Spring Valley Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Missouri.
- Location
- 2915 South Fremont Ave, Springfield, Missouri 65804
- CMS Provider Number
- 265188
- Inspections on file
- 43
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Spring Valley Health & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to complete and document required neurological assessments after multiple falls with potential head injury or unwitnessed falls. One resident with a history of stroke and fall risk had neuro checks started after a fall with head impact, but required time-interval checks and shift-based monitoring were missing, and staff gave conflicting accounts about whether checks were done and where the form was. Another resident with COPD, diabetes, obesity, gait problems, and repeated falls had several incidents where neuro checks were either partially documented, missing for required intervals, or referenced in notes without corresponding neuro logs, including falls with manual or Hoyer lifts used and one with bleeding from the foot. A third resident with cancer and other comorbidities, care-planned for fall risk and delayed reporting, self-reported multiple unwitnessed falls with hip pain; neuro checks were initiated but only partially completed and documented, and some falls were not contemporaneously charted. Staff and leadership interviews confirmed that neuro checks were expected for 72 hours after unwitnessed or head-impact falls, but revealed inconsistencies in understanding duration, responsibility, and documentation practices, resulting in incomplete adherence to the facility’s neuro-check protocol.
A resident with an order for boric acid vaginal suppositories did not receive the medication as prescribed due to unavailability and documentation errors. Staff failed to accurately record administration or non-administration on the MAR, did not consistently notify the physician of missed doses or refusals, and did not update the care plan to address the medication use or refusals. Interviews revealed confusion among staff about medication procurement, documentation, and notification procedures.
A resident dependent on tube feeding did not consistently receive the ordered nutrition due to staff confusion and errors in documenting intake, failure to record variances from physician orders, and lack of physician notification when discrepancies occurred. Staff interviews revealed misunderstandings about MAR documentation and inconsistent practices, resulting in inadequate monitoring and care for the resident at nutritional risk.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Several residents with cognitive and physical impairments did not receive showers as preferred, with some only receiving bed baths or experiencing long gaps between bathing. Staff interviews revealed confusion about shower schedules, documentation, and honoring resident preferences, resulting in unmet requests and a lack of support for resident self-determination.
Surveyors found that the facility failed to maintain clean and homelike conditions, with multiple residents experiencing unclean rooms, persistent odors, damaged furniture and fixtures, and uncomfortable temperatures. Staff and residents reported ongoing issues with cleanliness, odor control, and delayed maintenance, affecting both cognitively intact and impaired individuals.
The facility did not provide or document scheduled group and one-on-one activities for several residents, including those with cognitive impairment and chronic illnesses. Activities listed on the calendar were not conducted as scheduled, and staff failed to record activity participation or offer meaningful engagement, especially on the dementia unit. Some residents reported not being informed about available activities or receiving one-on-one visits, while staff interviews confirmed inconsistent documentation and lack of instruction regarding activity provision.
The facility failed to ensure proper documentation of medication administration or refusal on the MAR for multiple residents, including those with complex medical needs. In several cases, staff did not record whether medications were given or refused, and did not follow up on new prescriptions from outside providers, resulting in residents not receiving ordered treatments. Staff and leadership interviews confirmed that these actions did not meet facility policy or expectations.
Staff failed to administer medications as ordered, resulting in a medication error rate of 20%. Errors included giving incorrect doses of folic acid and iron supplements to multiple residents, as well as administering the wrong type of iron supplement. Additionally, insulin pens were not primed before use for two residents with diabetes, contrary to manufacturer and facility guidelines. Staff interviews confirmed a lack of adherence to medication administration protocols and insufficient knowledge regarding insulin pen priming.
Staff failed to document insulin administration and blood glucose checks for two residents with diabetes, leaving multiple MAR entries blank despite active orders. Additionally, two other residents received insulin via prefilled pens that were not primed before use, contrary to facility policy and manufacturer instructions. Interviews revealed staff were unaware of the need to prime insulin pens with each use, and leadership confirmed this was required. These actions resulted in significant medication errors.
Three of seven stove burner control knobs were missing in the kitchen, and staff continued to use the stove despite the deficiency. Dietary staff and management were aware of the missing knobs, but replacements had not yet been obtained. The facility lacked a policy for kitchen appliance upkeep.
Surveyors observed unsanitary conditions in the kitchen, including dirty floors, food debris, mold-like substances, and grease on walls and baseboards. Staff interviews revealed inconsistent cleaning practices and uncertainty about responsibilities, resulting in the kitchen not being kept clean and free of debris as required by facility policy.
Surveyors found that the facility did not maintain an effective pest control program, with multiple residents experiencing flies and gnats in their rooms. Observations included flies landing on residents and their food, dirty rooms with food debris, and pest control equipment not in use. Staff interviews revealed inconsistent pest control practices and a lack of a documented policy.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures were not consistently implemented to avoid the development of new ulcers. Surveyors found that necessary interventions were lacking for both treatment and prevention.
A deficiency was found due to the facility's failure to provide appropriate care for residents who are continent or incontinent of bowel/bladder, including inadequate catheter care and insufficient measures to prevent UTIs.
