River City Living Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Jefferson City, Missouri.
- Location
- 3038 West Truman Blvd, Jefferson City, Missouri 65109
- CMS Provider Number
- 265482
- Inspections on file
- 20
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at River City Living Community during CMS and state inspections, most recent first.
Staff failed to implement the facility’s grievance protocol when a cognitively intact resident reported a missing tablet. Facility policy required completion of a Grievance Complaint Report for lost resident items, documentation on a grievance log, and provision of a written copy and timely resolution to the resident. The grievance log showed only that the tablet was reported missing and staff were searching for it, with no completed grievance form or written response provided to the resident or guardian. The resident reported the tablet had been missing for about a month without resolution. The SSD stated he/she did not consider a missing item to be a grievance, did not complete a grievance form, and confirmed the tablet was neither found nor replaced, while the administrator acknowledged the resident should have received a resolution but did not.
Staff did not follow the facility’s investigation policy after a cognitively intact resident reported a missing tablet. The concern was recorded in the grievance log and staff searched for the item, but no thorough investigation was documented, and required interviews and reporting steps were not completed. The resident reported not receiving a response to the grievance, and the administrator acknowledged knowing about the missing tablet, speaking only with staff, and not conducting a full investigation as required by the misappropriation of property policy.
Staff failed to report an allegation of misappropriation of property to the state agency within the required timeframe. A cognitively intact resident reported a missing tablet, which was documented in the grievance log, and staff began searching for it. The facility’s abuse reporting policy addressed timelines for reporting abuse but did not specify requirements for reporting misappropriation of property. The administrator stated that staff were told to report missing items internally and acknowledged not knowing that such allegations had to be reported to the state, noting that missing items were usually found.
Facility staff did not obtain a physician's discharge order or provide a comprehensive discharge summary for a resident discharged to the community. The medical record lacked required documentation, including a summary of the resident's stay, treatment, and post-discharge care instructions, as well as a signed copy of the discharge summary. Staff interviews indicated a lack of awareness regarding follow-up resources and incomplete documentation of the discharge process.
A resident with diabetes developed a severe finger infection requiring hospitalization after a nursing assistant, unaware of the resident's diagnosis and facility policy, used an electric nail file to apply acrylic nails. The resident's care plan and facility policy specified that only licensed nurses or podiatrists should perform nail care for diabetic residents, but this was not followed, leading to a MRSA infection and surgical intervention.
Staff did not document the administration of prescribed medications for three residents, including those with severe cognitive impairment, diabetes, and chronic pain. Medications such as insulin, anti-seizure drugs, tube feedings, and pain management were not recorded as given according to physician orders, and one resident reported only receiving insulin upon request. These lapses were identified through interviews and review of medical records.
Staff failed to document the administration of medications and tube feedings for three residents, including those with severe cognitive impairment, diabetes, and ALS. Medications such as anti-seizure drugs, insulin, and nutritional feedings were not recorded as given on multiple occasions, particularly on weekends. Both the DON and administrator were aware of complaints about a weekend nurse not administering or documenting medications, but no clear action had been taken.
Staff did not notify the physician after a resident reported being touched inappropriately by another resident. Although the administrator, DHSS, corporate, and police were informed, there was no documentation of physician notification, despite facility policy requiring it when a resident's condition changes.
Facility staff did not ensure an RN was present for at least eight consecutive hours per day as required, with multiple days lacking adequate RN coverage. Time-keeping records and staff interviews confirmed the absence of an RN on several dates, and there was no policy in place for RN coverage. The DON and administrator acknowledged the deficiency and lack of a back-up plan when scheduled RNs did not report to work.
Staff did not document or complete required neurological checks for three residents with cognitive impairment after unwitnessed falls, despite facility policy and expectations from the DON, LPN, and administrator that such assessments be performed and recorded for up to 72 hours post-fall.
Facility staff did not prevent accident hazards by allowing three residents with mild cognitive impairment, all identified as smokers, to keep disposable lighters in their rooms and on their person. One resident also had oxygen therapy equipment in their room. Staff interviews confirmed awareness of the policy permitting this practice, but also acknowledged the associated safety risks.
Facility staff failed to serve food according to nutritionally calculated menus, serving smaller portions than directed. Observations showed residents on regular and pureed diets received less food than specified, with pureed bread omitted. Interviews revealed a lack of appropriate measuring tools and knowledge among staff, with the dietary manager and administrator unaware of the issue.
