Rocky Ridge Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Mansfield, Missouri.
- Location
- 3111 Highway A, Mansfield, Missouri 65704
- CMS Provider Number
- 265494
- Inspections on file
- 16
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Rocky Ridge Manor during CMS and state inspections, most recent first.
Facility staff failed to fully investigate a sexual abuse allegation when a cognitively intact resident with schizophrenia, anxiety, and impulse disorder told the DON that a restorative nurse aide had been making the resident suck the aide’s breast and "play" with them. The DON documented the allegation and interviewed the resident and the accused RNA with a CMT present, but did not suspend the RNA, did not interview any other staff or residents, and did not complete or document a full investigation as required by facility policy. Multiple CNAs, RNs, the SSD, and the Administrator stated that such conduct would constitute sexual abuse and that the usual process would be to suspend the accused staff and conduct an investigation, yet the RNA continued working and no complete, timely investigation was documented.
A resident with schizophrenia, anxiety, impulse disorder, and documented behavioral issues, but assessed as cognitively intact, reported to the DON that a restorative nurse aide had been making the resident suck the aide’s breast and play with them. The DON had a CMT present as a witness, called the aide into the office, and the resident quietly repeated the allegation; the aide denied it and described a recent conflict after the resident urinated on the floor and was told to change clothes. Despite facility policy and staff interviews confirming that such an allegation constitutes sexual abuse and must be reported to the Administrator and DHSS within two hours, the DON did not report the allegation, and DHSS records showed no report was made.
A resident with cognitive impairment and psychiatric diagnoses was denied smoke breaks by the Social Services Director after exhibiting disruptive behavior during an outing. Staff interviews revealed confusion about residents' rights, with several staff members confirming that withholding smoke breaks as punishment is not permitted for residents who are their own decision-makers. The facility's actions were not consistent with its policy on resident rights, resulting in a failure to treat the resident with dignity and respect.
A resident with dementia and psychiatric disorders made two separate allegations of abuse, which were not reported to the state agency within the required timeframe. Although staff assessed the resident and found no evidence of injury, there was no documentation or confirmation that the allegations were reported to facility administration or DHSS as mandated. Staff interviews revealed confusion about reporting procedures and timeframes, and both the DON and Administrator acknowledged the incidents were not reported as required.
Staff did not fully investigate or document two abuse allegations made by a resident with dementia and psychiatric disorders. The facility failed to interview other staff or residents, did not suspend the accused staff as required by policy, and did not document protective measures during the investigation. Interviews revealed inconsistent understanding and application of abuse protocols among staff and administration.
A resident with a history of mental health disorders repeatedly engaged in sexually abusive and inappropriate behaviors toward other residents, including physical contact and explicit verbal comments. Despite ongoing incidents reported by staff and residents, the facility failed to update care plans or implement new interventions beyond 15-minute checks, leaving affected residents feeling unsafe and unprotected.
Staff failed to report multiple incidents of sexual abuse by a resident toward peers to the State Survey Agency within the required timeframe. Despite clear documentation of inappropriate sexual behaviors and staff awareness that such incidents constituted abuse, the required notifications were not made, in violation of facility policy and federal regulations.
The facility did not conduct and document annual performance reviews and competency evaluations for CNAs, as required. Two CNAs lacked documentation of yearly reviews despite being employed for over a year. The DON confirmed the absence of documentation, and the QARN noted the lack of a specific policy for annual competencies, which should include essential skills like catheter care and hand washing.
The facility failed to provide a meaningful activity program for its residents, with a lack of variety and consistency in scheduled activities. Many activities were canceled, and there was insufficient documentation of resident participation and preferences. Residents expressed dissatisfaction with the repetitive nature of activities, and staff interviews revealed a lack of awareness and communication regarding activity preferences.
The facility staff failed to maintain the ice machine and kitchen area in a sanitary condition, with observed buildup on the ice machine and unclean light fixtures, ceiling, and vents. Inconsistencies in cleaning schedules and unclear responsibilities among staff contributed to these deficiencies.
A resident with flaccid hemiplegia and severe cognitive impairment had their call light consistently placed out of reach, contrary to the care plan and facility policy. Staff interviews confirmed the expectation for call lights to be accessible, particularly on the non-affected side, but observations showed this was not adhered to.
