Silverstone Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Rolla, Missouri.
- Location
- 2735 Eagleson Dr, Rolla, Missouri 65401
- CMS Provider Number
- 265851
- Inspections on file
- 22
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Silverstone Place during CMS and state inspections, most recent first.
A CMT administered another resident's insulin to a resident with diabetes managed by metformin, not insulin, after failing to properly verify the resident's identity. The error occurred because two residents had similar first names and were new admissions located near each other. The resident received 24 units of Novolog insulin without a physician's order, but did not experience immediate adverse effects.
The facility did not timely report suspected abuse, neglect, or theft, nor did it report the results of the investigation to the proper authorities as required.
A nurse administered a Fentanyl patch intended for one resident to another, cognitively intact resident with congestive heart failure who did not have an order for Fentanyl. The error occurred when the LPN, unfamiliar with the day shift routine, failed to follow medication verification procedures and only realized the mistake during charting about 30 minutes later.
Facility staff failed to ensure dietary staff had the appropriate competencies and skills for kitchen sanitation. Observations showed the dishwashing machine operating below required temperatures, and items were not properly sanitized in the three-compartment sink. Interviews revealed insufficient training and lack of documented competency assessments.
Facility staff failed to thaw frozen food properly, store frozen food at safe temperatures, and allow cleansed dishes to air-dry before stacking. Observations showed improper thawing of meat, reach-in freezer temperatures above recommended levels, and wet pans being stacked in storage. Interviews revealed a lack of understanding and adherence to proper procedures.
The facility staff failed to perform Criminal Background Checks (CBC) and Employee Disqualification List (EDL) checks in accordance with their policy for six out of ten sampled staff members. Significant delays were observed, with some CBC results being received as late as 329 days after hire and EDL checks being performed up to 63 days after hire. The Human Resources Manager acknowledged the missing documentation and admitted that the policy had not been followed.
Facility staff failed to notify the Ombudsman of resident transfers to the hospital for five residents. Medical records and monthly transfer logs lacked documentation of these notifications. Interviews revealed confusion among staff about the notification process, and the facility did not provide a policy for Ombudsman notification.
Facility staff failed to provide written information about the bed hold policy to residents and/or their responsible parties during hospital transfers. This deficiency affected eight residents, with no signed bed hold agreements found in their medical records. Interviews revealed confusion among staff about who was responsible for this task.
Staff failed to document the dosage of insulin administered to three residents, despite facility policies requiring such documentation. The MARs for these residents showed multiple instances of undocumented dosages, and interviews revealed that the facility's electronic system was not set up to record this information.
Facility staff failed to maintain hot food temperatures at or above 120°F when serving hall trays to residents. Observations and interviews revealed that food items were consistently below the required temperature, and staff did not offer to reheat the food. The Dietary Manager and other staff members had inconsistent understandings of the required food holding temperatures, and there was a lack of proper training and communication.
The facility staff failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. One resident experienced falls without consistent intervention, another had missing directions for essential equipment, and a third lacked seizure management instructions. Staff interviews revealed issues with care plan access and communication.
Medication Error Due to Improper Resident Identification
Penalty
Summary
Facility staff failed to ensure residents remained free of significant medication errors when a Certified Medication Technician (CMT) administered another resident's Novolog insulin to a resident who did not have a physician's order for insulin. The error occurred because the two residents had similar first names, were admitted around the same time, and were located across the hall from each other. The CMT, who was unfamiliar with the residents, did not properly verify the resident's last name and date of birth prior to administering the medication, relying only on the resident's verbal confirmation of their first name. The facility's policy required staff to identify residents before administering medication and to never administer medications supplied for one resident to another. The resident who received the incorrect medication was cognitively intact and had a diagnosis of diabetes managed with metformin, not insulin. After receiving 24 units of Novolog insulin, the resident's blood glucose was monitored closely, and the physician was notified. The resident reported feeling scared by the incident but did not experience any immediate adverse effects. The CMT could not recall the specific reason for the error but acknowledged not following proper identification procedures.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on a review of facility practices and documentation, which showed that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting to authorities were not completed within the mandated timeframe. The report does not provide specific details about the individuals involved or the nature of the incident, but it clearly states that the reporting and communication requirements were not met.