Facility staff failed to store food properly, leading to potential contamination and outdated use. Observations revealed undated and open food items in the refrigerator, freezer, and dry goods storage, contrary to the facility's Safe Food Handling policy. Interviews with staff indicated that the Dietary Manager and cooks were responsible for labeling and dating food, but this was not consistently done, potentially affecting all residents.
The facility failed to maintain an effective infection prevention and control program, with improper storage and handling of oxygen and nebulizer equipment for several residents. Observations showed equipment left uncovered, undated, and improperly stored, with some found on the floor. Additionally, hand hygiene practices during wound care were inadequate, as a nurse failed to perform hand hygiene and change gloves between tasks, increasing infection risk. Interviews revealed a lack of training and awareness among staff regarding infection control protocols.
The facility failed to provide and document education on the COVID-19 vaccine for staff. Policies lacked direction for staff vaccination, and interviews revealed gaps in responsibility and awareness. The business office manager, responsible for new hire paperwork, had quit, and the Infection Preventionist was unaware of staff education efforts.
The facility failed to obtain physician-ordered blood work for four residents, including tests like Hemoglobin A1C, CBC, CMP, and Depakote levels. Interviews revealed a lack of clarity in the process, with the RN unsure of who uploads results and the DON unaware of the missed tests, citing a disconnect between agency nurses and facility processes.
The facility failed to provide an ongoing activity program during weekends and evenings, affecting two residents. One resident with mild cognitive impairment did not have their activity preferences assessed, while another comatose resident's care plan preferences were not consistently followed. Observations showed limited activities and a lack of staff engagement, partly due to reliance on agency staff.
The facility failed to ensure nursing staff had the necessary skills and competencies to meet residents' care needs, lacking regular in-services and documentation of skills. Nurse aides did not receive the required 12 hours of annual training. Staff interviews revealed inadequate training on essential care areas, with reliance on previous experience. The DON acknowledged inconsistency in training, especially with agency staff, and the administrator was unaware of past training practices.
The facility failed to implement an effective antibiotic stewardship program, as staff did not track residents on antibiotics for infections. The Infection Preventionist (IP) and Director of Nursing (DON) were unclear about their responsibilities, leading to incomplete tracking. The administrator was unaware of the program's lack of implementation.
The facility failed to document the administration or refusal of pneumococcal vaccines for three residents, despite having an immunization policy. The records lacked necessary documentation, and the CDC's vaccination guidelines were not followed. Interviews revealed a lack of clarity and consistency in the immunization process, with staff unsure of the procedures and tracking systems for ensuring residents were up to date.
Facility staff failed to develop comprehensive care plans for residents, leading to deficiencies in addressing medical and nursing needs. One resident's care plan lacked directions for oxygen use and medication self-administration, while another's did not include shower preferences. A third resident experienced multiple falls without updated fall prevention interventions. The MDS Coordinator and DON acknowledged the oversight, citing workload as a contributing factor.
The facility failed to ensure the activities program was directed by a qualified professional. The Activity Director, in position since early 2024, was not certified and unaware of the requirement. The administrator also confirmed the lack of certification, only realizing it when asked for documentation.
A resident with dementia was sexually assaulted by a CNA, witnessed by another CNA who failed to report the incident immediately. The perpetrator continued working for 18 shifts post-assault. The facility's policy to protect residents from abuse was not enforced, leading to an Immediate Jeopardy situation.
A resident with dementia was allegedly sexually abused by a CNA, but the incident was not reported to the administrator until nearly a month later. The alleged perpetrator continued working additional shifts during this time. The facility's policy requires immediate reporting of such incidents, but the administrator failed to notify the DHSS within the required timeframe due to misinformation. The witnessing CNA delayed reporting, seeking proof, and was unaware of reporting protocols.
The facility failed to ensure that two CNAs received mandatory abuse and neglect training upon hire, as required by their policy. Personnel records lacked documentation of training for CNAs hired in 2020 and 2023. Interviews with facility staff, including the administrator, DON, and staffing coordinator, revealed a lack of oversight and documentation regarding the training of newly hired and agency staff.
Facility staff failed to thoroughly investigate an alleged sexual assault by a CNA on a resident with dementia. The investigation lacked interviews with the resident, other residents, and the charge nurse on duty, and did not include observations of behaviors. The former administrator delayed the investigation due to misinformation about prior reporting. The new administrator and DON acknowledged the investigation's incompleteness.