A facility failed to complete the required PASARR screening for a resident with mental disorders before admission. The resident's care plan and MDS assessment indicated diagnoses of paranoid schizophrenia and anxiety disorder. The PASARR Level I screening submitted by the hospital was incomplete, and necessary corrections were not made by the facility. Interviews revealed that the MDS Coordinator, who was new and part-time, missed the correction request, and the facility lacked a written PASARR policy.
The facility failed to update care plans for two residents receiving hospice services. One resident with COPD and other conditions was on hospice, but this was not reflected in their care plan or MDS. Another resident with schizophrenia and other diagnoses was also on hospice, as documented in weekly summaries, but their care plan was not updated. Staff interviews confirmed the oversight, and the MDS Coordinator cited time constraints as a factor.
A facility failed to assist a dependent resident with peri-care following an episode of incontinence. The resident, who required substantial assistance for toileting hygiene, was not provided with peri-care by two CNAs after using the toilet. Interviews with staff confirmed that peri-care should be performed with each incontinence episode, but the CNAs did not follow this protocol, nor did they perform hand hygiene between glove changes.
A resident with an indwelling suprapubic catheter did not receive proper catheter care due to a nurse's failure to change gloves and perform hand hygiene during the procedure. The resident, with a history of urinary tract infections, required catheter care every shift. The nurse acknowledged forgetting to change gloves, and facility leadership confirmed the need for proper hand hygiene and glove changes during catheter care.
A hospice resident with severe pain was not provided timely pain management in a LTC facility. Despite frequent complaints and visible distress, staff failed to administer pain relief promptly. The resident's care plan included PRN medications and non-pharmacological interventions, but these were not effectively implemented. Staff interviews revealed communication gaps and a lack of adherence to pain management policies.
A facility failed to provide trauma-informed care for a resident with PTSD. The resident's PTSD diagnosis was not documented in the care plan, and staff were unaware of the resident's history and triggers. Despite the facility's commitment to managing PTSD, the care plan lacked necessary details, leading to inadequate care. Interviews revealed staff were not informed about the resident's psychological background, resulting in a lack of appropriate interventions.
The facility failed to maintain effective infection control during wound care for a resident with a stage 4 pressure ulcer and catheter care for another resident. The RN did not perform hand hygiene after changing gloves and improperly used PPE, such as pulling down the face mask during care. The DON and Administrator confirmed the expectation for proper hand hygiene and mask use.
Failure to Fully Investigate Resident’s Sexual Abuse Allegation Against Staff
Penalty
Summary
Facility staff failed to complete and document a full investigation of an allegation of sexual abuse made by one cognitively intact resident against a restorative nurse aide (RNA). The resident, who had diagnoses including metabolic encephalopathy, schizophrenia, generalized anxiety disorder, impulse disorder, restlessness, agitation, and a documented history of cussing, yelling, agitation with staff and other residents, lying about staff behavior, and using manipulative tactics, reported to the DON that the RNA had been making the resident "suck his/her boob and play with him/her" and stated this had been occurring "for a while." The resident’s care plan also noted physical and verbal behavioral symptoms directed toward others and other behavioral symptoms. Despite this behavioral history, the allegation itself was clearly documented by the DON in a progress note. The facility’s abuse policy stated that each resident will be free from abuse, that all employees alleged to have committed abuse will be suspended immediately pending investigation, and that the facility will complete an investigation. In this case, the DON interviewed the resident and the accused RNA in the presence of a CMT as a witness. The resident repeated the allegation quietly with head down, and the RNA denied any inappropriate conduct, stating the resident had urinated on the floor, was told to change clothes, became angry, and threatened to get the RNA fired. The DON decided not to send the RNA home and instead instructed the RNA and resident to have no contact. No additional staff or residents were interviewed, and there was no documented, complete, and timely investigation of the allegation as required by policy. Multiple staff interviews confirmed that a staff member asking a resident to suck their breast or play with them would be considered sexual abuse and should be reported and investigated, with the accused staff typically suspended pending investigation. CNAs, RNs, the SSD, and the Administrator all characterized such conduct as sexual abuse and described that the usual process would include suspending the accused staff and conducting an investigation. The SSD reported that the DON told him about the allegation and that the RNA continued to work and was not suspended. The Administrator stated he was not informed that the resident had actually made the sexual abuse allegation, and when the DON’s note was read to him, he agreed it should have been reported as sexual abuse. Review of state records showed the facility did not provide a documented, complete, and timely investigation of the allegation of abuse, and the DON acknowledged not completing a full investigation beyond interviewing only the resident and the RNA.
