident did not receive their pain medication because it was not available in the facility, and the LPN failed to reorder it in a timely manner. Another resident did not receive their insulin as scheduled because the LPN was unable to administer it on time. Other residents also experienced delays in receiving their medications, including those for diabetes, pain management, and other chronic conditions. The interim director of nursing confirmed that medications should be given at the time ordered by the physician and acknowledged the lapses in timely administration. These failures highlight significant issues in medication management and adherence to physician orders within the facility.
Failure to Implement and Maintain Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and maintain their infection prevention and control (IPCP) program critical element to monitor and evaluate antibiotic use and to track measures of usage in the facility for their entire population of residents, which had a census of 115. The facility's policy on the Antibiotic Stewardship Program, updated on 10/01/22, outlined guidelines for monitoring antibiotic use, including collecting reports on antibiotic susceptibility patterns, reviewing the appropriateness of antibiotic administration, establishing standards for clinical monitoring of adverse drug events from antibiotic use, and using microbiology culture data to guide future antibiotic selection. During an interview, the Infection Preventionist (IP) acknowledged familiarity with the IPCP standards and goals but admitted to not having implemented them yet and could not provide documentation for the facility's ongoing review of antibiotic stewardship. The Corporate Nurse also confirmed awareness of the lack of documentation and stated that the goal was to improve the program towards compliance with IPCP regulations, policies, and procedures.
Failure to Notify Ombudsman of Unplanned Hospital Discharges
Penalty
Summary
The facility failed to ensure the Ombudsman was notified of two unplanned, facility-initiated hospital discharges for a resident. The resident, who had diagnoses including spinal stenosis, osteomyelitis, and a right leg below-the-knee amputation, experienced an unplanned discharge to the hospital on two separate occasions. The first discharge occurred on 11/09/23 due to an urgent medical need related to a wound infection, and the second discharge occurred on 03/27/24 due to a non-healing wound on the left foot with drainage and odor. In both instances, the Ombudsman was not notified of the discharges as required. The Social Services Director (SSD) typically provided a monthly report of all discharges to the Ombudsman but failed to include the resident in question on the discharge lists for November 2023 and March 2024. The SSD acknowledged that the resident did not appear on the discharge list for those months and admitted that an extra step was needed to ensure hospitalizations were included. The failure to notify the Ombudsman was confirmed during staff interviews and a review of the facility's records.
Inaccurate MDS Assessments for PASARR and Antipsychotic Medication
Penalty
Summary
The facility failed to ensure the accurate completion of the Minimum Data Set (MDS) assessment under the Pre-Admission Screening and Resident Review (PASARR) for two residents and under the Antipsychotic Medication section for one resident. Resident 7 was admitted with diagnoses including schizophrenia and anxiety disorder. Despite having a PASARR Level II evaluation indicating a serious mental illness and requiring a structured environment and medication management, the MDS assessment inaccurately documented that the resident had not been evaluated by PASARR Level II. Additionally, the MDS assessment inaccurately documented that the resident had not received antipsychotic medications, despite records showing a prescription for olanzapine for schizophrenia. The MDS Coordinator admitted to completing the MDS without always having access to the paper chart, leading to these inaccuracies. Resident 41 was admitted with diagnoses including intellectual disabilities, schizophrenia, and major depressive disorder. The PASARR Level II Evaluation Report indicated a serious mental illness but no intellectual disability requiring specialized mental health services. However, the MDS assessment inaccurately documented that the resident had not been evaluated by PASARR Level II. The MDS Coordinator also admitted to not being aware of the PASARR Level II evaluation for this resident and completing the MDS without always having access to the paper chart, resulting in the inaccurate documentation.
Failure to Develop Comprehensive Care Plan for Chronic Wounds and Edema
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan to address a resident's chronic wounds and edema. The resident, who was admitted with diagnoses including edema and stroke affecting the right side of the body, had orders for Lasix and Bumex to manage edema. Despite these orders and the resident's ongoing treatment for chronic wounds and edema, the care plan did not include any specific measures for these conditions. This oversight was confirmed through a review of the resident's electronic medical record and interviews with staff members. During interviews, the Administrator acknowledged that care plans should be updated based on information gathered in morning meetings. The Minimum Data Set Registered Nurse (MDSRN) also confirmed that the chronic edema and wound care should have been included in the care plan and expressed uncertainty about how this was missed. The resident was not interviewable, and the facility census at the time was 115.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to administer physician-ordered glaucoma eye drops as prescribed for one resident (R44) out of a sample of 29 residents. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had specific orders for timolol, latanoprost, Trusopt, and Brimonidine eye drops to be administered at various times throughout the day. However, a review of the resident's Medication Administration Record (MAR) for April 2024 revealed multiple instances where the administration of these medications was not documented, indicating that the medications may not have been given as prescribed. During an interview, the interim director of nursing confirmed that the absence of documentation in the MAR boxes under the specified dates meant that the facility could not prove the medications were administered. This failure to document and potentially administer the prescribed medications constitutes a deficiency in meeting professional standards of quality care for the resident.
Failure to Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to ensure that pain medication (Hydrocodone) was available for a resident (R24) who required it. R24, who was admitted with diagnoses including polyneuropathy, diabetes mellitus, rheumatoid arthritis, pain, and a history of right femur fracture, had a physician's order for Hydrocodone-Acetaminophen 5-325 mg to be administered twice a day. However, from 04/11/24 to 04/19/24, the medication was not available, and the resident did not receive the prescribed pain management. During this period, the resident reported moderate pain levels and expressed frustration over the lack of effective pain relief, despite repeatedly asking staff about the medication's availability. The staff failed to assess the resident's pain adequately or offer alternative pain management solutions during this time. Additionally, the resident's Medication Administration Record (MAR) indicated that the pain medication was not administered as ordered, and the pain scale was documented as zero for each shift, which contradicted the resident's reported pain levels. Interviews with staff revealed a lack of knowledge and training on reordering medications, and the Interim Director of Nursing (IDON) was unaware of the issue until it was brought to their attention. The IDON stated that emergency pharmacies could have been used to obtain the medication promptly, but this option was not utilized. The facility's failure to ensure the availability of prescribed pain medication and to provide appropriate pain management for R24 resulted in the resident experiencing unmanaged pain for an extended period.
Failure to Maintain Qualified Administrator
Penalty
Summary
The facility failed to maintain a qualified administrator on duty from February 15, 2024, to March 3, 2024, as required by state laws. Administrator B informed the state survey agency on February 14, 2024, that they were no longer the Administrator of record. Subsequently, Administrator A, who had completed the Administrator in Training program but had not yet taken the test to obtain an administrator license, assumed the role. However, Administrator A was not listed as a current Missouri Licensed Administrator, and there was uncertainty about whether anyone at the corporate level was a licensed administrator in Missouri to act in the interim. The application process for Administrator A's Temporary Emergency License (TEL) was mishandled. A partial application was submitted on February 15, 2024, but it lacked the full licensure application, application fee, and required records such as a birth certificate and proof of high school graduation. Despite follow-up emails from the Missouri Board of Nursing Home Administrators (MBNHA) on February 20 and February 26, 2024, the necessary documents were not promptly provided. The full application and fee were only received on February 27, 2024, but still lacked some required documents. Consequently, a TEL was not issued to Administrator A until March 4, 2024.
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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