Failure to Implement Grievance Process for Resident’s Missing Tablet
Penalty
Summary
Facility staff failed to follow the facility’s grievance protocol when a cognitively intact resident reported a missing tablet. The facility’s undated Grievance Protocol policy stated that the purpose of the Grievance/Complaint Report and Grievance Log is to provide a written record of each resident and family concern and to ensure proper follow-up through appropriate disciplines, with the Social Service Director (SSD) responsible for the program and the administrator ultimately responsible for its implementation. The policy specified that a Grievance Complaint Report should be used for situations involving lost or unlocatable resident articles, including ongoing concerns about lost items and laundry issues, and that the SSD would obtain the original report and forward a copy to the appropriate discipline. Review of the grievance log showed an entry indicating the resident had reported a missing tablet and that staff were searching for the item, but there was no documentation that a grievance form had been completed or that a copy had been provided to the resident or guardian. During interviews, the resident stated the tablet had been missing for about a month, that he/she had reported it to an unknown staff member, and that he/she had not been given a resolution. The SSD reported that staff were directed to report grievances to him/her or to direct residents to do so, but acknowledged not considering a missing item to be a grievance and therefore did not complete a grievance form or provide a copy to the resident. The SSD confirmed the tablet was not found or replaced and that the resident had not been provided with a resolution, and also stated being newer to the position and not recalling training on the grievance process. The administrator stated the SSD was responsible for completing a grievance form, providing it to the resident, and giving a resolution within twenty-four hours, and acknowledged that the resident’s tablet had not been replaced and that the resident should have had a resolution but it “slipped through the cracks.”
Failure to Investigate Allegation of Misappropriated Resident Property
Penalty
Summary
Facility staff failed to follow their 2017 Investigation policy requiring that every allegation of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriated resident property be thoroughly investigated and reported to the administrator and State Survey Agency within five days. The policy specified that residents, employees, family members, visitors, and others may be interviewed about their knowledge of events, and emphasized that all health care workers are mandatory reporters of abuse. Despite this, when a cognitively intact resident reported a missing tablet, staff only documented the concern in the grievance log and noted they were still searching for the item, without initiating or documenting a formal investigation as required by policy. The resident’s quarterly MDS showed the resident was cognitively intact and had been admitted earlier in the year. The grievance log entry indicated the resident reported the tablet missing, but the medical record for the relevant month contained no documentation of an investigation into the missing property. In an interview, the resident stated the tablet had been missing for about a month, that it had been reported to an unknown staff member, and that there had been no response to the grievance. In a separate interview, the administrator acknowledged awareness of the missing tablet and stated that staff searched for the item and that he/she spoke with staff, but admitted not conducting a full investigation, not following the misappropriation of property policy, and not interviewing other residents, believing instead that the item would likely turn up as missing items typically do.
Failure to Report Alleged Misappropriation of Resident Property to State Agency
Penalty
Summary
Facility staff failed to timely report an allegation of misappropriation of property to the state agency (DHSS) within the required 24-hour timeframe. The facility’s Abuse and Neglect Reporting Instructions policy directed staff to immediately report events of abuse, no later than one hour after the event, so the Administrator or designee could report abuse to the DHSS/Abuse Hotline within two hours, but the policy did not address reporting misappropriation of property within 24 hours. The facility census was 51.1. Record review showed a cognitively intact resident, admitted on a specified date, had a quarterly MDS completed on a specified date. The grievance log documented that on 01/16/26 the resident reported a missing tablet and staff noted they were searching for it. In an interview on 03/27/26, the resident stated the tablet was missing and that they had reported this to an unknown staff member. In a subsequent interview on 03/31/26, the Administrator stated staff were instructed to report missing items to the Social Service Director or to the Administrator, and acknowledged not knowing that missing items were required to be reported to DHSS, explaining that staff typically locate missing items and therefore reporting to DHSS had not been considered.
Failure to Obtain Discharge Order and Provide Comprehensive Discharge Summary
Penalty
Summary
Facility staff failed to obtain a physician's discharge order and did not provide a comprehensive discharge summary for a resident who was discharged to the community. The resident's medical record lacked documentation of a discharge order from the attending physician, and there was no evidence that a discharge summary, including a summary of the resident's stay, diagnosis, course of illness, treatment, therapy, pertinent lab and radiology results, pending lab results, special instructions for ongoing care, post-discharge plan of care, advance directive information, and medication reconciliation, was provided to the resident or their representative. Additionally, there was no signed copy of the discharge summary or post-discharge plan by the resident or their representative in the medical record. Interviews with staff revealed that the discharge process was initiated on the day of discharge, but staff were unaware of any follow-up resources being set up, such as home health services. The administrator confirmed that the facility's expectation was for the Social Services Director to arrange necessary resources and communicate them to the resident or representative, with documentation in the medical record. However, the administrator acknowledged that there was not a single form containing all required discharge information and confirmed the absence of a physician's discharge order in the resident's electronic medical record.
