Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rest Haven Health Care Center during CMS and state inspections, most recent first.
An LPN heated water in a microwave and gave it to a cognitively intact resident for coffee, and the resident spilled the hot liquid on both legs, causing a burn injury. The resident’s care plan did not include directions for serving hot liquids, and the facility lacked a policy for assessing safety with hot liquids. In a separate event, a CNA attempted to roll a resident who required two-staff assistance by him/herself, and the resident slid off the bed and was sent out for evaluation.
LPN Applied Burn Treatment Without Physician Order: An LPN applied petrolatum ointment to a resident’s burn injury after the resident spilled hot water on his/her legs, but did not obtain a physician order before giving the treatment. The resident was cognitively intact, and the POS did not include an order for the ointment. Later, another LPN contacted the physician for a treatment order, while the DON and NP stated an order should have been obtained first and that petrolatum ointment was not an appropriate initial treatment.
A non-verbal resident with intellectual and developmental disabilities was not protected from sexual abuse when a CNA gained prolonged, unsupervised access to the resident’s room during a night shift. An LPN entered the room for morning medications, found the curtain drawn, and discovered the CNA and the resident in bed, both undressed from the waist down, with pornography on the CNA’s phone. Staff had difficulty getting the CNA to leave the room, and the CNA returned to the resident’s room at least once before finally going outside, where police later detained him/her. A SANE RN later reported the resident appeared timid and afraid to be touched. Interviews revealed that the CNA admitted to having sex with the resident multiple times that night and previously, while other staff, including the ADON and CNAs, failed to report or act on the CNA’s unexplained absence from assigned duties and did not consistently perform resident checks, allowing the abuse to occur and continue.
Surveyors found that dietary staff did not follow facility policies for food labeling and storage, dishwashing machine operation, or hand hygiene. Unlabeled and undated food items, including prepared foods and opened containers such as sour cream, mayonnaise, pimento spread, and dressings, were stored in dry storage and a reach-in cooler despite posted requirements for dating and discarding leftovers after three days. The low-temp dish machine repeatedly operated below required wash and rinse temperatures while being used to clean plates and food processor parts that were then used to prepare mechanical soft and pureed pork served to residents, and dietary staff reported they did not monitor water temperatures. Staff also failed to wash hands between dirty and clean tasks when changing gloves, including when moving from scrubbing soiled pans or handling soiled plates to assembling equipment and preparing a peanut butter sandwich and pureed meals for residents.
The facility staff failed to follow infection control procedures, leading to deficiencies in care. Oxygen and nebulizer tubing were not stored correctly, catheter bags were found touching the floor, and Enhanced Barrier Precautions were not implemented effectively. Staff did not wear appropriate PPE, and glucometers were not sanitized between uses, increasing the risk of cross-contamination.
The facility failed to appoint a qualified Infection Preventionist (IP) to manage its infection prevention and control program. The Chief Nursing Director and Director of Nursing (DON) confirmed the absence of an IP, with the Assistant Director of Nursing (ADON) yet to start certification. The DON, new to the role, was unsure about infection control responsibilities, while the interim Administrator was unaware of the situation.
The facility failed to maintain a safe, clean, and homelike environment, with observations of disrepair and unsanitary conditions in resident rooms and common areas. Issues included rusted bathroom door frames, cracked floor tiles, and unsanitary grab bars. Interviews revealed a lack of communication and awareness among staff regarding maintenance responsibilities, contributing to the ongoing deficiencies.
The facility failed to develop comprehensive person-centered care plans for eight residents, resulting in unmet medical, nursing, mental, and psychosocial needs. Issues included missing directions for respiratory therapy, pain management, and wound care, as well as discrepancies in assistance needs for residents with cognitive impairments, stroke, and other conditions. Staff interviews revealed a lack of coordination and communication in updating care plans, with reliance on corporate oversight without facility-level input.
Facility staff failed to document and obtain necessary physician orders for hospice services and indwelling catheters for several residents. Two residents on hospice care lacked documented orders, and three residents with catheters did not have orders specifying details about the catheters. Additionally, weekly skin assessments were not documented for three residents, and a smoking assessment was missing for one resident. Interviews with facility staff revealed a lack of awareness and oversight regarding these deficiencies.
Facility staff failed to meet the basic hygiene needs of several residents, as observed through greasy hair, long fingernails, and unkempt appearances. Despite policies requiring assistance with bathing and grooming, residents reported missed showers and expressed distress over inadequate care. Staff interviews revealed that staffing shortages hindered adherence to hygiene schedules, leading to neglect of residents' needs.
The facility failed to lock medication carts and safely store hazardous materials, leading to potential safety risks. Medication carts were observed unlocked and unattended, and shower rooms containing hazardous materials were left accessible. Staff interviews confirmed the responsibility to secure these areas to prevent resident access.
The facility failed to provide sufficient nursing staff, resulting in unmet resident needs such as poor personal hygiene and inadequate care. Residents reported infrequent showers and long wait times for assistance, while staff confirmed high turnover and lack of support. Observations showed residents in soiled conditions, highlighting the facility's inability to provide timely care.
A facility experienced a 53.85% medication error rate due to late administration of medications following an electrical outage. Staff were unprepared, lacking access to electronic medical records and MARs, and no backup system was in place. This affected residents with various medical conditions, as medications were administered four to five hours late.
The facility failed to conduct a comprehensive facility-wide assessment to determine necessary resources for resident care during regular operations and emergencies. The assessment lacked critical information on resident capacity, staff competencies, and facility resources. Interviews revealed that key staff, including the interim DON and Assistant DON, were unaware of the assessment process, contributing to the deficiency.
Facility staff failed to provide adequate dialysis care and communication for a resident requiring dialysis services. The resident's Physician Order Sheet lacked dialysis orders, and the care plan did not include dialysis direction. Staff interviews revealed that assessments and vital signs were not conducted before transport to the dialysis clinic, contrary to facility policy. The Director of Nursing and other staff acknowledged these oversights, highlighting a failure to adhere to established protocols.