A deficiency was cited when a resident did not receive sufficient food and fluids to maintain their health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not provide further details about the circumstances or the resident's condition.
A resident with a chronic indwelling catheter did not consistently receive or have documented catheter care, output monitoring, or assessment for infection as required by physician orders and care plans. Staff failed to document catheter care and output on multiple occasions, did not always transcribe or update orders, and did not revise the care plan to reflect changes in catheter management or involvement by urology. Interviews revealed confusion among staff about documentation and order requirements, and there was a lack of coordination with urology providers.
A resident with multiple chronic conditions experienced a change in mental status, prompting a provider to order a stat urinalysis with culture and sensitivity. Despite this, staff did not obtain the urine sample for ten days, with inconsistent documentation and no evidence of timely provider notification or explanation for the delay. Staff interviews confirmed confusion about the process and acknowledged the delay was excessive, resulting in a failure to meet professional standards of care.
A resident with significant medical needs reported to an LPN that a CNA had jerked and broken their leg during a transfer. The LPN assessed the resident and discussed the incident with the involved CNAs, but did not consider it an abuse allegation and failed to report it to the Administrator or state agency within the required timeframe. Multiple staff interviews indicated that such statements should be reported as abuse, but the required self-report to the state was not made.
Staff did not immediately investigate or take protective measures after a resident with multiple medical conditions alleged that a CNA was rough and broke their leg during a transfer. Despite the facility's abuse prevention policy requiring immediate action, the accused CNA continued working, and no written investigation was completed. Interviews with staff confirmed that the incident was not reported as abuse to administration, and both the DON and Administrator were unaware of the specific allegation, resulting in no formal investigation.
The facility failed to provide care according to standards of practice, resulting in deficiencies in wound care and medication administration for several residents. Wound care orders were not obtained or documented for all wounds, and medication administration was inconsistently documented, suggesting potential non-administration. Interviews with staff revealed that undocumented medications might not have been given, highlighting a significant deficiency in care.
The facility failed to ensure residents were free from significant medication errors due to staff not documenting the administration of multiple medications for three residents. This included critical medications for conditions such as CHF, diabetes, and schizophrenia. Interviews confirmed that undocumented medications were possibly not given, highlighting a significant lapse in medication management.
A facility failed to maintain effective infection control practices, as staff did not sanitize multi-use equipment, use barriers for supplies, or perform hand hygiene while managing diabetes care for residents. Observations revealed that an LPN did not adhere to hand hygiene protocols or clean equipment between uses, increasing the risk of cross-contamination. Interviews with staff confirmed a lack of adherence to infection control policies.
A facility failed to provide pressure ulcer care per standards of practice for a resident with a sacral pressure ulcer. Despite physician orders to cleanse and dress the wound every three days, staff did not document treatment completion on multiple occasions. The resident's care plan also lacked updates regarding the pressure ulcer. Interviews confirmed that staff should have followed orders and documented wound changes, leading to a deficiency in care.
The facility failed to properly store and administer medications, as a resident was found with medication left at their bedside without a physician's order, and medication carts were observed unlocked and unattended. Staff interviews confirmed these practices were against facility policy.
The facility failed to maintain a sanitary environment, with observations of unclean conditions in shower rooms and resident areas. Used towels, plastic gloves, and fecal matter were found in various locations, and staff were unaware of priority cleaning needs. Housekeeping staff followed a checklist but faced interruptions, and there was no written policy for cleanliness.
Failure to Complete and Document Post-Fall Neurological Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide and document complete neurological assessments after falls with potential for head injury, contrary to its own Fall Management and Neurological Evaluation policies. Those policies required a licensed nurse to perform a structured neuro evaluation for 72 hours after a potential head injury or unwitnessed fall, with checks every 15 minutes for one hour, every 30 minutes for one hour, every hour for two hours, every two hours for eight hours, every four hours for 12 hours, and then every shift for 48 hours. Staff interviews confirmed that nurses and aides understood that neuro checks were required after unwitnessed falls or when a resident hit their head, and that checks were to be completed in full and documented on a neurological evaluation form. Despite this, surveyors found multiple instances where neuro checks were either not initiated as described, not carried out for the full required duration, or not documented as required. For one resident with a history of stroke, hemiplegia, impaired mobility, and a care plan identifying fall risk, staff documented that the resident slipped on melting snow, hit the back of the head and bottom, and that neuro checks were initiated. The neurological evaluation log showed checks were completed through the 15‑minute, 30‑minute, and hourly phases, but there were no documented checks every two hours for eight hours, missing entries in the four‑hour phase, and no documentation of shift‑based checks for 48 hours. Staff interviews reflected confusion and inconsistency: one LPN believed the resident was near the end of neuro checks and completed only one set, another did not believe neuro checks had been initiated, and another reported starting the checks but later could not find the sheet and was told by another nurse they were unaware the resident was on neuro checks. The NP stated the resident should have received neuro checks for 72 hours, while the ADON was unaware of the