Shirkey Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Missouri.
- Location
- 804 Wollard Blvd, Richmond, Missouri 64085
- CMS Provider Number
- 265708
- Inspections on file
- 20
- Latest survey
- May 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Shirkey Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
During a survey, it was observed that the facility did not adhere to food storage and labeling protocols. Open and undated food items were found in the kitchen, including a bag of yellow cake mix, thickener with scoops inside, loaves of bread, and a bag of frozen chicken breasts. The Dietary Manager acknowledged that scoops should not be kept in containers and that staff were expected to label and date items properly. The deficiency had the potential to impact all 86 residents consuming food from the facility's kitchen, posing possible health risks due to compromised food safety standards.
The facility failed to have the Medical Director or designee attend the last two quarterly QAPI meetings. The QAPI Nurse confirmed the absence and acknowledged the regulatory requirement for attendance.
The facility failed to update Care Plans for two residents, one with Alzheimer's disease exhibiting undocumented behaviors and another with chronic conditions requiring continuous oxygen, leading to deficiencies in care.
The facility failed to provide scheduled showers to two residents who preferred showers, leading to a diminished quality of life. Both residents, who were cognitively intact and required substantial assistance, missed multiple showers due to staffing shortages, as confirmed by documentation and staff interviews.
The facility failed to assess and monitor a resident's falls, leading to multiple incidents without proper intervention. Additionally, the facility did not provide necessary safety equipment in smoking areas and failed to conduct proper smoking assessments, increasing the risk of harm to residents.
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in the management of oxygen and C-PAP equipment. Oxygen tubing was not dated or labeled, C-PAP machines were improperly placed, and there was no evidence of regular cleaning or changing of equipment. Staff admitted to inconsistent maintenance, and the DON confirmed the lack of proper documentation and adherence to protocols.
The facility failed to ensure sufficient nurse staffing, resulting in two residents not receiving scheduled showers and a lack of meaningful activities for residents in the secured dementia unit. Observations and staff interviews confirmed that the unit was understaffed, affecting the quality of care and engagement for the residents.
The facility failed to complete AIMS assessments for residents on antipsychotic medications, including a resident with heart failure and diabetes, another with Alzheimer's disease, and a third with dementia and bipolar disorder. This oversight placed residents at risk for unrecognized side effects.
The facility failed to prepare, store, and label medications according to standard nursing practice. A CMA was observed leaving a medication cart unattended with unlabeled medications and admitted to premixing medications against facility policy. The DON confirmed that medications should not be prepared in advance or left unattended.
The facility failed to document the completion of 12 hours of required in-service training, including dementia care and abuse prevention, for five CNAs. Despite conducting annual trainings, there was no evidence that the required hours were met, and the facility did not track the actual hours completed.
The facility failed to inform a resident and/or their representative about the risks and benefits of prescribed psychotropic medications. The resident, who was cognitively intact, was not informed about the medications Seroquel and Rexulti, and the documentation in the Progress Notes was incomplete. Interviews with staff confirmed that the process for informing residents was not properly followed.
The facility failed to investigate an injury of unknown source for a resident with a history of osteoarthritis, falls, and heart failure. Despite the resident's complaints of knee pain and a reported femur fracture, no investigation was initiated by the nursing staff or the Director of Nursing Services. The resident was later sent to the hospital, where an x-ray revealed a femur fracture. Interviews revealed that the facility did not follow its policy for investigating injuries of unknown source.
The facility failed to provide a program of meaningful activities for a resident with Alzheimer's disease, who was often left without engaging activities and seen wandering or sitting on the floor. The CNA/CMA was unaware of the resident's preferences, and the Activity Director admitted to delays in developing the Activity Care Plan and acknowledged that residents were spending more time in bed.
The facility failed to ensure that a CMA had the necessary skills and competency to safely perform medication administration. CMA 3 had not been assessed for medication competency since 2023 and was only observed for insulin, eye drops, and inhalers.
Non-Compliance with Food Storage and Labeling Requirements
Penalty
Summary
The facility failed to comply with food storage and labeling requirements during the survey. Observations revealed open and undated food items in the kitchen, including an open bag of yellow cake mix, thickener with scoops inside, undated loaves of bread, and an undated bag of frozen chicken breasts. The Dietary Manager acknowledged that scoops should not be kept in containers, and staff were expected to label and date items properly. The DM also mentioned the expectation for staff to close items after use and ensure proper labeling and dating procedures were followed. The deficiency had the potential to impact all 86 residents who consumed food prepared in the facility's kitchen. The lack of proper labeling and dating of food items could compromise food safety standards and potentially lead to health risks for the residents. The facility's policy on Resident Food Storage required labeling and dating of food brought into the facility for monitoring food safety, emphasizing the importance of following these procedures to ensure the well-being of the residents.
