Riverbend Heights Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Lexington, Missouri.
- Location
- 1221 Highway 13 South, Lexington, Missouri 64067
- CMS Provider Number
- 265358
- Inspections on file
- 28
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Riverbend Heights Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple serious respiratory infections, MRSA, sepsis, tracheostomy, and gastrostomy was discharged from the hospital with an order for Zerbaxa IV every eight hours, with no oral alternative due to NPO status. After readmission, the resident returned without IV access, staff were unable to start an IV, and the resident was sent to the hospital where a PICC line was placed and one dose of Zerbaxa was given, with instructions to continue the course. Back at the facility, Zerbaxa was not entered on the MAR or TAR, pharmacy reported delays, and the resident missed multiple scheduled doses while remaining in the facility. Interviews showed staff and providers knew Zerbaxa was the only effective antibiotic, that payment issues and the high cost delayed obtaining it, and that the resident ultimately did not receive any Zerbaxa doses at the facility during this period.
The facility failed to maintain cleanliness and proper food storage, with grease buildup, dust, and unlabeled items in the kitchen. Milk was stored at unsafe temperatures, and there was a shortage of dishes, affecting meal service. Cutting boards were not easily cleanable, and staff did not sanitize thermometer probes. The Maintenance Director was not informed about cleaning needs, and the Administrator noted delays in dish collection.
The facility failed to maintain the walk-in fridge and automated dishwasher in proper working order. The fridge was operating above the required temperature due to a broken control knob, and the dishwasher failed to spray on the first cycle due to a malfunctioning motor and calcium buildup. These issues persisted for weeks without resolution.
The facility failed to maintain a clean and safe environment, with rust on a commode riser, dust buildup in ceiling vents and fans, and indentations on a commode seat. The Maintenance and Housekeeping Directors indicated a lack of communication and coordination in addressing these issues.
The facility failed to include necessary dosage parameters in medication orders for Acetaminophen for three residents. The orders lacked the specification of not exceeding three grams in 24 hours, which is crucial to prevent toxicity. Staff interviews confirmed the absence of these parameters, and the DON was unaware of the issue despite having expectations for such parameters to be included.
The facility failed to maintain proper drainage, resulting in backups and odors in storage areas, and did not ensure cleanliness in the Serenity Unit dining room and laundry room. Additionally, a restroom ceiling vent in a resident room was found to be loose due to missing screws.
The facility failed to maintain cleanliness in the kitchen, leading to an ant infestation. Observations revealed unwashed dishes from the previous night and ants around the soiled dishes. The Dietary Manager acknowledged that the dishes should have been washed earlier. This affected the kitchen area with a census of 92 residents.
A resident with cognitive impairments and specific activity preferences was not provided with individualized or adapted activities in a LTC facility. Despite interests in music, animals, and religious services, the resident primarily attended BINGO and food-related activities. Observations showed a lack of engagement and interaction, and activity calendars lacked specific times or locations for activities. Interviews revealed inconsistent activity offerings and a lack of 1:1 attention to the resident's preferences.
A resident with PTSD did not receive a meal during lunch service, despite being in full view of staff, triggering feelings of anxiety and isolation. The facility's new meal service process failed to ensure the resident received a meal, as the meal card was not properly managed. The oversight highlighted a deficiency in the facility's trauma-informed care and meal service process.
The facility failed to ensure dietary staff followed the recipe for pureed eggs, leading to unpalatable food. During breakfast preparation, a disorganized recipe book was found, and a staff member prepared eggs without consulting it, omitting salt, pepper, and margarine. The eggs were bland, and the staff member did not taste them before serving. This affected two residents on pureed diets.
A resident with intellectual disabilities and behavioral issues accessed a sharps container on a medication cart and poked their finger with an insulin pen needle while left unsupervised by an LPN. The sharps container was overfilled, and the resident lifted the lid to access the needle.