The facility failed to ensure that four nurse aides completed their certification within the required timeframe. The policy lacked guidance on handling delays, and staffing shortages led to uncertified aides working on the floor. The DON and HR were aware of the issue, but the administrator was not informed.
The facility failed to implement an effective Antibiotic Stewardship Program (ASP) as outlined in their policy. The ASP lacked documentation of tracking antibiotic trends, and interviews revealed the absence of an Infection Preventionist (IP) to track, trend, or implement the ASP. Key staff members, including the Chief Nursing Director and interim administrator, were unaware of the lack of tracking and trending of antibiotic use, resulting in the deficiency.
Facility staff failed to update care plans after falls for four residents and did not invite two residents to their care conferences. Despite multiple falls and cognitive impairments, care plans lacked documentation and new interventions. The MDS Coordinator admitted to not keeping up with care plan meeting forms, and both the DON and administrator confirmed the expectation for updates and invitations, but were unsure why these were not done.
The facility failed to provide the services of an RN for at least eight consecutive hours per day, seven days a week, from October 2023 to April 2024. The DON and administrator acknowledged the lack of RN coverage, citing staffing shortages and difficulties in obtaining agency staff.
Facility staff failed to keep residents' medical records accessible and systematically organized for 23 residents. The records for falls, skin assessments, wound documentation, labs, GDR, pharmacy recommendations, and immunization records were not accessible. The DON acknowledged the lack of a system for documenting falls and limited access to the lab portal, contributing to the issue.
Facility staff failed to notify a resident's representative in a timely manner after a report of potential abuse. The resident had severe cognitive impairment and multiple diagnoses. Interviews with staff revealed that the nurse did not contact the resident's family as required by facility policy.
Facility staff failed to document accurate MDS assessments for three residents by incorrectly coding them as taking anticoagulant medications when they were not prescribed such medications. The MDS nurse admitted to the error due to a lack of knowledge and not consulting the RAI manual recently.
Facility staff failed to ensure proper labeling and disposal of medications, and stored non-medication items in the medication refrigerator. Observations revealed undated and unlabeled medications, expired medications, and food items in the medication storage areas. Staff interviews confirmed lapses in adherence to the facility's Storage of Medication policy.
Facility staff failed to follow up on a resident's grievance about a missing gaming console within the required 72 hours. The Social Services Director acknowledged the grievance but had not completed the investigation or taken action to replace the item. Conflicting information from the Director of Nursing and the administrator about the grievance process and notification timelines contributed to the deficiency.
Facility staff failed to report an allegation of physical and verbal abuse to DHSS within the required two-hour timeframe for a resident with severe cognitive impairment. Interviews revealed that the DON and administrator did not believe the situation involved abuse or were unaware of the specifics, leading to a deficiency in the facility's abuse reporting policy.
Facility staff failed to serve food in accordance with nutritionally calculated menus and standardized recipes by not providing the correct portion sizes to three residents who received pureed food items. Observations showed that residents received incorrect portion sizes of beef stroganoff, egg noodles, and green beans. The dietary supervisor acknowledged that staff should have provided the correct portions even though the items were combined.
Facility staff failed to perform appropriate hand hygiene and glove changes during incontinence care, catheter care, and wound care for multiple residents. Observations showed staff did not follow the facility's policies on standard precautions, leading to improper care practices. Interviews confirmed that staff were aware of the correct procedures but failed to follow them due to being in a hurry or nervous.
The facility staff failed to maintain fifteen months of MDS assessments in the active clinical records for eight residents admitted for more than 15 months. The assessments were stored in boxes, making them inaccessible to other staff, and the MDS nurse was unaware of the requirement.
Facility staff failed to post required nurse staffing information in an area readily accessible to residents and visitors. The DON was unaware of the specific location requirement, and the administrator confirmed the posting was in a rarely used back dining room not open to the public.
Unsafe hot liquid handling and improper bed repositioning led to resident injury and a fall
Penalty
Summary
The facility failed to ensure a resident remained free from accidents when an LPN heated water in a microwave and handed it to the resident for instant coffee. The resident, who was cognitively intact, independent with eating, and without impairment to the hands or arms, removed the lid from the cup and spilled the hot water on both legs, resulting in a burn injury. The resident’s care plan noted a preference for coffee extremely hot, but it did not include interventions directing staff on how to provide hot liquids to the resident, and the facility did not have a policy for assessing resident safety with hot liquids. The resident’s progress notes documented redness and peeling after the spill, followed by treatment orders for burn care and an antibiotic. The LPN stated the water was heated for about a minute, the lid was placed on the cup, and the resident was told it was hot and to wait a few minutes before removing the lid. The resident stated he/she was eager to make the coffee and spilled the hot water while trying to remove the lid. The DON stated staff would be expected to ensure hot liquids were not served above 120 degrees F, and the administrator stated staff should educate the resident and ensure the water was not above 120 degrees F when delivered. The facility also failed to prevent a resident from falling from bed during care. The resident’s MDS showed substantial/maximal assistance was required to roll left and right in bed, and the care plan stated the resident was totally dependent on two staff for repositioning and turning in bed every two hours and as necessary. A CNA documented that while attempting to roll the resident onto one side by him/herself, the resident’s legs came too far over the side and the resident slid off the bed. The resident was assessed after the fall, sent to the emergency room for evaluation and treatment, and later returned to the facility without injuries and without new orders.