Injury and Infection Following Improper Nail Care for Diabetic Resident
Penalty
Summary
Facility staff failed to prevent an injury to a resident when a nursing assistant (NA) used an electric nail file to apply acrylic nails, resulting in a cut to the resident's finger. The resident had a diagnosis of diabetes and was assessed as cognitively intact, with a care plan indicating a risk for unstable blood sugars and a need for assistance with activities of daily living. According to facility policy, nursing assistants are not permitted to perform nail care on residents with diabetes or vascular disease; such care must be provided by a licensed nurse or podiatrist. Despite this, the NA performed nail care using an electric nail file on the diabetic resident, unaware of the resident's diagnosis and the associated restrictions. Following the nail care, the resident developed pain, redness, tenderness, and swelling in the right hand and arm, with symptoms rapidly progressing. Medical records documented that the resident was sent to the emergency department for probable intravenous therapy. The resident was subsequently admitted to the hospital for septic arthritis of the right index finger and underwent surgical intervention to remove infected tissue. Cultures revealed a Methicillin-resistant Staphylococcus aureus (MRSA) infection. The resident continued on antibiotics after returning from the hospital. Interviews with facility staff revealed that the NA was not aware of the prohibition against providing nail care to diabetic residents and did not realize the resident was diabetic. The NA admitted to using an electric nail file but denied causing injury or observing any immediate signs of harm. The administrator acknowledged that the NA was not supposed to perform acrylic nails or clip nails due to lack of certification. Both the facility and hospital physicians indicated that the use of the electric nail file could have contributed to the resident's infection and subsequent hospitalization.
Failure to Document Medication Administration as Ordered
Penalty
Summary
Facility staff failed to document the administration of medications as directed by physicians for three sampled residents. According to the facility's medication administration guidelines, staff are required to promptly record medication administration, including the date, time, dosage, and signature, immediately after giving the medication. For one resident with severe cognitive impairment, a feeding tube, and multiple diagnoses including stroke and epilepsy, staff did not document the administration of skin prep, tube feeding formula, several anti-seizure and psychiatric medications, or the required feeding tube flushes on multiple occasions as ordered by the physician. Another resident, assessed as cognitively intact with diabetes, had undocumented administration of prescribed insulin on two separate occasions. This resident reported that insulin was only given upon request and that staff sometimes claimed it was documented even when it was not received. A third resident, also cognitively intact and diagnosed with diabetes, chronic pain, and pneumonia, had no documentation of receiving prescribed pain medication, bronchodilator, and diabetes medication on a specified date. These failures were identified through interviews and record reviews, indicating noncompliance with established medication administration and documentation protocols.
Failure to Document Medication and Feeding Administration
Penalty
Summary
Facility staff failed to document the administration of medications for three residents, as required by the facility's medication administration guidelines. The guidelines specify that medications must be given as prescribed and promptly recorded in the medical record by the person administering them. For one resident with severe cognitive impairment, a feeding tube, and multiple diagnoses including stroke, seizure disorder, depression, cerebral palsy, and anxiety, staff did not document the administration of several medications, including anti-seizure drugs, antidepressants, and vitamin supplements, across multiple dates in March, April, and May. Another resident, cognitively intact and diagnosed with diabetes, had undocumented administration of insulin on several occasions, particularly on weekends, and reported not receiving insulin doses unless requested. A third resident, also cognitively intact with ALS and a feeding tube, had undocumented administration of tube feedings on several dates, with the resident reporting missed feedings on weekends. Interviews with the DON and the administrator confirmed awareness of complaints regarding a weekend nurse not administering or documenting medications, with the DON stating that issues had been reported to administration but was unsure if any action had been taken. The administrator acknowledged concerns with the weekend nurse and emphasized the expectation that staff follow physician orders and document medication administration, stating that if it is not documented, it is considered not done.
Failure to Notify Physician After Allegation of Inappropriate Contact
Penalty
Summary
Facility staff failed to notify the physician in a timely manner after an allegation of inappropriate touching was made by one resident against another. According to the facility's policy, staff are required to observe, record, and report any change in a resident's condition to the attending physician. In this incident, staff documented the allegation, notified the administrator, the Department of Health and Senior Services, corporate, and the police department, but did not document that the physician was notified. The investigation records and nurse's notes for both residents involved did not show evidence of physician notification. The residents involved included one who was cognitively intact with a diagnosis of anxiety disorder, and another who was moderately cognitively impaired with a diagnosis of bipolar disorder. Following the accusation, the resident accused was placed on fifteen-minute checks, and the administrator conducted an investigation. During an interview, the administrator acknowledged that physician notification should have occurred but was missed during the process.
