Seasons Rehab And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Missouri.
- Location
- 15600 Woods Chapel Road, Kansas City, Missouri 64139
- CMS Provider Number
- 265850
- Inspections on file
- 21
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Seasons Rehab And Healthcare Center during CMS and state inspections, most recent first.
Administration failed to ensure secure, individual computer access for medication administration, resulting in a CMT repeatedly using an LPN’s login to access the MAR/TAR and document medications for residents. Despite written policies prohibiting password sharing and falsifying records, the CMT reported ongoing inability to log in under CMT credentials while still being scheduled to pass medications, and instead documented under the LPN’s name, including for controlled substances. HR managed credential setup and password resets and had instructed the CMT not to use another staff member’s sign-in but was unaware the problem persisted; the DON and Administrator also reported they were not aware the CMT was using another staff member’s login. The LPN, who had gone PRN and had not worked for an extended period, denied giving permission or login information and described computers that often remained logged in or displayed passwords, while leadership and the Regional Nurse confirmed that each staff member should have their own sign-in and that staff should not work if unable to chart.
A CMT repeatedly used an LPN’s electronic login to document medication administration for multiple residents with complex conditions, including dementia, Alzheimer’s disease, COPD, CKD, HTN, depression, anxiety, hypothyroidism, diabetes, and cerebrovascular disease. The facility’s policy required that the person administering medications document them on the MAR/TAR with their own initials and signature, but MAR/TAR reviews showed medications and treatments recorded under the LPN’s name on numerous occasions when the LPN was not working. The CMT reported ongoing problems accessing the MAR/TAR under CMT credentials and stated that leadership (administrator, HR, DON, ADON) had been informed of the access issues while HR continued to schedule the CMT to pass meds. The CMT stated that, after initially using the LPN’s login during a shared shift, he/she continued to chart under that login, including for controlled substances, resulting in inaccurate documentation of who actually administered medications.
The facility did not post the actual hours worked by RNs, LPNs, CMTs, and CNAs per shift, instead showing staff numbers for a 24-hour period without detailing hours worked per eight-hour shift. This was contrary to the facility's policy, as confirmed by the Staffing Coordinator and Director of Nursing.
The facility failed to provide two residents with the necessary QIO contact information on their NOMNC forms, which are required for appealing the decision to end Medicare Part A coverage. The Social Services Director was unaware of this omission, which affected residents whose services were expected to end in 2024.
The facility failed to provide individualized activities for two residents who did not participate in group activities, resulting in a lack of mental, physical, and psychosocial stimulation. One resident, with dementia, had an outdated care plan and spent significant time in bed without engaging activities. Another resident, with a stroke and dementia, lacked an activities care plan and also spent much time in bed. The facility's activity program policy was not effectively implemented, with limited one-to-one visits and no weekend activities, leading to insufficient engagement for these residents.
A facility failed to document behaviors and develop a care plan for a resident on psychotropic medication. The resident, with dementia, was prescribed Quetiapine Fumarate, but the care plan lacked target behaviors or symptoms justifying its use. The MAR and progress notes were insufficiently detailed, and staff interviews revealed a lack of awareness and documentation regarding the resident's behaviors and mood-related issues.
A resident with Alzheimer's and a history of falls was improperly moved by staff after a fall without a nurse's assessment, leading to a delay in calling EMS. The resident expressed pain, but staff attempted to move them to the dining room, causing further discomfort. The resident was eventually assessed by a nurse and transported to the hospital nearly two hours later for surgery on a broken hip.
Improper Use of Shared Computer Login for Medication Administration and Documentation
Penalty
Summary
Administration failed to safeguard medication administration by not ensuring a Certified Medication Technician (CMT) had a functioning, individual computer sign-in to access the Medication Administration Record (MAR) and Treatment Administration Record (TAR). The facility’s Employee Handbook, acknowledged in writing by both the CMT and a Licensed Practical Nurse (LPN), prohibited sharing passwords and falsifying records or signatures, and required compliance with federal False Claims Act provisions. Despite these policies, the CMT reported ongoing problems signing in under CMT credentials, while still being scheduled to pass medications, and ultimately used the LPN’s login to document medication administration for residents. Human Resources (HR) was responsible for setting up and managing staff computer credentials, including creating sign-ins after background checks and resetting passwords. HR stated that the CMT had been transferred from CNA to CMT credentials and that the CMT’s password had been reset multiple times. HR also reported telling the CMT not to use another staff member’s sign-in, but was not aware the CMT continued to have access issues and was using the LPN’s credentials. The DON stated HR handled credential setup and that staff could contact HR or the DON at any time for sign-in problems, but the DON was unaware the CMT was having ongoing access issues or using another staff member’s sign-in. The Regional Nurse indicated that each staff member should have their own sign-in, staff should not work if they cannot chart, and PRN staff who have not worked in over three months should be made inactive in the system. The CMT stated that the Administrator, HR, DON, and ADON were all informed on several occasions that the CMT could not sign in as a CMT, only as a CNA, yet the CMT continued to be assigned medication-passing shifts. The CMT described working a shift with the LPN during which the CMT could not chart medications, and the LPN allowed use of the LPN’s sign-in to document in residents’ medical records; the CMT then continued to use the LPN’s sign-in after the LPN went PRN, signing out controlled substances in the narcotic book under the CMT’s own name but documenting administration in the MAR under the LPN’s initials. The LPN, who had not worked since going PRN, denied giving the CMT permission or login information and reported that the computer often remained logged in or displayed passwords, and that the LPN was never asked to change a password. The Administrator, DON, HR, and Regional Nurse all reported they were not aware that the CMT was using the LPN’s sign-in to pass and document medications. This situation had the potential to affect all residents in the facility, which had a census of 74.