LPN Applied Burn Treatment Without Physician Order
Penalty
Summary
Facility staff failed to maintain professional standards of care when an LPN administered treatment to a resident’s burn injury without first obtaining a physician’s order. Resident #1 was assessed as cognitively intact and without impairments to the hands, arms, or legs on the quarterly MDS dated 03/17/26. On 05/07/26 at 5:49 A.M., the LPN documented that the resident spilled hot water on his/her legs, with redness and peeling observed, and that petroleum ointment was applied. The note did not document that an order had been obtained from the physician for the treatment, and the resident’s POS for 05/01/26 through 05/07/26 did not contain an order for petroleum ointment to the legs. During interviews, LPN B stated that after receiving report from LPN A, he/she assessed the resident with the wound nurse and contacted the physician at approximately 7:30 A.M. to obtain a treatment order. LPN A stated that he/she cleaned the hot liquid from the resident’s legs, applied petrolatum ointment to the burn areas, and passed the information to the oncoming nurse, but did not obtain a treatment order from the physician. The DON stated the nurse should obtain an order from the physician and follow the treatment orders, and the NP stated the nurse should initially apply a cold compress, assess for pain, and contact him/her for a treatment order; the NP also stated petrolatum ointment was not an appropriate treatment for the burn injury.
Failure to Protect Non-Verbal Resident From Sexual Abuse by CNA
Penalty
Summary
Facility staff failed to protect a non-verbal resident with intellectual and developmental disabilities from sexual abuse by a CNA. The resident’s MDS showed non-verbal status and diagnoses including psychological development disorders, intellectual disabilities, and developmental disorder. On the early morning in question, an LPN entered the resident’s room to administer morning medications and found the curtain drawn, which was unusual for this resident. Upon pulling back the curtain, the LPN observed the CNA and the resident lying on their right sides in the resident’s bed, with the CNA’s pants around his/her ankles and the resident’s sweatpants and underwear on the bed. The LPN reported that it appeared they were having intercourse, although he/she was not certain, and the CNA greeted the LPN when discovered. Additional staff were summoned to the room, including an RN, another LPN, a CMT, and another CNA. When the RN arrived, the CNA had his/her pants back on and was sitting on the resident’s bed next to the resident, who remained naked from the waist down. The RN and other staff repeatedly instructed the CNA to leave the resident’s room; however, the CNA initially remained in the room and attempted to close the door. The CNA left the room, then returned again to the resident’s room while the resident was still undressed from the waist down, and was again told to leave. Staff observed that the CNA’s phone, left on the resident’s bed, had pornography pulled up. The resident was later noted pulling up his/her black slacks without assistance. Police were called, and the CNA was ultimately detained outside the facility. A SANE RN later examined the resident at the hospital and reported the resident appeared very timid and afraid to be touched, and only a limited exam could be completed. Interviews and record review showed that the CNA admitted to law enforcement that he/she had sex with the resident prior to the nurse entering the room and stated that they were watching pornography when the nurse came in. The CNA further told the detective that he/she had been in the resident’s room from approximately 11:00 or 12:00 the previous night and had sex with the resident two or three times before, and claimed that sex was part of the resident’s daily living activities. Staffing and supervision issues during the night shift contributed to the CNA’s prolonged, undetected access to the resident. The ADON, who was the charge nurse, last saw the CNA around 1:15 A.M., could not locate the CNA afterward, and found the CNA’s phone at the nurse’s station but did not notify anyone, assuming the CNA had left and focusing on completing his/her own work. Another CNA assigned to the same hall reported that the CNA sometimes disappeared for one to two hours on previous occasions and that on this night he/she had to cover the hall alone after about 1:00 A.M., but did not report the CNA’s absence because he/she felt it was not his/her place. The CNA assigned to check residents every two hours stated he/she did not believe he/she entered this resident’s room the entire shift because he/she was busy. These actions and inactions allowed the CNA to remain alone with the resident for an extended period, during which the sexual abuse occurred. The facility’s abuse and neglect policy defined abuse as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, including sexual abuse, and specified that sexual abuse is non-consensual contact of any type with a resident. The CNA had previously signed an abuse and neglect acknowledgement and had a criminal background check indicating eligibility to work in LTC. Despite this, the CNA was able to enter and remain in the resident’s room for hours during the night without detection or intervention by nursing staff or CNAs responsible for monitoring residents and coworkers’ whereabouts. The failure of staff to promptly identify, report, and act upon the CNA’s unexplained absence from assigned duties, combined with the lack of timely checks on the resident, directly led to the situation in which the CNA was found in bed with the resident, both undressed from the waist down, and to the CNA’s subsequent admission of repeated sexual contact with the resident.