Failure to Administer Ordered IV Antibiotic for Medically Complex Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide a prescribed IV antibiotic, Zerbaxa, to a resident as ordered following readmission from the hospital. The resident had multiple serious diagnoses, including ventilator-associated pneumonia, COPD, acute respiratory failure, MRSA pneumonia and sepsis, bronchopneumonia, traumatic brain injury, tracheostomy status, and gastrostomy status, and was not cognitively intact per the reentry MDS. Hospital discharge instructions ordered Zerbaxa IV every eight hours through a specified completion date, and the facility’s physician order sheet reflected Zerbaxa 3000 mg IV every eight hours for six days. The resident was NPO and dependent on a feeding tube, and Zerbaxa was only available as an IV medication, making IV access and timely administration essential to follow the ordered regimen. Upon the resident’s return to the facility, nursing staff documented that the resident arrived without IV access. On the following day, nursing staff attempted twice to place an IV line without success and then sent the resident to a nearby hospital for vascular access. At the hospital, a PICC line was placed, and one dose of Zerbaxa was administered, with instructions that staff were to continue the antibiotic through the previously prescribed end date. The resident returned to the facility the same day with the PICC line in place. However, the medication administration records (MAR and TAR) for December did not contain any order entries for Zerbaxa, and there is no documentation that any doses of Zerbaxa were administered at the facility. Nursing notes indicated that on one day the pharmacy reported being backed up and would send the antibiotic later that evening, and the DON later stated the resident missed multiple scheduled doses over two days. Interviews with the RN, physician, NP, and DON revealed that the facility was aware of difficulties obtaining the specialty compounded medication, including that Medicaid had denied payment and that the facility owner was reportedly unwilling to pay for it. The physician and an infectious disease physician had agreed that there was no substitute for Zerbaxa and that it was the only appropriate antibiotic for the resident’s infection. Despite this, the medication was not available and not administered at the facility, and the resident went without the ordered doses while remaining in the facility. The NP and physician both stated they were unaware during this period that the resident was not receiving the ordered Zerbaxa at the facility.
Facility Fails to Maintain Cleanliness and Food Safety Standards
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage practices in the kitchen and dining areas, as observed during multiple inspections. There was a significant buildup of grease and grime under the deep fat fryer and the six-burner stove, as well as dust on the wall-mounted fan and ceilings, including the sprinkler heads. Unidentified items were found in the reach-in fridge, and several food items, such as beef paste, chicken base, and lemon juice, were not refrigerated as required by their labels. Utensils were stored in containers with food debris, and two containers of a white powdery substance were not labeled. Additionally, the lower spray wand of the dishwasher was clogged with debris, and the floor of the walk-in fridge had a buildup of grime. During the breakfast meal preparation, further issues were noted, including the absence of a thermometer in the Serenity Court kitchenette and milk being stored at an unsafe temperature of 53.2°F. The facility also lacked sufficient dishes, such as coffee cups and silverware, to serve residents, leading to delays in meal service. Cutting boards were found to be in poor condition, with numerous indentations and stains that rendered them not easily cleanable. The dietary staff did not sanitize the thermometer probe before use, and the chicken in the walk-in fridge was not dated when removed from the freezer. Interviews with staff revealed that the dietary department was short on essential items like plate covers and that the cleaning of certain areas, such as the dishwasher nozzles and the walk-in fridge floor, was not performed regularly. The facility's Maintenance Director was not informed about the need to clean the kitchen ceilings and sprinkler heads. The Administrator acknowledged that the shortage of dishes might be due to delays in collecting them after meals, leading to increased use of disposable plates.