Improper Medication Documentation Using Another Nurse’s Electronic Login
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications and treatments were documented on the MAR and TAR by the person actually administering them, as required by the facility’s Medication Administration Policy. The policy stated that the licensed nurse or CMT must chart the drug, time administered, and initial his/her name with each medication administration, and that documentation must be completed by the person who administers the drug or treatment. Contrary to this policy, for approximately three months, a CMT used an LPN’s electronic sign-in to document medication administration for multiple residents, resulting in inaccurate attribution of who administered medications and treatments. The residents affected included individuals with multiple chronic and serious conditions such as dementia, Alzheimer’s disease, COPD, chronic kidney disease (various stages), hypertension, hyperlipidemia, major depressive disorder, anxiety, hypothyroidism, chronic pain, neuropathy, peripheral vascular disease, diabetes type II, cerebrovascular disease, stroke, malignant neoplasm of the head/face/neck, diverticulosis, depression, and delusional disorder. These residents were admitted or readmitted on various dates and were receiving ongoing medication and treatment regimens documented in their MARs and TARs. Review of the facility’s MARs and TARs for November 2025, December 2025, and January 2026 showed that medications and treatments were recorded as being administered by the LPN on numerous dates to at least eight sampled residents, even though timecard records showed the LPN had not worked at the facility after a specific date in late November and had gone to PRN status. Interviews and record reviews revealed how the misdocumentation occurred. The CMT reported that after becoming certified in October 2025, he/she had ongoing problems signing into the electronic system as a CMT and could only sign in under CNA credentials, which did not allow access to the MAR/TAR for medication charting. The CMT stated that he/she informed the Administrator, HR, DON, and ADON on several occasions that the sign-in problem persisted, but it was not corrected, and HR continued to schedule the CMT to pass medications. The CMT said that while working a shift with the LPN, he/she was unable to chart medications, and the LPN allowed him/her to use the LPN’s sign-in to document medication administration. The CMT then continued to use the LPN’s sign-in to chart medications after the LPN went PRN, signing out controlled substances in the controlled drug book under his/her own name but documenting administration in the electronic record under the LPN’s initials. HR confirmed that the CMT had an existing sign-in from CNA status, that passwords had been reset multiple times, and that the CMT had stated he/she could use another staff member’s sign-in, which HR said was not permitted. The Administrator stated he/she was not aware the CMT was having sign-in issues or using the LPN’s credentials, and that staff were not to share passwords. The LPN stated he/she was not aware the CMT was using his/her sign-in, did not give permission or share login information, and described that the computer system sometimes remained logged in or displayed passwords and did not require password changes during his/her employment.
Failure to Post Accurate Staffing Hours
Penalty
Summary
The facility failed to post the actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Medication Technicians (CMTs), and Certified Nursing Assistants (CNAs) responsible for resident care per shift. Instead, the facility posted the number of staff for a 24-hour period without detailing the hours worked per eight-hour shift. This deficiency was observed in the Staffing Ratio and Census Reports from 12/27/24 to 1/27/25, which did not comply with the facility's policy dated 10/24/2022 that required posting the current date, total number, and actual hours worked by nursing staff per shift. During an interview, the Staffing Coordinator confirmed that the posted staffing sheets only showed the number of nurses, CNAs, and CMTs for a 24-hour period and did not include the hours worked. The Director of Nursing (DON) acknowledged that until 1/28/24, the staffing sheets did not include total hours worked for licensed and unlicensed staff and covered a 24-hour period rather than each eight-hour shift. The DON and the Administrator were responsible for monitoring the posting of staffing, which was displayed at the reception desk and on resident living units at the nurse's stations.