Improper Food Storage, Dishwashing Temperatures, and Hand Hygiene in Dietary Services
Penalty
Summary
Facility staff failed to store and label food in accordance with facility policy and posted instructions, resulting in multiple instances of unlabeled, undated, and potentially outdated food in the kitchen. Surveyors observed in the dry goods storage area a service cart with plastic containers and bowls of cereal, including two opened plastic storage bags of cereal without dates. In the reach-in cooler, despite a sign stating that every item must have an open date with no exceptions, staff stored an unlabeled and undated plastic bag with an unknown white substance, containers of tan and brown gravy-like substances dated 11/28, an unlabeled and undated container of an applesauce-like substance, an unlabeled and undated metal container of sliced fruit in juice, two opened and undated containers of sour cream with soiled lids, an opened and undated mayonnaise jar, an opened and undated bottle of key lime juice, an undated partially uncovered pan of cooked beans with meat, an unlabeled and undated large pan of cornbread, a large opened and undated container of pimento spread with black material on the lid and below the lip, and an opened and undated container of Italian dressing. The dietary manager and administrator both stated that all kitchen staff were responsible for labeling and dating opened food items and discarding leftovers after three days, but the dietary manager acknowledged he/she did not know why unlabeled or older food items remained in the cooler, and the administrator stated he/she was not aware of any food storage issues. Facility staff also failed to ensure the dishwashing machine operated according to manufacturer’s instructions and facility policy to achieve proper wash and rinse temperatures. Policy required the low-temperature dishwasher to maintain wash temperatures of 120–140°F and rinse temperatures of 102–150°F, and the machine’s placard indicated minimum wash and rinse temperatures of 120°F. However, when a dietary aide ran a load of plates, a calibrated digital thermometer showed a maximum water temperature of 78°F during wash and rinse cycles. When the cook used the dishwasher to clean food processor parts between uses, the thermometer showed a wash temperature of 78°F and a rinse temperature of 85°F, and the same processor was then used to prepare mechanical soft and pureed breaded pork served to residents at the noon meal. Later, another rack of soiled lunch plates was run through the dishwasher and the highest temperature recorded was 108°F. Dietary staff interviewed reported they did not check dishwasher water temperatures and were unaware of the required temperature range, and the maintenance director and administrator both stated they were not aware the dishwasher was not reaching proper temperatures. In addition, kitchen staff did not perform hand hygiene as required by facility policy when transitioning from dirty to clean tasks and when changing gloves. Policy required handwashing before beginning work, after contact with unsanitary surfaces, when working with different food substances, and before donning gloves, with gloves to be changed as often as hands needed washing. One cook rinsed food processor parts, ran them through the dishwasher, then scrubbed soiled pans in a three-compartment sink, removed gloves, and donned a clean pair of gloves without washing hands before reassembling the food processor and using it to prepare mechanical soft and pureed pork for seven residents. A dietary aide accepted a stack of soiled plates, used gloved hands to clear food and debris, then removed gloves and donned a clean pair without handwashing before preparing a peanut butter sandwich that was then served to a resident. Both staff members later acknowledged they should have washed their hands before putting on clean gloves, and the administrator stated he/she was not aware that kitchen staff were failing to wash hands when required.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to adhere to proper infection control procedures, leading to multiple deficiencies in the care of residents. Observations revealed that oxygen and nebulizer tubing were not changed or stored correctly, with visible debris on equipment and tubing not bagged when not in use. This was noted for three residents, including one who was cognitively impaired and required oxygen due to heart failure. Interviews with the Director of Nursing (DON) and other staff indicated a lack of awareness and adherence to the facility's policies regarding the maintenance and storage of respiratory equipment. Additionally, the facility staff did not maintain proper catheter care practices, as observed with three residents whose catheter drainage bags were found touching the floor. This improper handling poses a risk of infection. Interviews with the DON and other staff confirmed that catheter bags should be kept off the floor, yet this practice was not consistently followed. The facility's policy lacked specific guidance on keeping catheter bags and tubing off the floor, contributing to the oversight. The facility also failed to implement Enhanced Barrier Precautions (EBP) effectively. Observations showed that staff did not wear appropriate personal protective equipment (PPE) when providing care to residents with feeding tubes, wounds, or catheters. PPE was not readily available near residents' rooms, and staff were not consistently educated on EBP protocols. Interviews with the DON and other staff highlighted a lack of awareness and training regarding EBP, with the absence of an infection preventionist cited as a contributing factor. Furthermore, the facility did not ensure proper hand hygiene and glove changes during wound care, and glucometers were not sanitized between uses, increasing the risk of cross-contamination among residents.
Lack of Designated Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) to oversee its infection prevention and control program, as required by its policy. The policy, revised on March 5, 2025, mandates the employment of one or more qualified individuals for this role. Interviews revealed that the facility currently lacks an IP. The Chief Nursing Director acknowledged the absence of an IP and mentioned that the Assistant Director of Nursing (ADON) is in the process of obtaining certification. The Director of Nursing (DON), who recently assumed the position, was unaware of who was responsible for infection control duties and mentioned working as a charge nurse. The ADON expressed uncertainty about finding time to pursue certification and was unclear about the time commitment required for the IP role. The interim Administrator was also unaware of the lack of an IP in the facility.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of disrepair and unsanitary conditions in resident-occupied rooms and common areas. Specific issues included rusted and deteriorating bathroom door frames, cracked and discolored floor tiles, floors with black stains and heavy urine odors, sticky bathroom floors, and grab bars with brown substances. These conditions were observed in several resident rooms, indicating a widespread issue with maintenance and cleanliness. Interviews with facility staff, including the Director of Nursing, Certified Nurse Assistant, Licensed Practical Nurse, and the administrator, revealed a lack of clarity and communication regarding the process for reporting and addressing maintenance issues. The Maintenance Director acknowledged responsibility for building repairs but admitted to being unaware of several specific issues, such as rusted light fixtures and a brown sink. Additionally, the administrator, who was new to the position, was not fully aware of the pending repairs, further highlighting the facility's failure to maintain a safe and homelike environment for its residents.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for eight residents, which led to deficiencies in meeting their medical, nursing, mental, and psychosocial needs. For Resident #1, the care plan lacked direction for respiratory therapy despite the resident's severe cognitive impairment, shortness of breath, and need for oxygen therapy due to heart failure and profound intellectual disability. Observations confirmed the resident was consistently on oxygen, yet the care plan did not reflect this need. Resident #2's care plan was missing guidance for advanced directives, pain management, and skin/wound prevention, despite the resident being on a pain management schedule and having a Stage III pressure injury and diabetic foot ulcer. The resident expressed having daily pain related to cancer, which was manageable with medication and rest, but the care plan did not address these needs. Similarly, Resident #9 required substantial assistance for toilet hygiene and transfer due to a stroke and impaired vision, yet the care plan inaccurately stated the resident could toilet independently with supervision, leading to a discrepancy between the care plan and actual care needs. The facility's care plans for other residents, such as Resident #12, #18, #25, #45, and #258, also lacked necessary directions and interventions for their specific conditions, including hospice services, oxygen use, catheter care, and fall prevention. Interviews with facility staff revealed a lack of coordination and communication in updating care plans, with the corporate nurse being the only one responsible for updates. The absence of a dedicated MDS nurse and the reliance on corporate oversight without facility-level input contributed to the incomplete and non-personalized care plans, failing to meet the residents' comprehensive care needs.