Failure to Provide Required RN Coverage
Penalty
Summary
Facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days per week, as required. Review of the facility's policies revealed there was no policy in place for RN coverage. Examination of time-keeping records showed that on multiple dates in December 2024, January 2025, and February 2025, the facility did not have an RN present in the building for the required eight consecutive hours. Specifically, there were several days where no RN was present for the mandated time, and on some days, no RN was present at all. Interviews with the Director of Nursing (DON) and the administrator confirmed awareness of the requirement for RN coverage. The DON, who had only recently started at the facility, was not aware of who was previously responsible for ensuring RN coverage. The administrator acknowledged ultimate responsibility for ensuring eight hours of RN coverage daily and admitted there were days without adequate RN presence, including instances where the scheduled RN did not report to work and no back-up plan was in place.
Failure to Document and Complete Neurological Checks After Unwitnessed Falls
Penalty
Summary
Facility staff failed to ensure that services provided met professional standards of practice by not documenting and completing neurological checks for three residents who experienced unwitnessed falls. According to the facility's policies, staff are required to assess and document neurological status after such events, with the expectation that neurological checks are performed for up to 72 hours following an unwitnessed fall or a fall with potential head injury. However, record reviews revealed that for three residents with cognitive impairments and a history of falls, there was no documentation in the electronic medical record (EMR) or on paper forms indicating that neurological checks were completed after their respective unwitnessed falls. Interviews with the DON, LPN, and administrator confirmed that the expectation was for staff to complete and document neurological checks after unwitnessed falls, and that these checks were to be recorded on paper and uploaded to the EMR. Despite these directives, the required documentation was missing for the identified residents, and the DON acknowledged that neurological checks should have been completed and documented for each unwitnessed fall. The facility's failure to follow its own policy and professional standards resulted in a deficiency related to the lack of post-fall neurological assessments and documentation.
Failure to Secure Lighters and Prevent Accident Hazards for Smoking Residents
Penalty
Summary
Facility staff failed to ensure the resident environment was free from accident hazards by allowing three residents, all assessed with mild cognitive impairment and identified as smokers, to keep disposable lighters in their rooms and on their person. Facility policy permitted residents with independent smoking privileges to retain cigarettes and disposable safety lighters, and staff documented these residents as safe smokers in their care plans and smoking assessments. Observations confirmed that each resident kept cigarettes and lighters in their rooms and on their person, and used them during smoking activities outside the facility. One resident had an order for oxygen therapy and an oxygen concentrator present in their room, while also keeping a lighter in their possession. Interviews with staff, including the MDS Coordinator, CNA, and administrator, acknowledged awareness of the policy but also recognized the safety concerns associated with residents keeping lighters in their rooms, particularly the risk of smoking in rooms and potential fire hazards, especially in the presence of oxygen equipment.
Failure to Serve Correct Food Portions
Penalty
Summary
The facility staff failed to serve food in accordance with the nutritionally calculated menus to all residents, as observed during a survey. The facility's policy required measured utensils to serve portions as described on the menu. However, during an observation, it was noted that residents on regular diets were served less than the directed portions of stroganoff, noodles, and vegetables. Similarly, residents on pureed diets received smaller portions of stroganoff and noodles than specified, and pureed bread was not served at all. Interviews revealed that the cook responsible for setting serving utensils was unsure of the correct portion sizes due to a lack of appropriate measuring tools and knowledge. The dietary manager acknowledged that the cooks should serve food according to the menus but was unaware of the incorrect serving sizes. The administrator also stated that the dietary manager was responsible for ensuring correct portions were served but was not aware of the issue. The facility census was 39 with a capacity of 87.
Food Storage Deficiency in LTC Facility
Penalty
Summary
Facility staff failed to store food in a manner that prevents potential contamination and outdated use, as observed during a survey. The facility's Safe Food Handling policy requires all food, including bulk items, to be tightly sealed with an identifying label and date. However, during an observation, several food items in the reach-in refrigerator were found to be undated and open to the air, including a plastic container of pineapple, hot dogs, lettuce, tuna salad, and a zipper bag of meat. Additionally, a cardboard flat of eggs contained five broken eggs, and a one-gallon container of soy sauce was open to the air. Similar issues were observed in the reach-in freezer and dry goods storage room, where bags of beef patties, fish, pasta elbows, cookie crumbs, tortilla chips, and gravy mix were found open and undated. Interviews with facility staff, including the Dietary Manager (DM) and the administrator, revealed that the cooks and the DM were responsible for ensuring all food items were labeled, dated, and not open to the air. The DM stated that open canned items were good for seven days, and cooked items were good for three days, and no food items should be open to the air. The administrator confirmed that the DM was responsible for ensuring all food items were labeled and dated, and that prepared food items were good for three days. This failure to adhere to the facility's food storage policy has the potential to affect all residents, given the facility's census of 39 with a capacity of 87.