Failure to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment, specifically the walk-in fridge and the automated dishwasher, in proper working order. Observations on multiple occasions revealed that the walk-in fridge was operating at temperatures above the required 41 degrees Fahrenheit, with readings of 46.5 and 46.4 degrees Fahrenheit. Interviews with the Maintenance Director and Dietary Manager indicated that the temperature control knob was broken, preventing adjustments. The issue had persisted for about three weeks, and the Maintenance Director was unaware of the problem until it was pointed out by a state surveyor. The Administrator was also not informed about the improper temperature settings. The automated dishwasher was also not functioning correctly, as it failed to spray on the first cycle. The Dietary Manager reported that the dishwasher had been delimed, but the problem persisted. The Maintenance Director was informed about the issue but had not yet inspected the dishwasher, acknowledging that the repair might require a service professional. A subsequent phone interview revealed that the dishwasher's motor was malfunctioning, and there was a calcium buildup in the pump, which contributed to its improper operation.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by several observations and interviews. In one instance, a commode riser in a resident's room was found to have rust spots, making it not easily cleanable. The Maintenance Director was unaware of this issue until it was pointed out during the survey. Additionally, there was a heavy buildup of dust in the restroom ceiling vents of multiple resident rooms, as well as in the Greystone shower room and the resident smoke room. The Maintenance Director indicated that the housekeeping department was responsible for cleaning these areas, but the issue persisted. Further observations revealed numerous indentations on the commode seat in the Greystone shower room, rendering it not easily cleanable. A personal fan in a resident's room also had a heavy buildup of dust. Interviews with the Housekeeping Director and Supervisor indicated that while the housekeeping department had tools to clean these areas, there was a lack of communication and coordination between departments, leading to the deficiencies observed. The facility census at the time was 92 residents.
Failure to Include Acetaminophen Dosage Parameters
Penalty
Summary
The facility failed to include necessary parameters in medication orders for medications containing Acetaminophen for three residents. Specifically, the orders did not specify the maximum allowable dosage of three grams of Acetaminophen in 24 hours from all sources. This oversight was identified in the medication orders for three residents, who were prescribed various dosages of Acetaminophen for pain management. The absence of these parameters was confirmed through interviews with staff, including Certified Medication Technicians and a Licensed Practical Nurse, who acknowledged the importance of these parameters to prevent potential toxicity. The Director of Nursing (DON) expressed an expectation that all orders containing Acetaminophen should include the parameter of not exceeding three grams in 24 hours. The DON also expected nurses to ensure this parameter was added to all relevant orders and to contact the doctor if it was missing. Despite these expectations, the DON was unaware of the missing parameters, and it was noted that the Assistant Director of Nursing was responsible for auditing new orders. The deficiency was highlighted during interviews with staff, who confirmed the absence of the necessary parameters in the medication orders for the affected residents.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain several areas in good repair, leading to potential health and safety issues for residents and staff. Observations revealed a brownish substance with particles backing up through the drains in the dry goods storage room and the walk-in refrigerator, accompanied by a pungent smell of standing water. The Maintenance Director confirmed that the drainage pipes were collapsed, causing improper drainage. The Dietary Manager noted that the drainage issue had persisted for at least four years, and the Administrator was aware of the backup but believed it was a one-time occurrence. Additionally, the facility did not maintain cleanliness in several areas. There was a heavy buildup of dust under the vending machines in the Serenity Unit dining room, which the Housekeeping Director attributed to not requesting the vending machine company to move the machines for cleaning. In the laundry room, fans had a heavy buildup of dust, and the Housekeeping Director admitted they had not been cleaned since December 2023. Furthermore, a restroom ceiling vent in a resident room was found to be loose due to missing screws, as noted by the Maintenance Director.
Ant Infestation Due to Unwashed Dishes in Kitchen
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen area, specifically near the window and the two-compartment sink, which resulted in an ant infestation. Observations made on June 13, 2024, at various times in the morning, revealed numerous unwashed dishes from the previous night and the presence of ants around the soiled dishes. During an interview, the Dietary Manager acknowledged that the dishes left at the window sill area should have been washed the previous night. This deficiency affected the kitchen area of the facility, which had a census of 92 residents.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to ensure that activities identified as being of interest to a resident with Huntington's disease, major depression, and anxiety disorder were offered daily on a 1:1 basis or adapted to meet the resident's cognitive and physical limitations. The resident, who was significantly cognitively impaired and required assistance with activities of daily living, had expressed interests in activities such as listening to music, being around animals, and participating in religious services. However, the facility did not provide individualized or bedside activities, and there was no documentation explaining why the resident did not engage in these activities. Observations over several months revealed that the resident was often not engaged in any group or 1:1 activities, and there was a lack of interaction with staff. The activity calendars for the resident's unit did not include specific times or locations for activities, and there were no designated 1:1 or bedside activity times. Despite the resident's interest in music and religious activities, participation logs showed that the resident primarily attended BINGO and food-related activities, with no participation in music, pet/animal, or religious activities. Interviews with activity assistants and the Director of Nursing indicated that activities were not consistently offered on the resident's unit, and there was a lack of individualized attention to the resident's preferences. The activity staff acknowledged that they had not conducted 1:1 activities with the resident, despite the resident's capability to engage in simple activities with assistance. The facility's failure to provide appropriate activities and document the resident's participation or lack thereof contributed to the deficiency.