Deficiencies in Documentation and Orders for Hospice and Catheter Services
Penalty
Summary
The facility staff failed to meet professional standards of quality care by not documenting and obtaining necessary physician orders for hospice services and indwelling catheters for several residents. Specifically, two residents receiving hospice care did not have documented orders for these services, and three residents with indwelling catheters lacked orders specifying the reason, type, size, and balloon size of the catheters. This lack of documentation and orders was observed despite the presence of hospice staff and catheter equipment during the survey. Additionally, the facility did not adhere to its policy on pressure injury prevention and management, as evidenced by the absence of documented weekly skin assessments for three residents. These residents were either at risk for skin breakdown or had existing pressure ulcers, yet their medical records did not reflect the required weekly assessments. Furthermore, one resident who smoked did not have a documented smoking assessment, which is necessary to ensure their safety and the safety of others. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the administrator, revealed a lack of awareness and oversight regarding these deficiencies. The ADON and DON were unaware of the missing orders and assessments, and the administrator, who was new to the facility, was also not informed of these issues. The DON is responsible for ensuring that nursing staff complete necessary assessments and obtain required orders, but these responsibilities were not fulfilled, leading to the identified deficiencies.
Deficiency in Resident Hygiene Care
Penalty
Summary
The facility staff failed to provide adequate care to meet the basic hygiene needs of five residents, as observed and documented in the report. The facility's policy on Activities of Daily Living (ADL) and Resident Showers mandates that residents receive assistance with bathing, grooming, and other hygiene-related activities based on their needs and preferences. However, observations revealed that several residents were left with greasy hair, long fingernails, and unkempt appearances, indicating a lack of adherence to these policies. Resident #11, who is cognitively intact but requires substantial assistance with bathing and personal hygiene, was observed with greasy hair on multiple occasions. Similarly, Resident #12, who has a diagnosis of bilateral above-knee amputation and diabetes, was found with greasy hair and long fingernails, and reported missing scheduled showers. Resident #13, who is cognitively impaired and dependent on staff for hygiene, was repeatedly observed with long facial hair, unkempt hair, and long fingernails. Resident #27, also cognitively impaired and dependent on staff, was noted to have long facial hair, long fingernails with a dark substance underneath, and unkempt hair, with incomplete documentation of shower schedules. Resident #42, with moderate cognitive impairment, was observed with greasy hair and expressed distress over the lack of assistance with personal hygiene. Interviews with staff, including nurse aides and the Director of Nursing, highlighted issues with staffing shortages, which impacted the ability to adhere to the facility's hygiene and shower schedules. Staff acknowledged the challenges in maintaining the required grooming standards due to being understaffed, which resulted in the neglect of residents' hygiene needs. The administrator admitted uncertainty about the effectiveness of the current grooming practices, further underscoring the deficiency in providing adequate care to the residents.
Medication and Hazardous Material Storage Deficiencies
Penalty
Summary
The facility staff failed to adhere to the Medication Storage policy by leaving medication carts unlocked and unattended on multiple occasions. Observations revealed that the medication cart at the nurse station was left unlocked and unattended several times, with an insulin pen left on top of the cart. Interviews with the Director of Nursing (DON), a Certified Medication Technician (CMT), and a Licensed Practical Nurse (LPN) confirmed that staff are responsible for ensuring medication carts are locked when unattended to prevent residents from accessing medications that could be harmful. Additionally, the facility did not comply with its Chemical Storage and Labeling policy, as hazardous materials were not stored safely in two of the three shower rooms. Observations showed that the 200 hall and 100 hall shower rooms were left unlocked and unattended, containing hazardous materials such as disposable razors, lime remover, and WD40. Interviews with the DON, a Certified Nurse Aid (CNA), and an LPN indicated that shower rooms and cabinets containing hazardous materials should be locked to prevent resident access and potential injury.
Inadequate Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of its residents, as evidenced by multiple observations and interviews. Residents expressed concerns about insufficient staff, particularly during night shifts, which resulted in unmet needs such as unanswered call lights, lack of assistance with personal hygiene, and inadequate care for residents with specific medical conditions. The facility's staffing records confirmed that there were instances where only one licensed nurse and one certified nurse aide were on duty for the entire building, which had a census of over 50 residents. Several residents were observed with poor personal hygiene, including greasy hair, long fingernails, and unkempt appearances, indicating a lack of assistance with activities of daily living. Residents reported receiving showers less frequently than required, sometimes only once a week, due to staff being pulled from shower duties to assist with other tasks. Additionally, residents were found in soiled conditions, with some having saturated sheets and strong odors of urine, highlighting the facility's inability to provide timely and adequate care. Interviews with staff and residents revealed systemic issues with staffing, including high turnover rates, lack of training, and insufficient support from management. The facility had experienced a significant loss of administrative and nursing staff, leaving critical roles unfilled and further exacerbating the staffing crisis. The Acting Director of Nursing and other staff members acknowledged the challenges in maintaining adequate care and the impact on residents' well-being, with reports of unmet medical and emotional needs due to the staffing shortages.
Medication Administration Errors Due to Lack of Contingency Plan
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than 5%, resulting in a 53.85% error rate during a survey. Out of 52 medication administration opportunities observed, 28 errors occurred, affecting three residents. The errors were primarily due to medications being administered significantly later than the prescribed time, with delays ranging from four to five hours past the scheduled administration time. The deficiency was linked to a lack of preparedness for an electrical outage, which resulted in staff not having access to electronic medical records or Medication Administration Records (MARs). Certified Medication Technician (CMT) B administered medications late due to the outage, and there was no backup system in place, such as printed MARs, to guide timely medication administration. Interviews with staff, including the Director of Nursing (DON) and Assistant Director of Nursing (ADON), revealed that there was no established protocol for handling such situations, and staff were not educated on contingency plans for power outages. The residents affected by the late medication administration included those with various medical conditions requiring timely medication, such as antihistamines, antipsychotics, diabetes treatments, and anticonvulsants. The facility's failure to have a plan in place for accessing medical records during an outage directly contributed to the medication errors, as staff were unable to verify current orders and administer medications within the prescribed time frames.