Medical Director Absence from QAPI Meetings
Penalty
Summary
The facility failed to have the Medical Director and/or designee attend the last two quarterly QAPI (Quality Assurance and Performance Improvement) committee meetings. Review of the QAPI sign-in sheets for the meetings on 11/28/23 and 02/20/24 revealed that the Medical Director did not attend and was marked as 'unable to attend' for both meetings. During an interview on 04/05/24, the QAPI Nurse confirmed that the Medical Director did not attend the last two meetings and acknowledged awareness of the regulatory requirement for the Medical Director or their designee to attend these meetings.
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure resident Care Plans were updated and revised for two residents, leading to deficiencies in care. Resident 84, diagnosed with Alzheimer's disease, exhibited behaviors such as sitting on the floor, which were not documented in her Care Plan. Despite observations and staff acknowledgment of this behavior, it was not included in the Care Plan, leaving staff without guidance on how to address it safely. The Unit Manager confirmed that the behavior was reported but not documented in the Care Plan, indicating a lapse in updating the resident's Care Plan to reflect her current status. Resident 6, with diagnoses including chronic congestive heart failure and chronic atrial fibrillation, had a continuous oxygen order that was not included in their Care Plan. Despite the resident using oxygen since their last hospital visit, the Care Plan did not address this need. The Assistant Director of Nursing, responsible for updating Care Plans, admitted to missing the oxygen requirement during the last significant change assessment. This oversight left staff without proper instructions on managing the resident's oxygen needs.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
The facility failed to provide showers to two residents who preferred showers, leading to a diminished quality of life. Resident 8, who was admitted with diagnoses including Parkinson's disease, dementia, and anxiety, had a BIMS score indicating she was cognitively intact and required substantial assistance with showering. Despite her care plan specifying she should receive showers twice weekly, there were multiple instances where she did not receive a shower, which she attributed to staffing shortages. Documentation confirmed the lack of showers on specific dates in January, February, and March 2024. Similarly, Resident 73, admitted with cerebral palsy and mental illness, also had a BIMS score indicating cognitive intactness and required substantial assistance with showering. Her care plan indicated she should receive showers twice weekly, but she reported not receiving them due to staffing issues. Documentation confirmed missed showers on specific dates in January, February, March, and April 2024. An LPN confirmed that staffing shortages were likely the reason for the missed showers, as the facility could not always assign a CNA to assist with showers when understaffed.
Failure to Assess Falls and Provide Smoking Safety Measures
Penalty
Summary
The facility failed to adequately assess and monitor a resident's falls, leading to multiple incidents without proper intervention. Resident 23, who was admitted with various diagnoses including dementia and epilepsy, experienced fourteen falls over a six-month period. Despite these frequent falls, there was no documentation of fall assessments or root cause analysis. Interviews with staff and family members revealed a lack of consistent interventions and monitoring, with the resident often found in unsafe conditions such as a raised bed without proper supervision or safety measures in place. The Director of Nursing (DON) admitted that no root cause analysis or evaluations had been conducted for the resident's falls, and the facility's records did not indicate when or what interventions were implemented to prevent further falls and injuries for Resident 23. The facility also failed to provide necessary safety equipment in designated smoking areas and did not conduct proper smoking assessments for residents. Observations revealed that the three designated smoking areas lacked fire blankets and fire extinguishers, posing a significant risk to residents who smoke. One resident, who was supposed to be supervised while smoking, was observed smoking unsupervised for several minutes before a staff member arrived. The DON admitted that smoking assessments were not conducted, and there was no documentation to show that the resident's smoking abilities had been assessed. This lack of assessment and supervision increased the risk of harm to residents who smoke. Interviews with staff and review of facility policies highlighted systemic issues in the facility's approach to resident safety and risk management. The facility's policies on unusual occurrences and smoking were not adequately followed, leading to repeated incidents and potential hazards. The DON and other staff members were often unaware of the specific interventions or assessments required to ensure resident safety, indicating a need for improved training and adherence to established protocols.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in the management of oxygen and C-PAP equipment. For one resident, the oxygen tubing was not dated or labeled, and the C-PAP machine was improperly placed on the floor. Additionally, there was no evidence that the C-PAP mask, tubing, and water chamber were cleaned or changed as per physician orders. Interviews with the resident and staff revealed inconsistencies in the maintenance and documentation of respiratory equipment, with staff admitting to changing the equipment on an 'as needed' basis rather than following a set schedule. Another resident was observed with a nasal cannula that was not properly positioned in both nares, and the oxygen concentrator filter was found to be dirty. The resident was also seen without her oxygen on multiple occasions, and staff were unsure why the oxygen was not being used. The facility's Director of Nursing (DON) and other staff members confirmed that the oxygen tubing and C-PAP equipment were not being maintained as required, and there was a lack of proper documentation to verify that the necessary cleaning and changes were being performed. The facility's policy required weekly cleaning and changing of oxygen and C-PAP equipment, but observations and interviews indicated that these tasks were not being consistently carried out. The DON acknowledged the deficiencies and stated that the night shift aides were responsible for these tasks, but the lack of documentation suggested that the procedures were not being followed. This failure to adhere to established protocols placed the residents at risk for respiratory illnesses and contamination of their respiratory equipment.