Failure to Provide Trauma-Informed Care During Meal Service
Penalty
Summary
The facility failed to provide trauma-informed care to a resident diagnosed with Post-Traumatic Stress Disorder (PTSD), resulting in the resident not receiving a meal during lunch service. The resident, who had a history of trauma related to homelessness and brain tumor surgery, was seated in an open area in full view of staff during meal service. Despite being visible, the staff passed by the resident multiple times without serving a meal, and the kitchen window was closed after meal service without the resident receiving lunch. The resident expressed feelings of anxiety and isolation due to not receiving a meal, which triggered memories of past trauma, including being bullied as a child and experiencing homelessness. The resident reported that this oversight happened often, and staff ignored him/her, making him/her feel invisible. The Social Services Director acknowledged the resident's PTSD and the potential for not receiving a meal to trigger an emotional response related to past trauma. The facility had recently implemented a new meal service process involving laminated meal cards, which were intended to ensure all residents received their meals. However, the system failed in this instance, as the resident's meal card was not placed back with the others, leading to the oversight. The Director of Nursing expected staff to notice if a resident did not receive a meal and to address the issue, but this did not occur, highlighting a deficiency in the facility's meal service process.
Failure to Follow Recipe for Pureed Eggs
Penalty
Summary
The facility failed to ensure that dietary staff followed the recipe for pureed eggs, resulting in the eggs being unpalatable. This deficiency was observed during a breakfast meal preparation, where a disorganized recipe book was found, and the dietary staff member, referred to as DC A, prepared pureed eggs without consulting the recipe. DC A added cold milk and an unmeasured amount of thickener to the eggs, without adding salt, pepper, or margarine as specified in the recipe. The state surveyor noted that the eggs had a bland taste, and DC A did not taste the eggs before serving them. Interviews revealed that DC A was not properly trained in making pureed foods and was instructed by a previous Dietary Manager not to add salt. Another dietary staff member, DC B, mentioned tasting all pureed foods except those containing eggs and onions, relying on dietary aides to taste those items. The current Dietary Manager expected cooks to taste everything they prepared, but acknowledged that DC A was following previous instructions not to add salt. This practice potentially affected two residents on pureed diets in a facility with a census of 92 residents.
Resident Accesses Sharps Container and Pokes Finger
Penalty
Summary
The facility failed to provide adequate protective oversight for a resident who accessed a sharps container on the medication cart, found the tip/needle portion of an insulin pen, and poked their finger. The resident, who had intellectual disabilities and a history of behavioral and mental disorders, was left unsupervised when an LPN left the nurse's station to use the restroom. Upon returning, the LPN found the resident with the insulin pen needle in their hand, having poked their finger. The sharps container was found to be filled just above the fill line, and the resident had lifted the protective lid to access the needle. The resident's care plan indicated that they were not cognitively intact and had severe mood issues and behaviors that put them and others at risk. Despite this, the resident was left unsupervised, leading to the incident. The LPN acknowledged that they should have arranged for another staff member to watch the resident, given the resident's impulsivity and curious nature. The facility's policy for sharps disposal required that containers be sealed and replaced when 75% to 80% full, but this was not adhered to in this case. The facility's follow-up investigation confirmed that the resident was monitored for any adverse reactions and that there were no changes in their health status. The Administrator and ADON stated that they would have expected the sharps container to be emptied once it was half full and the lid to be completely closed after placing the insulin pen needle in the box. They also expected staff to notify another staff member to watch the resident while the LPN was away.
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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