Failure to Conduct Comprehensive Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for resident care during both regular operations and emergencies. The facility's policy required monthly updates to the Facility Assessment, considering factors such as resident population, staff competencies, physical environment, and resources. However, the Facility Needs Assessment dated 03/03/25 was found lacking in several critical areas, including resident capacity, staff competencies, and facility resources. Additionally, it did not address ethnic, cultural, or religious factors that could affect care, nor did it include a facility-based and community-based risk assessment using an all-hazards approach. Interviews with facility staff revealed a lack of understanding and involvement in the facility assessment process. The interim Director of Nursing (DON) admitted to not receiving training for the role and was unaware of the facility assessment requirements. Similarly, the Assistant DON and the Interim Administrator were not involved in the assessment process, with the latter noting that both the Administrator and DON were new to their roles and had not completed the assessment since their tenure began. This lack of documentation and staff awareness contributed to the deficiency in meeting the facility's assessment requirements.
Failure to Provide Adequate Dialysis Care and Communication
Penalty
Summary
Facility staff failed to provide thorough orders, monitoring, and ongoing communication with the dialysis clinic for a resident requiring dialysis services. The facility's Dialysis policy mandates ongoing assessment and oversight of residents before and after dialysis treatments, as well as communication and collaboration with the dialysis clinic. However, the review of Resident #48's records revealed that the Physician Order Sheet did not contain orders related to dialysis, and the care plan lacked direction for dialysis. Additionally, there was no documentation of staff assessing the resident prior to being transported to dialysis. Interviews with facility staff, including LPNs and the Director of Nursing, confirmed that staff did not assess the resident's condition or take vital signs before transport to the dialysis clinic, relying instead on the clinic to perform these assessments. The Director of Nursing acknowledged that vital signs should be taken before transport, and the Regional MDS director and the administrator both stated that dialysis should be included in the care plan and POS. The lack of assessment and communication represents a failure to adhere to the facility's policy and poses a risk to the resident's health and safety.
Non-compliance with Nurse Aide Certification Timeline
Penalty
Summary
The facility failed to ensure that four out of six nurse aides completed the required nurse aide training program within four months of their employment. The facility's policy did not specify a timeline for completion or procedures for handling situations where nurse aides exceed the 120-day requirement. Nurse aides C, D, E, and F were identified as not having completed their certification within the required timeframe. Interviews revealed that NA D had been working for eight months without passing the necessary certification test and had to rely on certified staff or nurses to assist residents with care needs. The Director of Nursing acknowledged the issue, stating that nurse aides should be certified within 120 days and should be reassigned if they fail to meet this requirement. However, due to staffing shortages, uncertified aides continued to work on the floor. The Human Resources staff, who recently took over tracking responsibilities, stated that they would need to consult corporate for guidance if a nurse aide exceeded the 120-day limit without certification. The facility administrator, new to the position, was unaware of the non-compliance and indicated that Human Resources, in coordination with the DON, was responsible for ensuring compliance with certification timelines.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program (ASP) as required by their policy revised on 06/29/23. The policy outlined that the ASP should optimize antibiotic use and reduce unnecessary laboratory tests and antibiotics through a systematic approach. It required compliance with state and federal laws, leadership by an Antibiotic Steward, and involvement of a team including the Director of Nursing, a nurse with administrative duties, and a charge nurse. The program was supposed to include systematic evaluation of ongoing treatment, tracking and monitoring of antibiotic prescribing practices and resistance patterns, and monthly reviews of the Infection Log generated in the Point Click Care (PCC) system. However, the facility's ASP lacked documentation of tracking antibiotic trends. Interviews revealed that the facility did not have an Infection Preventionist (IP) to track, trend, or implement the ASP. The Chief Nursing Director acknowledged the absence of an IP and the lack of tracking and trending of antibiotic use. The Assistant Director of Nursing was unaware that the ASP was not being implemented, and the interim administrator was also unaware of the lack of tracking and trending of antibiotic use. Consequently, the facility did not have an active ASP in place, leading to the deficiency.
Failure to Update Care Plans and Invite Residents to Care Conferences
Penalty
Summary
Facility staff failed to review and revise care plans after falls for four residents. Resident #4, who had severe cognitive impairment and a diagnosis of moderate intellectual disabilities, experienced multiple falls between January and February 2024, but the care plan dated February 27, 2024, did not document these falls or include new fall interventions. Similarly, Resident #24, who was modified independent and had no falls documented in the quarterly MDS, experienced falls in February, March, and April 2024, but the care plan dated February 6, 2024, did not reflect these incidents or new interventions. Resident #36, with moderate cognitive impairment and a diagnosis of dementia, had an unwitnessed fall in March 2024, but the care plan dated April 9, 2024, incorrectly stated no falls had occurred since admission. Resident #47, with severe cognitive impairment and a diagnosis of dementia, experienced multiple falls from January to March 2024, but the care plan dated March 26, 2024, did not document these falls or new interventions. Additionally, the facility staff failed to invite residents to their care conferences. Resident #32, who was independent with all activities of daily living (ADLs) and participated in assessment and goal setting, reported not being invited to care plan meetings and was unaware of their existence. Resident #35, also independent with all ADLs and involved in assessment and goal setting, similarly reported never being invited to care plan meetings. The MDS Coordinator admitted to not keeping up with forms documenting care plan meetings and attendance since 2022-2023, despite care plan meetings occurring approximately every three months or with significant changes. Interviews with the Director of Nursing (DON) and the administrator confirmed the expectation that care plans should be updated with falls and new interventions, and that residents and family members should be invited to care plan meetings. However, both were unsure why these updates and invitations were not being consistently implemented. The DON and the administrator reiterated that the MDS Coordinator was responsible for updating and maintaining care plans, but the deficiencies in documentation and communication persisted.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. The facility's RN staff schedule from October 2023 to April 2024 showed multiple instances where there was no RN coverage on specific Saturdays and Sundays. The facility census was 45, indicating a significant number of residents potentially affected by this deficiency. The facility also lacked a policy for RN coverage, further contributing to the issue. During interviews, the Director of Nursing (DON) and the administrator acknowledged the lack of RN coverage. The DON mentioned that there were only two RNs on staff, including themselves, and that they worked Monday through Friday for 8-10 hours. The administrator stated that they would contact agency staff for coverage when there was no RN available, but this did not always result in obtaining the necessary coverage. This deficiency highlights a systemic issue in ensuring adequate RN staffing in the facility.