Medication Error: Fentanyl Patch Administered to Incorrect Resident
Penalty
Summary
Facility staff failed to ensure that a resident remained free from significant medication errors when a nurse administered another resident's Fentanyl patch to the wrong individual. The error occurred when the nurse, who was not accustomed to working the day shift, attempted to keep up with the pace and mistakenly applied the Fentanyl patch intended for a different resident. The nurse did not locate the existing patch and assumed it may have fallen off, leading to the incorrect administration. The error was discovered approximately 30 minutes later during charting, at which point the nurse realized the mistake. The affected resident was cognitively intact, had a diagnosis of congestive heart failure, and was on a scheduled pain regimen that did not include Fentanyl. The resident's care plan indicated the use of acetaminophen for pain management, and there was no physician's order for a Fentanyl patch. Facility policies required staff to verify medications and resident identity multiple times before administration, but these procedures were not followed, resulting in the medication error.
Inadequate Training and Sanitation Procedures in Kitchen
Penalty
Summary
Facility staff failed to ensure dietary staff had the appropriate competencies and skills to safely and effectively carry out the functions of food and nutrition services. Specifically, staff did not provide effective training related to kitchen ware washing and sanitation. Observations showed that the dishwashing machine was consistently operating below the required minimum temperature of 120 degrees Fahrenheit, with temperatures recorded as low as 110 degrees Fahrenheit. Interviews with dietary aides and cooks revealed that they were unaware of the correct temperature requirements for the dishwashing machine, and training on this aspect was either insufficient or non-existent. The dietary manager also failed to document training or maintain competency records for kitchen staff. Additionally, the facility staff did not follow proper procedures for sanitizing kitchenware using the three-compartment sink. Observations showed that items were not soaked in the sanitizer solution for the required two minutes. Instead, items were either dipped briefly or not sanitized at all. Interviews with kitchen staff indicated a lack of proper training on the use of the three-compartment sink, with some staff members stating they had never received training or in-services on the correct procedures. The dietary manager admitted to conducting informal, undocumented verbal reviews with new staff, which did not follow a structured schedule. The facility's failure to ensure proper training and adherence to sanitation procedures in the kitchen posed a risk to the safety and effectiveness of the food and nutrition services. The lack of documented training and competency assessments further exacerbated the issue, as there was no way to verify that staff were adequately prepared to perform their duties. The administrator acknowledged that the dietary manager was responsible for kitchen staff competency but did not provide specific details on how this was monitored or enforced.
Improper Food Thawing, Storage, and Dish Drying Procedures
Penalty
Summary
Facility staff failed to thaw frozen food in a manner to prevent potential contamination. Observations showed that large tubes of ground meat were submerged in standing water at 108 degrees F, which is above the recommended temperature for safe thawing. The meat was later placed on the prep counter at room temperature before being cooked. Interviews with the cook and dietary manager (DM) revealed a lack of understanding and adherence to proper thawing procedures, with the DM acknowledging that meat should not be thawed in warm standing water or in the sanitizer sink. The facility also failed to store frozen food at safe temperatures. Observations of the reach-in freezer showed internal temperatures ranging from 8 degrees F to 24 degrees F, which is above the recommended temperature of zero degrees F or less. The freezer contained items like bread sticks that were soft to firm pressure, indicating they were not properly frozen. Interviews with staff revealed confusion about who was responsible for monitoring and recording freezer temperatures, and the DM admitted that the temperature logs did not include the reach-in freezer. Additionally, the facility failed to allow cleansed dishes to air-dry prior to stacking them in storage. Observations showed multiple instances of wet pans being stacked on metal storage shelves, some of which contained dried food debris. Interviews with kitchen staff indicated a lack of training and awareness about the importance of air-drying kitchen items. The DM confirmed that kitchen items should air-dry and should not be put away wet, but staff were not following this procedure.