Failure to Timely Report Resident’s Sexual Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of sexual abuse to the Administrator and to the state licensing agency (DHSS) within the required two-hour timeframe, as required by facility policy. The facility’s abuse policy states that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property must be reported immediately, and no later than two hours when abuse or serious bodily injury is alleged. Review of DHSS records showed the facility did not report the allegation in question. Multiple staff interviews confirmed their understanding that an allegation of a staff member asking a resident to suck their breast or play with them constitutes sexual abuse and must be reported to the state within two hours. The resident involved had diagnoses including metabolic encephalopathy (acute), restlessness and agitation, acute pain due to trauma, schizophrenia, generalized anxiety disorder, and impulse disorder. The admission MDS indicated the resident was cognitively intact but had physical and verbal behavioral symptoms directed toward others and other behavioral symptoms occurring one to three days in the lookback period. The resident’s care plan documented a history of cussing, yelling, agitation with staff and other residents, lying about staff behavior or other residents, using manipulative tactics to gain attention or avoid certain actions, hitting objects and threatening to hit staff or others, and taking medications for schizophrenia, anxiety, and impulse disorder. On the date of the incident, the DON documented that the resident came to the DON’s office in the morning and stated that a restorative nurse aide (RNA) was making the resident suck the aide’s breast and play with the aide, and that this had been happening “for a while.” The DON brought in a CMT as a witness and called the RNA into the office, then asked the resident to repeat the accusation; the resident quietly repeated the allegation without looking at anyone. The RNA stated the resident had just left the therapy room after urinating on the floor, became angry when told to change clothes, and had said they would get the RNA fired. The resident denied this statement. The DON did not report the allegation to the state, stating that whether such conduct would be abuse would depend on the circumstances and that, in this case, the resident was upset with the RNA. The Administrator later stated they were not informed that the resident had actually made the specific sexual abuse allegation and, when the note was read to them, agreed it should have been reported as sexual abuse. DHSS records confirmed no report of the allegation was made.
Resident's Rights Violated by Withholding Smoke Breaks as Punishment
Penalty
Summary
The facility failed to ensure that a resident was treated in a dignified manner and allowed to exercise their rights, specifically regarding the withholding of smoke breaks as a form of punishment. The incident involved a resident with multiple diagnoses, including dementia, major depressive disorder with psychotic symptoms, anxiety disorder, and PTSD. The resident was noted to have moderate cognitive impairment and a history of verbal and physical aggression, requiring substantial assistance with activities of daily living. On the day in question, the Social Services Director (SSD) accompanied the resident to the social security office, where the resident exhibited disruptive behaviors, including yelling and making threats about the facility. Following these behaviors, the SSD withheld the resident's smoke breaks for the remainder of the day as a consequence. Interviews with staff revealed inconsistent understanding and application of residents' rights regarding the withholding of privileges such as smoke breaks. Several staff members, including CNAs, a CMT, and the DON, stated that it was against residents' rights to withhold smoke breaks as punishment, especially for residents who are their own legal decision-makers and do not have a guardian. Some staff believed that smoke breaks could only be withheld if a guardian had given explicit permission, but this was not the case for the resident involved. The DON and other staff confirmed that the resident was his/her own person and that the action taken by the SSD was not appropriate. The facility's policy on residents' rights emphasizes the right to a dignified existence, self-determination, and freedom from interference or reprisal in exercising those rights. The SSD's decision to withhold smoke breaks as a punitive measure was not in accordance with this policy, and staff interviews confirmed that this action was recognized as a violation of the resident's rights. The incident was attributed to a miscommunication and a lack of clarity among staff regarding the proper procedures for managing resident behaviors and upholding resident rights.