Failure to Maintain Accessible and Organized Medical Records
Penalty
Summary
Facility staff failed to keep residents' medical records accessible and systematically organized in accordance with accepted professional standards for 23 residents out of a sampled 23 residents. The medical records for falls, skin assessments, wound documentation, labs, gradual dose reductions (GDR), pharmacy recommendations, and immunization records were not accessible. The Director of Nursing (DON) acknowledged that there was no system in place for documenting falls, and that GDR and pharmacy recommendations should be filed together in the resident's chart. The DON also noted that only he/she and one other staff member had access to the lab portal, which contributed to the issue of lab results not being filed in the residents' charts. Additionally, the DON admitted that no one wanted to file the documents, leading to the information not being included in the medical records as expected. During an interview, the administrator confirmed that her expectation was for all resident care information to be in the residents' charts and accessible to staff. However, the facility failed to meet this expectation, resulting in incomplete and inaccessible medical records for the sampled residents. This deficiency was observed through a combination of observation, interview, and record review, highlighting a significant lapse in the facility's record-keeping practices.
Failure to Notify Resident's Family After Abuse Allegation
Penalty
Summary
Facility staff failed to notify Resident #26's representative in a timely manner after a report of potential abuse involving Resident #1. The facility's policy mandates that any suspected or witnessed account of abuse must be reported to the Administrator, DON, the resident's representative, doctor, and the State Agency immediately, but no later than two hours after the incident. However, the Incident/Accident Report for Resident #26, dated 04/13/24, did not contain documentation that the resident's family member was contacted. Resident #26 had severe cognitive impairment and diagnoses of high blood pressure, Alzheimer's, anxiety, and depression. Interviews with facility staff, including an LPN, the administrator, and the DON, revealed that staff are educated to notify the resident's family after an allegation of abuse. The LPN stated that the DON or administrator is responsible for contacting the resident's family member, but was unsure if this had been done. Both the administrator and the DON confirmed that the nurse should have notified the resident's family after the report of abuse, but acknowledged that this did not occur in this instance.
Inaccurate MDS Assessment Coding for Anticoagulant Use
Penalty
Summary
Facility staff failed to document an accurate Minimum Data Set (MDS) assessment for three residents by incorrectly coding them as taking anticoagulant medications when they were not prescribed such medications. The facility's MDS completion and submission timeframes policy, dated 2010, did not provide direction for coding the MDS assessment. The Resident Assessment Instrument (RAI) manual, dated October 2023, clearly states that antiplatelet medications like aspirin and clopidogrel should not be coded as anticoagulants. However, the MDS assessments for Residents #7, #23, and #40 were incorrectly coded for anticoagulant use in their respective 7-day lookback periods, despite their physician order sheets showing no such prescriptions for anticoagulants during the relevant timeframes. During interviews, the MDS nurse admitted to coding Plavix and aspirin as anticoagulants due to a lack of knowledge and not consulting the RAI manual recently because of other responsibilities, including resident care. The administrator confirmed that the MDS coordinator is responsible for accurate MDS coding and should use the RAI manual for guidance. The administrator also mistakenly believed that aspirin and Plavix were considered blood thinners and should be coded as anticoagulants.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Facility staff failed to ensure multi-dose medications contained an open date and/or resident name, dispose of expired medications, and store only medications in the medication storage refrigerator. Observations revealed multiple instances of undated and unlabeled medications, including fluticasone propionate nasal spray, lubricant eye drops, timolol mal sol 0.5%, rhopressa sol 0.02%, systane complete sol 0.6%, and polyethylene glycol. Additionally, expired medications such as multi-probiotic, Imodium AD, and ferrous sulfate were found in the medication room. Interviews with staff indicated a lack of adherence to the facility's Storage of Medication policy, which mandates proper labeling, disposal of expired medications, and separation of medications from food items in storage areas. Further observations showed that the medication refrigerator contained non-medication items such as chocolate candy, an uncrustable sandwich, a cinnamon roll, and a plastic cup with a brown frozen drink. Interviews with various staff members, including a Certified Medication Technician (CMT), Licensed Practical Nurse (LPN), Director of Nursing (DON), and the administrator, confirmed that food and drink should not be stored in the medication refrigerator due to contamination risks. The staff acknowledged their responsibility to check for expired medications and ensure proper storage practices, but lapses in these duties were evident during the survey.
Failure to Follow Up on Resident Grievance
Penalty
Summary
Facility staff failed to provide a resident with an appropriate follow-up plan or resolution in response to their grievance within 72 hours. The resident reported a missing gaming console, and the grievance form did not contain documentation of follow-up within the required timeframe. Interviews with the resident and staff revealed that the resident had reported the missing item to social services, but there was no follow-up on the grievance. The Social Services Director acknowledged the grievance but stated that the investigation was not completed, and there was talk about replacing the item, but no action had been taken yet. The Director of Nursing and the administrator provided conflicting information about the grievance process and timelines for notifying residents. The Director of Nursing mentioned a 30-day notification period, while the administrator stated that residents should be notified within five days. The lack of consistent follow-up and communication with the resident regarding the missing item and the grievance process led to the deficiency.