Staffing Shortages Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to ensure sufficient nurse staffing to meet the needs of the residents, resulting in residents not receiving showers and a lack of meaningful activities in the secured dementia unit. Specifically, two residents, R73 and R8, did not receive their scheduled showers due to staffing shortages. R8 reported not having a shower for seven days, and R73 confirmed that showers were missed because of short staffing. Both residents were cognitively intact and expressed concerns about the lack of care. Additionally, the facility's quarterly Minimum Data Set (MDS) confirmed these residents' cognitive status and their unmet needs for showers. The facility also failed to provide a program of meaningful activities for residents in the secured dementia unit. Observations revealed that residents were often lying in bed or wandering without engagement. Only one staff member was available to assist nine residents with activities of daily living (ADL), medication administration, behavior management, and activities. Interviews with staff, including a Certified Nurse Aide (CNA), Licensed Practical Nurse (LPN), and the Activities Director (AD), confirmed that the unit was understaffed and that the move to a new hall had further limited the residents' access to outdoor activities and adequate care. The facility assessment indicated that the previous staffing levels were higher, but the current staffing was insufficient to meet the residents' needs.
Failure to Complete AIMS Assessments for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to complete Abnormal Involuntary Movement Scale (AIMS) assessments for residents who were administered antipsychotic medications, placing them at risk for unrecognized side effects. Resident 65 was admitted with diagnoses including heart failure, diabetes, and pulmonary disease. Despite being prescribed Seroquel and later Rexulti, there was no documentation of an AIMS assessment being completed. The Director of Nursing (DON) confirmed that AIMS assessments were the responsibility of Unit Managers and should be done upon admission and every six months thereafter, but could not confirm if these assessments were completed for Resident 65. Resident 84, admitted with Alzheimer's disease, was also not assessed using AIMS upon admission or when prescribed Olanzapine and Risperidone. The Unit Manager acknowledged that the AIMS assessment was not done and could not provide a reason. This oversight was confirmed during an interview, highlighting a gap in the facility's protocol for monitoring residents on antipsychotic medications. Resident 4, diagnosed with unspecified dementia, bipolar disorder, and anxiety, was observed exhibiting tongue thrusting, a potential side effect of antipsychotic medication. Despite a care plan that included AIMS assessments every three months, there was no documentation of these assessments being completed. The DON could not provide any records of AIMS evaluations or routine assessments for Resident 4's psychotropic medication use, indicating a failure to follow the care plan and monitor for side effects effectively.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to prepare, store, and label medications according to standard nursing practice, as observed during a medication pass. Certified Medication Aide (CMA3) was seen leaving a medication cart unattended with three individual plastic cups containing unlabeled medications. CMA3 admitted to premixing medications, including Lactulose, liquid protein, and Miralax, and leaving them on the cart. This practice was against the facility's policy, which mandates that medications should never be left unattended and should be locked inside the cart if the cart is left unattended. Further observations revealed that CMA3 continued this practice with another medication cart, which also had five individual plastic cups of unlabeled medications on top. CMA3 admitted to premixing these medications about an hour prior and stated that she could identify the medications without labels. The Director of Nursing (DON) confirmed that the expectation was for medications not to be prepared in advance and not to be left unattended on the carts.