Failure to Timely Report Allegations of Abuse to State Authorities
Penalty
Summary
The facility failed to ensure that all allegations of possible abuse were reported immediately to management and within two hours to the state licensing agency, as required by both facility policy and federal regulations. Specifically, two separate allegations of abuse made by a resident were not reported to the Department of Health and Senior Services (DHSS) in a timely manner. In both instances, the Social Services Director (SSD) and other staff became aware of the allegations but did not document or ensure notification to facility administration or DHSS as required. The resident involved had a complex medical history, including dementia, major depressive disorder with psychotic symptoms, anxiety disorder, PTSD, and physical limitations requiring substantial assistance with activities of daily living. The resident reported to the SSD that two staff members were abusing them and claimed to have bruising, but no bruising was found upon assessment by the SSD and the charge nurse. On another occasion, the resident made further allegations of abuse in a public setting, but again, there was no documentation of notification to administration or DHSS. Interviews with facility staff revealed inconsistent understanding of the reporting requirements, with some staff unsure of the exact timeframes or whether all allegations, regardless of perceived validity, should be reported to the state. The Director of Nursing and Administrator confirmed that the two incidents were not reported to the state, and there was a lack of clear documentation and follow-through on the required reporting process for abuse allegations.
Failure to Investigate and Document Abuse Allegations
Penalty
Summary
Facility staff failed to complete and document a full investigation into two separate allegations of abuse made by a resident against staff members. According to the facility's Abuse Prohibition Protocol, all alleged violations involving abuse must be reported, investigated, and documented, with accused staff suspended pending investigation. However, in both incidents, the facility did not conduct or document a comprehensive investigation, including interviews with other staff or residents, nor did they suspend the accused staff as required by policy. The resident involved had a complex medical history, including dementia, major depressive disorder with psychotic symptoms, anxiety disorder, PTSD, and physical limitations requiring extensive assistance with activities of daily living. The resident reported being abused by staff and claimed to have bruising, but assessments by the Social Services Director (SSD) and charge nurse found no bruising. Despite these allegations, there was no evidence in the records of a thorough investigation or documentation of steps taken to protect the resident during the process. Interviews with facility staff, including CNAs, CMTs, the DON, and the Administrator, revealed inconsistent knowledge and application of the abuse investigation protocol. Some staff were unaware of the allegations or the required suspension of accused staff, and the Administrator admitted to not completing or being aware of investigations for the reported incidents. The lack of a documented, comprehensive investigation and failure to follow facility policy led to the deficiency.
Failure to Protect Residents from Sexual Abuse Due to Lack of Updated Interventions
Penalty
Summary
Facility staff failed to protect residents from sexual abuse by not updating care plans or implementing new interventions after repeated incidents of sexually inappropriate and abusive behaviors by one resident toward multiple other residents. The resident in question, who had a history of schizoaffective disorder, bipolar disorder, and anxiety, was cognitively intact and had exhibited sexually inappropriate behaviors since admission, including exposing themselves, making explicit verbal comments, and physically grabbing other residents' genitals. Despite these ongoing behaviors, staff only implemented 15-minute checks and did not document or initiate additional interventions or care plan updates in response to new or repeated incidents. Multiple incidents were documented in which the resident engaged in sexual abuse or made sexually explicit comments to at least three other residents, some of whom were cognitively impaired and unable to consent. Staff and other residents reported that these behaviors occurred frequently, both in public areas and in residents' rooms, and that the affected residents felt uncomfortable, upset, and unsafe. Staff interviews confirmed that the behaviors were well known, had been reported to nursing leadership, and were considered abuse, but no new strategies or individualized interventions were added to the care plans to prevent recurrence. The facility's own policy required thorough investigation, prevention of further abuse during investigations, and appropriate corrective action, but documentation showed that after each incident, staff primarily redirected the resident or educated them about inappropriate behavior without further care planning. The lack of new interventions or care plan updates persisted even after repeated and escalating incidents, including physical sexual abuse of residents who could not consent. The facility did not document any new measures to ensure the safety of the affected residents beyond the initial 15-minute checks.