Failure to Perform Timely Background Checks and EDL Checks
Penalty
Summary
The facility staff failed to perform Criminal Background Checks (CBC) and Employee Disqualification List (EDL) checks in accordance with their policy for six out of ten sampled staff members. The policy mandates that all applicants must have a CBC submitted at least two days prior to the date of hire and that no applicant may be offered a position before checking the State EDL. However, the review of personnel records showed significant delays in performing these checks. For instance, LPN M was hired on 6/9/2023, but the CBC results were received 21 days after hire, and the EDL check was performed 20 days after hire. Similar delays were observed for other staff members, with some CBC results being received as late as 329 days after hire and EDL checks being performed up to 63 days after hire. During interviews, the Human Resources Manager acknowledged the missing documentation and admitted that the policy had not been followed. The Corporate Administrator and the facility administrator both expressed expectations that staff should follow the policy, but it was evident that these expectations were not met. The facility census at the time was 87, indicating a significant oversight in ensuring the safety and compliance of the staff employed at the facility.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
Facility staff failed to notify the Ombudsman of resident transfers to the hospital for five residents out of 22 sampled. The facility census was 87. The medical records for these residents did not contain documentation of staff notification to the Ombudsman for multiple hospital transfers. Specifically, Resident #4 was transferred for pneumonia, Resident #47 had multiple transfers, Resident #61 had two transfers, Resident #77 was transferred for a fracture and a head injury, and Resident #84 was transferred for changes in mental status and aggressive behavior. The facility's monthly resident transfer log also lacked documentation of these notifications for the specified dates. Interviews with facility staff revealed a lack of clarity and responsibility regarding the notification process. The Director of Nursing was unsure who was responsible for the notifications, the Social Service Director believed the requirement was for monthly notifications, and the Registered Nurse was also unsure of the responsible party. The administrator confirmed that the Social Service Director was responsible for the notifications but acknowledged that the notifications should be given with each resident discharge or transfer. The facility did not provide a policy for Ombudsman notification of resident transfers to the hospital.
Failure to Provide Written Bed Hold Policy Information
Penalty
Summary
Facility staff failed to provide written information to residents and/or their responsible parties regarding the bed hold policy at the time of transfer to the hospital. This deficiency was observed in eight residents out of a sample of 22, with the facility census being 87. The facility's policy stated that a copy of the bed hold policy should be sent with the resident upon transfer to the hospital, but this was not consistently done, and no signed bed hold agreements were found in the medical records of the affected residents. For Resident #2, the medical record showed multiple transfers to the hospital and returns to the facility without any documentation of a bed hold agreement. Similarly, Resident #4's records indicated a transfer to acute care for pneumonia and a subsequent readmission without documentation of the bed hold policy being communicated. Resident #47, assessed with moderate cognitive impairment, had multiple hospital transfers and returns without any bed hold policy documentation. Resident #61, with severe cognitive impairment, also had multiple transfers without the required documentation. Other residents, including Resident #76, Resident #77, Resident #84, and Resident #340, experienced similar issues with hospital transfers and returns without proper documentation of the bed hold policy. Interviews with facility staff, including the Social Service Director, Director of Nursing, and the administrator, revealed confusion and lack of clarity regarding who was responsible for ensuring the bed hold policy was communicated and documented. The corporate administrator confirmed that the facility should have signed copies of the bed hold agreements but was unsure why this was not being done.