Failure to Document Required In-Service Training Hours
Penalty
Summary
The facility failed to document the completion of a minimum of 12 hours of required in-service training, including dementia care and abuse prevention, for five Certified Nursing Assistants (CNAs). Despite annual trainings being conducted, there was no evidence that the required 12 hours were completed for CNAs 1, 2, 4, 6, and 7. Interviews with CNAs revealed that while they received some training on abuse and neglect, dementia care training was either minimal or non-existent. The facility's Facility Assessment indicated the need for 12 hours of annual training, but this requirement was not met or documented properly. The Infection Preventionist (IP) and Director of Nursing (DON) confirmed that they did not track the actual hours of training completed by staff. The IP mentioned that while they conducted various trainings, they did not document the number of hours. Similarly, the DON stated that although staff signed in for trainings, there was no system in place to ensure the 12-hour requirement was met. This lack of documentation and tracking led to the deficiency, putting residents at risk of not receiving adequate care from properly trained staff.
Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was informed of the risks and benefits of physician-ordered psychotropic medications. Specifically, Resident 65, who was cognitively intact with a BIMS score of 14 out of 15, was not informed about the risks and benefits of Seroquel and Rexulti, which were prescribed for increased behaviors, hallucinations, paranoia, and depression. The documentation in the Progress Notes did not show that the resident or their representative was informed prior to the initiation of these medications. During interviews, it was revealed that the facility's process for informing residents or their representatives about new psychotropic medications involved a phone call, which was then documented in the Progress Notes. However, in this case, the documentation was incomplete, and the Licensed Practical Nurse and Director of Nursing confirmed that if it was not documented, it did not happen. This failure placed the resident and/or representative at risk of not knowing the risks and benefits of the medications being administered.
Failure to Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to investigate an injury of unknown source for a resident, which placed the resident at risk for potential abuse. The resident, who had a history of osteoarthritis, falls, and heart failure, reported being unable to stand due to knee pain. Subsequent progress notes indicated that the resident mentioned breaking her femur and experiencing pain, but no falls were reported by the staff. Despite the resident's complaints and the family's concerns, no investigation was initiated by the nursing staff or the Director of Nursing Services (DNS) when the injury was first reported. The resident was later sent to the hospital at the family's request, where an x-ray revealed a femur fracture. The acuity of the fracture was uncertain, but it could not be excluded as an acute fracture. Upon readmission to the facility, the resident's condition had deteriorated, and she was no longer able to walk. The resident and her family reported that the resident had been dropped by staff, which was not documented or investigated by the facility. Interviews with the resident, family member, and staff revealed that the facility did not follow its policy for investigating injuries of unknown source. The Director of Nursing (DON) was unaware of the x-ray report and the resident's statements, and no investigation was conducted. This lack of action and communication among the staff led to the failure to investigate the resident's injury, which is a violation of the facility's policy and federal and state laws regarding the treatment of residents.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to consistently provide a program of meaningful activities in accordance with a resident's preferences. The resident, diagnosed with Alzheimer's disease and severely impaired in cognition, was admitted to the facility and had a documented preference for activities such as attending church, watching specific TV shows, hiking, and enjoying chocolate and Mountain Dew. However, observations revealed that the resident was often left without engaging activities, seen sitting on the floor or wandering around, with minimal staff intervention. The CNA/CMA on duty was unaware of the resident's specific activity preferences and there was no activity logbook available to guide staff in providing appropriate activities. The Activity Director admitted to delays in developing the resident's Activity Care Plan and acknowledged that the residents were spending more time in bed. The AD also noted that the aide on the dementia unit was supposed to conduct activities with the residents, but this was not happening consistently. The recent move of residents to a new unit had also impacted the availability of outdoor activities and other engagement opportunities. The AD mentioned attempts to engage residents with activities like bingo, but overall, the facility's efforts to provide meaningful activities were insufficient, leading to a diminished quality of life for the resident.
Failure to Ensure Medication Competency of Certified Medication Aide
Penalty
Summary
The facility failed to ensure that a Certified Medication Aide (CMA) had the necessary skills and competency to safely perform medication administration. Specifically, CMA 3, who was hired on 07/11/02, had not been assessed for medication competency since 04/11/23. The Skills and Drills sheet provided by an LPN showed that CMA 3 was only observed for insulin, eye drops, and inhalers, and had not been assessed for any other medication pass requirements. During an interview, the LPN confirmed that CMA 3 had not undergone a comprehensive medication pass observation since 2023.
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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