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to report multiple allegations of resident-to-resident sexual abuse to the State Survey Agency (DHSS) within the required two-hour timeframe. Despite having a policy that mandates immediate reporting of abuse, neglect, or exploitation, staff did not notify DHSS after several incidents involving a resident with a history of sexually inappropriate behavior. Documentation showed that the resident, who was cognitively intact and had diagnoses including schizoaffective disorder, anxiety, bipolar disorder, and alcohol abuse, engaged in repeated inappropriate sexual conduct toward other residents, such as grabbing genitals, making explicit verbal comments, and being found partially unclothed in another resident's room. Progress notes detailed at least five separate incidents where the resident either physically or verbally acted in a sexually inappropriate manner toward peers. In each case, staff documented the events, redirected the resident, notified the physician and family when appropriate, and sometimes sent the resident for evaluation. However, there was no documentation that any of these incidents were reported to DHSS as required by facility policy and federal regulations. Review of DHSS records confirmed that the facility did not self-report these allegations on the dates the incidents occurred. Interviews with staff, including CNAs, CMTs, nurses, the Social Services Director, and the Administrator, revealed a general understanding that such behaviors constituted abuse and should be reported to DHSS within two hours. Staff consistently stated that it was the responsibility of the charge nurse, DON, or Administrator to make the report. Despite this awareness, the required notifications were not made, resulting in a failure to comply with mandated reporting protocols for abuse allegations.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct and document annual performance reviews and competency evaluations for certified nurse aides (CNAs) as required. Specifically, two CNAs, who had been employed for over a year, did not have documentation of a yearly performance review. The Director of Nursing (DON) confirmed that while monthly in-services were conducted, there was no documentation of annual performance reviews. Additionally, the corporate Quality Assurance Registered Nurse (QARN) acknowledged the absence of a specific written policy for completing CNA annual competencies, which should include skills such as catheter care, transfers, peri-care, hand washing, and glove use. The Administrator also confirmed that the facility should be completing and documenting these competencies annually.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of meaningful activities tailored to the interests and abilities of its residents. The activity schedule lacked variety and consistency, with many activities being canceled or not conducted as planned. The facility's activity calendar often did not include specific times for activities, and there was a lack of documentation regarding resident participation and preferences. This deficiency affected nine residents out of a sample of 20, with a facility census of 39. Observations and interviews revealed that residents were often left without engaging activities, leading to boredom and dissatisfaction. For instance, one resident expressed frustration with the repetitive nature of activities like Bingo and Scrabble, desiring more variety. Another resident was not informed about ongoing activities and expressed a desire for playing cards, which were available but not offered. The facility's activity director acknowledged the lack of direction and support, noting that activities were often canceled due to insufficient staff. The facility's documentation practices were inadequate, with many residents' activity preferences and participation not recorded. Care plans often did not reflect residents' interests or provide guidance on encouraging participation. Staff interviews indicated a lack of awareness and communication regarding residents' activity preferences, and there was no consistent method for informing residents about scheduled activities. The facility's failure to maintain a comprehensive and engaging activity program compromised the psychosocial well-being of its residents.
Sanitation and Maintenance Deficiencies in Kitchen Area
Penalty
Summary
The facility staff failed to maintain the ice machine in a sanitary condition, as evidenced by observations of white and brown buildup on the machine's exterior. The facility's policy required weekly cleaning of the ice machine's exterior, but the last documented cleaning was on 08/31/24. Interviews with dietary aides and the dietary manager revealed inconsistencies in the cleaning schedule and responsibilities, with some staff unaware of the requirement to clean the machine daily. The dietary manager acknowledged the oversight and stated that the cleaning of the ice machine was not included in the kitchen's cleaning schedule. Additionally, the facility staff failed to maintain cleanliness in the kitchen area, as observed with brown spots on the fluorescent light and ceiling, and fuzzy lint on the ceiling vent. Interviews with dietary aides, the maintenance director, and the dietary manager indicated a lack of clarity regarding responsibilities for cleaning the lights, ceiling, and vents. The maintenance director admitted to only cleaning the lights when changing bulbs and did not clean the ceiling or vents. The administrator expected maintenance to handle these tasks but was unsure of the specific responsibilities, leading to the observed deficiencies.