Failure to Report Abuse Allegation Within Required Timeframe
Penalty
Summary
Facility staff failed to report an allegation of physical and verbal abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe for a resident with severe cognitive impairment. The facility's policy mandates immediate reporting of suspected abuse to the administrator, Director of Nursing (DON), the resident's representative, doctor, and the State Agency within two hours. However, the facility's investigation showed that the suspected incident involving a Certified Nurse Aide (CNA) and the resident was not reported to DHSS within the stipulated time. Interviews with staff revealed that the Licensed Practical Nurse (LPN) and the DON were aware of the reporting requirements but failed to act accordingly. The DON did not contact DHSS because he/she did not believe the situation involved abuse, and the administrator did not contact DHSS because he/she was unaware that the allegation included physical abuse. This failure to report the incident promptly led to a deficiency in adhering to the facility's abuse reporting policy.
Failure to Serve Correct Portion Sizes of Pureed Food
Penalty
Summary
Facility staff failed to serve food in accordance with the nutritionally calculated menus and standardized recipes by not providing the correct portion sizes to three residents who received pureed food items. The facility's policies did not contain instructions for staff to prepare multiple portions of pureed food items. Observations showed that residents received incorrect portion sizes of beef stroganoff, egg noodles, and green beans. Specifically, residents received four ounces of pureed beef stroganoff and noodles instead of the specified 3.2 ounces of beef stroganoff and four ounces of egg noodles. Additionally, residents received four ounces of beans instead of the specified 3.2 ounces. The facility's dietary supervisor acknowledged that staff should have provided the correct portions even though the items were combined. Resident #4's physician order sheet indicated that the resident was to receive mechanical soft foods with pureed meats and double portions or shakes with meals three times daily. However, observations showed that Resident #4 did not receive the correct portion sizes as specified. During interviews, Cook L admitted to combining servings incorrectly and not providing the correct portion sizes. The dietary supervisor confirmed that the pureed recipes were kept in his/her office and that it was his/her responsibility to ensure staff knew where the recipes were kept. The supervisor also acknowledged that staff should not have served pureed meat and noodles on top of noodles.
Failure to Perform Proper Hand Hygiene and Glove Changes
Penalty
Summary
Facility staff failed to perform appropriate hand hygiene and glove changes during incontinence care, catheter care, and wound care for multiple residents. Specifically, during incontinence care for one resident, staff did not perform hand hygiene before applying gloves, did not change gloves after cleaning the resident, and did not sanitize hands before applying new gloves. Similar failures were observed during catheter care for two residents, where staff did not change gloves between clean and dirty tasks and did not maintain proper catheter bag positioning. Additionally, during wound care for another resident, staff did not perform hand hygiene between glove changes and clean tasks, leading to potential cross-contamination. The facility's policies on standard precautions, perineal care, catheter care, and pressure ulcer treatment were not followed by the staff. These policies require staff to wash hands before and after glove use, change gloves between clean and dirty tasks, and maintain clean techniques during care procedures. However, observations showed that staff frequently skipped these steps, leading to improper care practices. Interviews with staff revealed that some were aware of the correct procedures but failed to follow them due to being in a hurry or nervous. The deficiencies were confirmed through multiple observations and interviews with staff, including nurse aides, certified medication technicians, licensed practical nurses, the Director of Nursing, and the administrator. All confirmed that the expected procedures were not followed, and hand hygiene was not consistently performed. The facility census at the time was 45, indicating that these practices could potentially affect a significant number of residents if not addressed.
Failure to Maintain 15 Months of MDS Assessments in Active Records
Penalty
Summary
The facility staff failed to maintain fifteen months of Minimum Data Set (MDS) assessments in the resident's active clinical record for eight residents who had been admitted for more than 15 months. The facility's policy on MDS completion and submission timeframes, dated 2010, did not provide guidance on maintaining these assessments. The Resident Assessment Instrument (RAI) manual, dated October 2023, mandates that nursing homes must keep all resident assessments from the previous 15 months in the active record and use them to develop, review, and revise the resident's comprehensive plan of care. However, the records for residents #1, #7, #13, #17, #23, #24, #26, and #32 did not contain the required 15 months of MDS assessments. During an interview, the MDS nurse revealed that the assessments were stored in boxes in his/her office and the social worker's office, making them inaccessible to other staff when the MDS nurse was not present. The MDS nurse was unaware of the requirement to keep these assessments in the active record. The Administrator confirmed that MDS information and assessments should be in the residents' active records and readily accessible for at least seven years, indicating a lack of adherence to the regulatory requirements.
Failure to Post Nurse Staffing Information in Accessible Area
Penalty
Summary
Facility staff failed to complete or post required nurse staffing information in an area readily accessible to residents and visitors. The facility's policy, revised in 7/2016, mandates that within two hours of the beginning of each shift, the number of Licensed Nurses and unlicensed nursing personnel directly responsible for resident care must be posted in a prominent location. Observations on multiple dates showed that the nurse staff posting sheet was not displayed in an accessible area. During an interview, the Director of Nursing (DON) admitted to being unaware of the requirement to post the information in a specific location. The administrator confirmed that the posting had been placed in a rarely used back dining room, which is not open to the public, based on previous advice.
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What surveyors actually found near you
We read the 56 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sedalia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fair View Health Care Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Sylvia G Thompson Residence Center, Inc | 2.7 mi | ★★★★★ | 13 | 0 |
| E W Thompson Health & Rehabilitation Center | 3 mi | ★★★★★ | 2 | 0 |
| Four Seasons Living Center | 3.8 mi | ★★★★★ | 32 | 1 |
| Good Samaritan Care Center | 16.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.