Infection Control Deficiencies in Equipment Handling and Hand Hygiene
Penalty
Summary
The facility staff failed to maintain an effective infection prevention and control program, as evidenced by improper storage and handling of oxygen and nebulizer equipment for several residents. Observations revealed that oxygen tubing and nebulizer masks were left uncovered, undated, and improperly stored, with some equipment found on the floor. This was noted for multiple residents, including those with cognitive impairments and respiratory conditions, indicating a lack of adherence to proper infection control protocols. Additionally, the facility's policies on oxygen administration and suctioning were found to be lacking in specific guidance on equipment storage and cleaning procedures. For instance, the suction machine used for a resident requiring tracheostomy care was observed with yellow contents inside, indicating it had not been cleansed after use. Interviews with staff, including registered nurses and certified medication technicians, revealed a lack of training and awareness regarding the facility's protocols for equipment storage and maintenance. The facility also demonstrated deficiencies in hand hygiene practices during wound care for residents with pressure injuries. Observations showed that a registered nurse failed to perform hand hygiene and change gloves between dirty and clean tasks, increasing the risk of infection spread. Interviews with the infection preventionist and director of nursing confirmed that proper hand hygiene was not consistently practiced, highlighting a significant gap in the facility's infection control measures.
Failure to Educate and Document COVID-19 Vaccine Information for Staff
Penalty
Summary
The facility staff failed to provide and document education regarding the COVID-19 vaccine's benefits, risks, and potential side effects for facility staff. The facility's Immunization policy dated February 26, 2022, and the COVID-19 for LTC policy dated May 15, 2023, did not include directions for the COVID-19 vaccine for staff. Interviews revealed that the business office manager, who was responsible for new hire paperwork including COVID-19 status review, had quit. The Infection Preventionist, new to the role since August, was unaware of any education being provided to staff and only tracked resident information. The administrator confirmed that the facility did not document education or offer guidance on obtaining the vaccine for staff.
Failure to Obtain Physician-Ordered Blood Work
Penalty
Summary
The report identifies a deficiency in the nursing facility's adherence to professional standards of care, specifically in obtaining physician-ordered blood work for four out of six sampled residents. The facility failed to provide a policy for obtaining blood work, which contributed to the oversight. Resident #1, diagnosed with diabetes, did not have a Hemoglobin A1C test conducted as ordered in August 2024. Resident #2, with heart disease and diabetes, lacked documentation for a complete blood count (CBC), complete metabolic profile (CMP), Depakote level, and Hemoglobin A1C, all of which were ordered every three months. Resident #4, diagnosed with hypertension, did not have a CBC or CMP conducted in September 2024 as ordered. Similarly, Resident #5, with hypertension, heart failure, and lung disease, did not have a CBC, CMP, or Depakote level test conducted in September 2024. Interviews with facility staff revealed a lack of clarity and responsibility in the process of obtaining and documenting blood work. RN D indicated uncertainty about who was responsible for uploading lab results into the electronic health record and suggested that the Director of Nursing (DON) should oversee the lab process. The DON, new to the role, was unaware of the missed blood work and acknowledged a disconnect between agency nurses and facility processes. The administrator, who recently hired a medical record staff member to manage document uploads, was also unaware of the issues with blood work completion and expected nursing staff to follow up on all physician orders.
Lack of Weekend and Evening Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing activity program during weekends and evenings, which did not meet the needs of two dependent residents. The activity calendar for September and October 2024 showed limited activities, primarily consisting of bible study and occasional puzzles or coloring. Interviews with staff and residents revealed that organized activities were lacking, particularly on weekends, and staff often did not have time to engage residents in activities. Resident #6, who had mild cognitive impairment, did not have their activity preferences assessed or included in their care plan. The resident expressed a desire for more organized activities on weekends. Resident #1, assessed as comatose with a diagnosis of persistent vegetative state, had specific preferences documented in their care plan, such as enjoying looking out the window, listening to gospel music, and being taken out of their room. However, observations showed the resident was often left in a dark room with curtains closed, contrary to their care plan. Interviews with staff indicated a lack of consistency in following the resident's preferences, partly due to the use of agency staff who may not be aware of the activity requirements. The Activity Director acknowledged the challenges in providing consistent activities due to staffing issues.