Inaccessible Call Light for Resident with Hemiplegia
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident by not ensuring the call light was accessible. The resident, who had been admitted with a diagnosis of stroke resulting in flaccid hemiplegia affecting the left side of the body, required maximum assistance with activities of daily living and was severely cognitively impaired. Despite the care plan specifying that the call light should be within reach at all times, observations on multiple occasions showed the call light was clipped to the head of the bed on the resident's left side, making it inaccessible. Interviews with staff, including CNAs, an RN, the DON, and the Administrator, confirmed that call lights should be placed within reach of residents, particularly on the non-affected side for those with impairments. However, the call light for this resident was consistently placed out of reach, contrary to the facility's policy and the care plan. This oversight was identified through observations and staff interviews, highlighting a deficiency in accommodating the resident's needs.
Failure to Complete PASARR Screening Prior to Admission
Penalty
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASARR) for a resident prior to or upon admission. The resident, who was admitted with a history of mental disorders including paranoid schizophrenia and anxiety disorder, did not have a completed PASARR Level I screening. The resident's care plan indicated the need for monitoring due to these conditions, and the Minimum Data Set (MDS) assessment confirmed the presence of these diagnoses. However, the PASARR Level I screening submitted by the hospital was incomplete and required corrections, which were not addressed by the facility. Interviews with facility staff revealed that the MDS Coordinator, who was relatively new and worked part-time, missed the email requesting further corrections to the PASARR submission. The Director of Nursing (DON), who had experience in MDS completion, was assisting the MDS Coordinator. Additionally, the facility lacked a written policy on PASARRs, and staff were instructed to follow regulations without specific guidance. The Corporate Quality Assurance Registered Nurse and the Administrator acknowledged that the PASARR should have been completed before admission, and the responsibility for corrections lay with the MDS Coordinator and DON.
Failure to Update Care Plans for Hospice Services
Penalty
Summary
The facility failed to ensure that the care plans for two residents receiving hospice services were accurate and up-to-date. Resident #39, who was admitted with diagnoses including COPD, stroke, depression, anxiety, and PTSD, was on hospice services as indicated by a physician order and a hospice book. However, the resident's care plan did not reflect the hospice services, and the admission MDS did not document the hospice care. Interviews with staff, including CNAs and an RN, confirmed that the resident was receiving hospice services, but it was not included in the care plan. Similarly, Resident #2, diagnosed with schizophrenia, urinary tract infection, dysphagia, and falls, was also receiving hospice services as documented in the patient's specific letter of agreement and weekly summaries. Despite this, the resident's care plan, revised in June, did not include hospice services. Interviews with RNs, the MDS Coordinator, the DON, and the Administrator confirmed the resident's hospice status and acknowledged that hospice should be included in the care plan. The MDS Coordinator noted that care plans should be updated quarterly or as needed, but due to time constraints, this was not adequately done.
Failure to Perform Peri-Care for Incontinent Resident
Penalty
Summary
The facility failed to assist a dependent resident with activities of daily living, specifically in maintaining good grooming and hygiene, following an episode of incontinence. The incident involved a resident with severe cognitive impairment, frequent bladder incontinence, and occasional bowel incontinence, who required substantial assistance for toileting hygiene. During an observation, two CNAs assisted the resident to the toilet after noticing the back of the resident's pants were wet. However, they failed to perform peri-care after the resident used the toilet, instead placing a new brief and clean pants on the resident without cleaning the peri-area. Interviews with facility staff, including CNAs and the Director of Nursing, revealed that the standard procedure for peri-care was not followed. Staff members acknowledged that peri-care should be performed whenever a resident is changed or after using the bathroom, regardless of output. The CNAs involved did not perform hand hygiene between glove changes, which is against the facility's protocol. The Director of Nursing and the corporate QA RN confirmed that staff should always perform peri-care with incontinence and/or toileting, and should change gloves and sanitize hands during care.
