Rest Haven Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sedalia, Missouri.
- Location
- 1800 South Ingram, Sedalia, Missouri 65301
- CMS Provider Number
- 265854
- Inspections on file
- 17
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Rest Haven Health Care Center during CMS and state inspections, most recent first.
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.
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.
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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