Inadequate Staff Training and Competency Assessment
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate skills and competencies to meet the care needs of residents. This was evidenced by the lack of regular in-services, re-evaluation, and documentation of skills and competencies for each employee. Additionally, nurse aides did not receive the required 12 hours of in-service education annually. The facility's Orientation and Training policy did not specify the frequency of education, documentation methods, or a comprehensive list of necessary in-services, including critical areas such as abuse and neglect, dementia care, and specialized resident needs. The facility's assessment highlighted the need for initial training upon hire, ongoing professional development, and periodic competency assessments for staff. However, the review of the facility's in-service annual training revealed incomplete documentation, with no records of skills and competencies or the required 12-hour nurse aide training. Interviews with staff, including a Certified Medication Technician, RNs, and CNAs, indicated that they did not receive adequate training on essential care areas such as oxygen use, COVID-19 protocols, dementia care, and other specialized care techniques. Staff often relied on their previous experience or knowledge rather than facility-provided training. The Director of Nursing acknowledged the inconsistency in training, particularly with agency staff, and admitted that the facility assumed agency staff were competent without conducting their own assessments. The administrator, who had only been at the facility for a few months, was unaware of previous training practices and confirmed that CNAs are required to have 12 hours of training annually. The facility had recently received a list of yearly trainings from the corporate office, but there was no evidence of a structured training program in place prior to this.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility staff failed to implement an effective antibiotic stewardship program, as evidenced by the lack of tracking of residents on antibiotics for various infections. The facility's Antibiotic Stewardship Program outlined responsibilities for the Infection Preventionist (IP) and designee, including auditing clinical assessment documentation and tracking antibiotic-resistant infections. However, the review of the Antibiotic Tracking binder showed it was incomplete, with the most recent line blank. Interviews revealed that the IP had only recently assumed the role and was not fully aware of the tracking responsibilities, while the Director of Nursing (DON) acknowledged not tracking antibiotics despite having received a form to do so. The administrator was under the impression that the antibiotic stewardship program was reviewed during weekly risk meetings but was unaware that it had not been implemented. The DON admitted to planning to start tracking antibiotics but had not yet begun the process due to other pressing issues. This lack of action and communication among staff members led to the deficiency in the antibiotic stewardship program, as there was no current and ongoing log of residents with active infections being treated with antibiotics.
Failure to Document Pneumococcal Vaccinations
Penalty
Summary
The facility staff failed to document the administration or refusal of the pneumococcal vaccine for three of five sampled residents, despite having an immunization policy in place. The policy required a physician order, consent from the resident or legal representative, and documentation of the vaccine administration in the resident's medical record. However, the records for these residents did not contain the necessary documentation, indicating a lapse in following the established procedures. The CDC's guidelines for pneumococcal vaccination were also not adhered to, as the records lacked evidence of the required vaccinations being administered or refused. Interviews with facility staff revealed a lack of clarity and consistency in the immunization process. The Director of Nursing acknowledged that immunizations were a work in progress and expressed uncertainty about the process before their tenure. The Infection Preventionist, responsible for vaccine status since August, admitted to only reviewing new admissions and not having a system for tracking long-term residents due for vaccines. The administrator confirmed that the Infection Preventionist was in charge of vaccine tracking but was unsure of how the process was being managed to ensure residents were up to date.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their medical and nursing needs. For one resident, the care plan did not include directions for oxygen use or the ability to keep medication at the bedside, despite observations of the resident using oxygen and having medication on the nightstand. The MDS Coordinator was unaware of these needs and acknowledged that oxygen use and self-administration should be part of the care plan. Another resident's care plan lacked information on shower preferences and the level of assistance required, even though the resident was assessed as cognitively impaired and requiring supervision during showers. The resident expressed feeling unclean due to not having a bath or shower while on isolation. The MDS Coordinator admitted there was miscommunication regarding the resident's shower abilities and that the care plan had not been updated. A third resident experienced multiple falls, yet the care plan did not include new interventions or updates for fall prevention. The MDS Coordinator stated that falls are usually updated in the care plan after weekly at-risk meetings but could not explain why this had not occurred. The DON and administrator acknowledged the responsibility of updating care plans with changes in resident status, but both cited being busy with other duties as a reason for the oversight.