Failure in Catheter Care and Infection Control
Penalty
Summary
The facility failed to adhere to acceptable standards of care during the management of a resident's indwelling suprapubic catheter. The resident, who was admitted with multiple diagnoses including bipolar disorder, generalized anxiety disorder, and a history of urinary tract infections, had an indwelling catheter due to benign prostatic hyperplasia and urinary retention. The care plan required catheter care every shift to prevent complications. However, during an observation, a registered nurse (RN) did not change gloves or perform hand hygiene after cleaning the catheter insertion site, which is a breach of infection control protocols. The RN was observed entering the resident's room with gloves, gown, and mask, and proceeded to perform catheter care without changing gloves or sanitizing hands after cleaning the catheter site. This included handling the catheter tubing and replacing the drain sponge without proper hand hygiene. The RN later acknowledged forgetting to change gloves during the procedure. Interviews with the facility's administrator and corporate QA RN confirmed that staff should wash or sanitize hands before donning gloves and change gloves after cleaning a catheter to prevent contamination.
Inadequate Pain Management for Hospice Resident
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident on hospice care, identified as Resident #39, who frequently experienced severe pain. The resident, who had a history of chronic obstructive pulmonary disease, stroke, depression, anxiety, and PTSD, was not on a scheduled pain regimen despite frequent complaints of pain affecting sleep and daily activities. The resident's care plan included goals for adequate pain control and instructions for staff to offer PRN pain medications and non-pharmacological interventions, but these were not effectively implemented. On a specific day, the resident was observed in significant distress, repeatedly calling out for pain relief over an extended period without receiving timely assistance. Despite vocal complaints and visible signs of pain, such as moaning and rubbing legs together, staff failed to respond promptly. A CNA eventually entered the room but was unsure about the resident's pain medication schedule and left to consult a nurse, further delaying pain relief. Interviews with staff revealed a lack of communication and understanding of responsibilities regarding pain management. The CNA did not report the resident's pain to the nurse, and the nurse was unaware of the resident's complaints until much later. The facility's policy required pain assessments and documentation, but these were not consistently followed, leading to inadequate pain management for the resident.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident's PTSD diagnosis was not documented in the medication record or care plan, and staff were not informed of the resident's history, triggers, or necessary interventions. This oversight occurred despite the facility's assessment indicating that they accept residents with PTSD and are committed to managing such conditions through person-centered care. The resident, who had a history of traumatic experiences including childhood abuse and a recent house fire, exhibited aggressive behaviors upon returning from an outing. The staff administered medication and eventually sent the resident for evaluation due to continued aggression. However, the care plan was not updated to reflect the PTSD diagnosis or to include specific triggers and interventions, leaving staff unaware of the resident's psychological background and care needs. Interviews with facility staff, including CNAs, LPNs, the MDS Coordinator, the Director of Nursing, and the Administrator, revealed a lack of awareness regarding the resident's PTSD diagnosis and history. The staff did not receive adequate information about the resident's emotional triggers, which were known to the resident's sibling. The facility's failure to incorporate this critical information into the care plan and communicate it to the staff resulted in inadequate care for the resident.
Infection Control Deficiencies in Wound and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and inappropriate use of personal protective equipment (PPE) during wound care for Resident #32. The registered nurse (RN) involved did not perform hand hygiene after changing gloves multiple times during the wound care process. Additionally, the RN pulled down their face mask, exposing their nose, and fanned their face with a gloved hand, which is against the facility's infection control policy. The Director of Nursing (DON) and the Administrator confirmed that the staff is expected to follow proper hand hygiene protocols and maintain mask coverage during care. Resident #32, who was admitted with diagnoses including a stage 4 pressure ulcer, heart failure, hypertension, and depression, required extensive assistance for personal care and was always incontinent of bowel and bladder. The resident's care plan mandated the use of enhanced barrier precautions (EBP) during care. However, during an observation, the RN failed to adhere to these precautions, compromising the infection control measures intended to protect the resident. Similarly, the facility failed to ensure proper hand hygiene during the care of Resident #20, who had a history of urinary tract infections and an indwelling suprapubic catheter. The RN did not change gloves or perform hand hygiene after cleaning the catheter insertion site and before handling clean items. This oversight was acknowledged by the RN and confirmed by the Administrator and the corporate Quality Assurance RN, who stated that staff should sanitize their hands before donning gloves and after cleaning a catheter.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