Failure to Provide QIO Contact Information on NOMNC Forms
Penalty
Summary
The facility failed to provide two residents, who were notified that their Medicare Part A coverage would likely end, with the necessary Quality Improvement Organization (QIO) contact information on their Notice of Medicare Non-Coverage (NOMNC) forms. This deficiency affected two residents, one who started services on July 5, 2024, and was expected to end on July 11, 2024, and another whose coverage began on September 3, 2024, and was expected to end on November 26, 2024. In both cases, the NOMNC forms lacked the QIO contact name and toll-free number, which are essential for residents to appeal the decision to end services. The Social Services Director was unaware that the QIO contact information was missing from the NOMNC forms provided to the residents. The facility's Medicare Denial Process policy requires that the NOMNC, Form CMS-10123, be delivered to the resident or their representative at least two calendar days before Medicare-covered services end, including the QIO contact information. The absence of this information on the forms meant that the residents were not fully informed of their rights to appeal the decision to end their Medicare coverage.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the needs of two residents who did not participate in group activities and relied on staff for mental, physical, and psychosocial stimulation. Resident #49, diagnosed with non-traumatic brain dysfunction and dementia, was severely cognitively impaired and unable to communicate preferences for activities. Despite having an activity care plan initiated, it was not updated to reflect meaningful activities for the resident, who enjoyed walking, people-watching, and listening to music. Observations showed the resident spent significant time in bed without engaging in stimulating activities, and there was no documentation of daily participation in activities. Resident #176, admitted with a primary diagnosis of stroke and dementia, also lacked an activities care plan. The resident's preferences included being outside, listening to music, and being around animals, but these were not reflected in the care plan. Observations indicated the resident spent much time in bed with no activities taking place, and there was no documentation of activities progress notes. Interviews with staff revealed that the resident might engage in activities if offered coffee or snacks, but there was no structured plan to address the resident's needs. The facility's activity program policy aimed to encourage participation and support residents' capabilities, but it failed to implement individualized care plans and document participation effectively. The activity calendars showed limited one-to-one visits and no scheduled activities on weekends, leaving residents without meaningful engagement. Interviews with staff highlighted a lack of activities on resident halls and insufficient documentation of residents' participation, contributing to the deficiency in meeting residents' needs for mental and social stimulation.
Inadequate Documentation and Care Planning for Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately document behaviors and develop a comprehensive care plan for a resident prescribed a psychotropic medication. The resident, diagnosed with dementia, was admitted to the facility and later prescribed Quetiapine Fumarate for mood disorder. However, the care plan did not specify target behaviors or symptoms justifying the use of the psychotropic medication. The facility's Behavior Management policy requires identifying residents whose behaviors may pose a risk, developing individualized care strategies, and ongoing assessment of behavior management programs, including the effectiveness of psychoactive drugs. The resident's Medication Administration Record (MAR) and progress notes lacked detailed documentation of behaviors and the effectiveness of interventions. Although the MAR recorded various behaviors such as hitting, kicking, and refusing care, the progress notes did not provide details on the duration, intensity, or possible causes of these behaviors. Additionally, the interventions' effectiveness was not consistently documented, which is crucial for future care planning and medication adjustments. Interviews with staff revealed a lack of awareness regarding the resident's mood-related behaviors and the absence of detailed documentation in the care plan. The facility's staff, including a CNA, LPN, MDS Coordinator, and the Director of Nursing, acknowledged the need for detailed documentation of behaviors and the inclusion of target behaviors in the care plan. The staff also recognized that psychotropic medications should be related to the resident's diagnosis, behaviors, and symptoms, with regular reviews by the pharmacist and physician. The deficiency highlights the facility's failure to adhere to its behavior management policy and adequately document and address the resident's behavioral needs.
Failure to Properly Assess and Respond to Resident Fall
Penalty
Summary
The facility failed to properly assess a resident who had fallen before moving them and did not call Emergency Medical Services (EMS) in a timely manner. The incident involved a resident with a history of Alzheimer's Disease, dementia, spinal stenosis, and other conditions, who was moderately cognitively impaired and had a history of falls. On the day of the incident, the resident fell while walking to the bathroom and was found by a CNA. The CNA moved the resident to a sitting position on the floor without waiting for a licensed nurse to perform an assessment. Subsequently, additional staff, including a Restorative Aide/CNA, entered the room and assisted the resident into a chair, again without a nurse's assessment. The resident expressed pain in the left leg and shoulder, but staff attempted to move the resident to the dining room, which caused further discomfort. The resident was left sitting in a chair with the door closed, and it was not until much later that a licensed nurse performed a full assessment and called EMS to transport the resident to the hospital. The delay in calling EMS and the improper handling of the resident after the fall were significant issues. The family member of the resident, who had a video camera in the room, was notified of the fall and requested multiple times for the resident to be sent to the hospital. Despite these requests, there was a delay in action, and the resident was not transported to the hospital until nearly two hours after the fall, where they underwent surgery for a broken hip.
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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