Unqualified Activity Director Leads to Deficiency
Penalty
Summary
The facility staff failed to ensure that the activities program was directed by a qualified professional. The facility's policy, dated March 2012, requires that the activity program be directed by a certified Activity Director who is directly responsible to the administrator. However, during an interview, the current Activity Director admitted to not being certified and was unaware of the certification requirement, despite having held the position since February 2024. Additionally, the administrator confirmed that the Activity Director was not certified and acknowledged being unaware of this until prompted to provide the certification.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility staff failed to protect a resident from sexual abuse when a Certified Nurse Assistant (CNA) sexually assaulted the resident. The incident was witnessed by another CNA, who did not intervene or report the abuse immediately. This failure allowed the perpetrator to continue working at the facility for 18 additional overnight shifts after the assault was observed. The facility's policy mandates that residents be free from abuse, neglect, and harm, but this policy was not effectively enforced in this case. The resident involved had a diagnosis of dementia, which impaired their ability to consent or understand the situation. The witnessing CNA documented the incident in a written statement and recorded a video of the assault, although the video quality was poor. Despite suspecting inappropriate behavior for some time, the witnessing CNA delayed reporting the incident due to a lack of concrete evidence and concerns about making false accusations. The local law enforcement was notified, and an investigation was conducted. The perpetrator admitted to having sexual intercourse with the resident, acknowledging the resident's dementia diagnosis. The facility's failure to act promptly and protect the resident from further abuse resulted in an Immediate Jeopardy situation, which was later addressed by the facility.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse involving a resident with dementia in a timely manner. The incident was witnessed by a Certified Nurse Assistant (CNA) on April 17, 2024, but was not reported to the administrator until May 13, 2024. During this period, the alleged perpetrator, another CNA, continued to work 18 additional shifts. The facility's policy requires that such allegations be reported to the administrator and the state survey agency within two hours if serious bodily injury is suspected. However, the administrator did not report the incident to the Department of Health and Senior Services (DHSS) within the required timeframe, as he/she was initially misinformed that the allegation had already been reported and investigated. The CNA who witnessed the incident did not intervene or report immediately because he/she wanted to gather proof by attempting to enhance a video recording of the event. The CNA was unaware of the timeframe for reporting abuse or neglect and had not attended recent abuse in-service training. Interviews with the current administrator and Director of Nursing revealed that staff are directed to remove residents to safety and report incidents immediately, but this protocol was not followed. The deficiency was identified as an immediate and serious jeopardy level violation, indicating a significant failure in the facility's abuse reporting procedures.
Failure to Implement Abuse and Neglect Training
Penalty
Summary
The facility failed to implement its abuse and neglect policies and procedures effectively, as evidenced by the lack of training for two Certified Nurse Aides (CNA A and D) out of four sampled staff. The facility's policy required all new employees and volunteers to receive training on the abuse policy before having any resident contact. However, a review of personnel records showed that CNA A, hired on 10/03/23, and CNA D, hired on 10/23/20, did not have documentation of receiving this mandatory training. Furthermore, during an interview, CNA D was unable to recall when they last attended an abuse in-service or the timeframe for reporting abuse or neglect. The facility's administration, including the current administrator, Director of Nursing (DON), and Staffing Coordinator, acknowledged the oversight in training. The administrator and DON both stated that the staffing coordinator was responsible for conducting abuse and neglect training for all newly hired staff, including agency staff, and ensuring annual training for existing staff. However, they could not find documentation that agency staff received the required training. The staffing coordinator, who was not in the position when CNA A and D were hired, confirmed conducting an abuse and neglect in-service during orientation for agency staff but did not provide evidence of training for the CNAs in question.
Incomplete Investigation of Alleged Sexual Assault
Penalty
Summary
The facility staff failed to conduct a thorough investigation following an allegation of sexual assault by a Certified Nurse Aide (CNA) against a resident. The facility's policy mandates that reports of abuse be promptly and thoroughly investigated, including interviews with involved parties and observations of behaviors. However, the investigation into the alleged incident, which reportedly occurred between 4:30 A.M. and 5:30 A.M., lacked documentation of interviews with the resident involved or any other residents, and there were no observations of resident and staff behaviors. Additionally, the charge nurse on duty during the incident was not interviewed. The former administrator did not initiate the investigation promptly, as they were initially informed that the allegation had been previously reported and investigated. It was later revealed that the allegation had not been reported, leading to a delayed investigation. Interviews with the newly hired administrator and Director of Nursing (DON) revealed that they believed the investigation was incomplete due to the lack of resident interviews and the omission of the charge nurse's interview. The facility census at the time was 52, and the resident involved had a diagnosis of dementia.
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Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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