Failure to Document Insulin Dosages
Penalty
Summary
Staff failed to maintain a professional standard of care by not documenting the dosage of insulin administered to three residents. The facility's policies on medication administration and the Eight Rights of Medication were not followed, as staff did not record the actual units of insulin given. This failure was observed in the Medication Administration Records (MAR) for Residents #2, #59, and #71, who all had orders for insulin administration due to their diabetes diagnoses. The MARs showed multiple instances where the insulin dosage was not documented, despite the administration being recorded. Resident #2 had orders for insulin lispro to be administered three times daily, with specific instructions on dosage calculation based on blood sugar levels and meal intake. However, the MAR for May 2024 showed numerous instances where the dosage was not documented. Similarly, Resident #59 had orders for both insulin lispro and insulin glargine, but the MAR lacked documentation of the dosages administered on multiple occasions. Resident #71 also had orders for insulin lispro, with the MAR showing 23 instances of undocumented dosages. Interviews with the Director of Nursing (DON), Certified Medication Technicians (CMTs), and Licensed Practical Nurses (LPNs) revealed that the facility's electronic medication administration system did not have a place to document the actual units of insulin given. The DON admitted that the system was not set up to record this information, and staff confirmed that they could not track the dosages administered. This lack of documentation could lead to medication errors and issues with blood sugar management, as there was no way to verify the correct amount of insulin was given to the residents.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
Facility staff failed to properly maintain the temperature of hot foods at or above 120 degrees Fahrenheit at the time of serving hall trays to six residents. Observations showed that the temperatures of various food items, such as broccoli, pork loin, and cornbread, were below the required 120 degrees Fahrenheit. Dietary Aide B did not offer to reheat the food for the residents, and multiple residents reported that their food was consistently cold. The facility's Food Service policy did not specify the expected temperature for food at the time of service, contributing to the issue. Interviews with residents and staff revealed that the problem of cold food was known but not adequately addressed. Residents who ate in their rooms frequently complained about receiving cold food, and staff members acknowledged these complaints. The Dietary Manager admitted to receiving complaints about cold food and mentioned that morning meetings to address such concerns had not been held that week. Additionally, the Dietary Manager and other staff members had inconsistent understandings of the required food holding temperatures, indicating a lack of proper training and communication. Further observations in the main dining room showed that food on the steam table was not maintained at the correct temperatures, with items like beef stroganoff and green beans being served at temperatures just above 120 degrees Fahrenheit. Interviews with kitchen staff revealed a lack of knowledge about proper food holding temperatures and inadequate training. The Dietary Manager confirmed that new cooks were trained by other kitchen staff without documented training procedures. The administrator also demonstrated a lack of awareness regarding the required food holding temperatures, indicating systemic issues in the facility's food service management.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility staff failed to develop and implement a comprehensive person-centered care plan for three residents, leading to deficiencies in their care. Resident #27, who was cognitively intact and dependent on staff for transfers, experienced falls from bed on two occasions. Despite the implementation of new interventions such as bilateral floor mats, these were not consistently in place as observed on multiple occasions. Additionally, the resident's care plan did not include directions for the use of a trapeze, mechanical lift transfer, or fall interventions, and there was a lack of documentation regarding the refusal of fall mats by the resident and family member. Resident #47, who had moderate cognitive impairment and was dependent on staff for activities of daily living and transfers, was observed multiple times in a wheelchair with a mechanical lift pad under them. However, the resident's care plan did not contain directions for the use of a low air loss mattress or mechanical lift, which were part of their physician's orders. This indicates a failure to update the care plan to reflect the resident's current needs and equipment. Resident #61, who had severe cognitive impairment and a diagnosis of a seizure disorder, had physician's orders for seizure medications and emergency interventions. Despite this, the resident's care plan did not contain directions for managing seizures or convulsions. Interviews with staff revealed that not all CNAs had access to care plans, and there was a lack of communication and training regarding the updating and accessibility of care plans. The Care Plan Coordinator (CPC) was responsible for updating care plans but lacked formal training and relied on verbal communication from nursing staff for updates, leading to inconsistencies and omissions in the care plans.
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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