circumstances of the fall and unsure if neuro checks were done. For a second resident with COPD, diabetes, morbid obesity, gait problems, muscle weakness, and a care plan noting fall risk and history of falls, surveyors identified several falls with incomplete or inconsistent neurological monitoring. After a fall over oxygen cords, staff documented that neuro checks were started, but the log showed missing entries in the two‑hour phase, no four‑hour checks, and incomplete shift‑based checks, followed by another fall with new neuro checks initiated. On another date, staff documented a fall with neuro checks within normal limits and stated that neuro checks were restarted and leadership notified, but there were no further progress notes or fall follow‑up/neuro assessments that day. A subsequent neuro log showed a full 72‑hour sequence starting the next evening, yet there was no progress note documenting a fall on that date, and another fall the following day had neuro checks ordered in the progress note but no corresponding neuro documentation. Additional falls later in the month showed neuro logs with missing entries in the 15‑minute, two‑hour, four‑hour, and shift‑based phases, and another fall with bleeding from the foot where neuro checks were said to be initiated but no documentation of restarted neuro assessments was found. For a third resident with malignant neoplasm of the head/face/neck, anxiety, depression, esophageal obstruction, chronic kidney disease, and a care plan noting fall risk, history of falls, and delayed reporting of unwitnessed falls, staff documented that the resident reported having fallen twice and complained of right hip pain. Neuro checks were initiated, but the log showed completion of the 15‑minute and 30‑minute checks only, with no documented hourly or two‑hour checks, and only sporadic four‑hour entries and no shift‑based checks for 48 hours. Later, the resident reported another fall that had occurred on a prior night, with staff documentation of hip pain and the resident’s written report of being given morphine and helped back to bed, but there was no progress note documenting a fall on those dates. A new neuro log was started, but the 15‑minute checks were not documented, and subsequent phases were only partially completed. Interviews with CNAs, CMTs, LPNs, the NP, DON, ADON, UM, and Administrator showed that while staff generally described a consistent fall and neuro‑check protocol, there were discrepancies in understanding of duration (two days vs. three days vs. 72 hours), who completed checks, and where forms were kept and filed, and some staff were unaware that certain residents were on neuro checks at the time of survey. Across these three residents, the surveyors determined that the facility did not ensure neurological assessments were consistently initiated, completed, and documented according to its policies and professional standards after falls with potential for head injury or unwitnessed falls. The medical records and neuro logs contained multiple gaps and missing entries in the required time intervals, and in some instances, falls were referenced by residents or in late entries without corresponding timely fall documentation or neuro‑check records. Leadership interviews confirmed expectations that neuro checks be completed in full for the required duration, that CNAs could obtain vitals but nurses must perform the neurological assessment, and that completed forms should be turned in to nursing leadership or medical records, yet the documentation reviewed did not reflect that these expectations were met for the residents involved.
Failure to Document, Administer, and Notify Regarding Ordered Medication
Penalty
Summary
Facility staff failed to provide care in accordance with accepted standards of practice for a resident who had an order for boric acid vaginal suppositories. The staff did not accurately document the administration or non-administration of the medication, with inconsistencies noted in the Medication Administration Record (MAR) and a lack of corresponding progress notes. There were instances where the medication was marked as refused or held, but staff interviews revealed that these entries may have been inaccurate, as the medication was not available in the facility at the time. Additionally, staff did not consistently notify the physician of missed doses or refusals as required by facility policy. The medication was not available for administration for several days after the order was written, and there was confusion among staff regarding the procurement and location of the boric acid suppositories. Central supply did not have the medication in stock and had to order it from an outside supplier, resulting in a delay. During this period, staff documented refusals or held doses on the MAR, but did not make explanatory notes or notify the physician in a timely manner. Interviews with nursing and supply staff indicated a lack of clarity about the process for obtaining over-the-counter medications and the appropriate documentation and notification procedures when medications are unavailable or refused. The resident's care plan did not address the use of or refusals related to the boric acid suppository, despite multiple missed doses and documentation issues. Staff interviews revealed uncertainty about who was responsible for updating care plans in such situations. The facility's policies required accurate documentation, timely physician notification, and care planning for medication refusals, but these procedures were not followed in this case.
Failure to Ensure Accurate Tube Feeding Documentation and Physician Notification
Penalty
Summary
The facility failed to ensure that all residents with tube feedings received sufficient nutrition due to staff misunderstanding and inconsistent documentation practices. Staff did not consistently document tube feeding intake accurately, failed to record when the amounts administered varied from the physician's orders, and did not notify the physician when such variances occurred. Multiple staff interviews revealed confusion regarding where and how to document tube feeding intake and output in the Medication Administration Record (MAR), with some staff documenting anticipated amounts rather than actual amounts administered, and others mistakenly recording oral intake or water flushes as tube feeding intake. There were also discrepancies in the timing of documentation, with the MAR not aligning with the actual start and end times of tube feedings as ordered by the physician. A resident with a history of nontraumatic intracerebral hemorrhage and dysphagia was identified as being at nutritional risk and dependent on tube feeding for adequate nutrition. The resident's care plan and physician orders specified the required tube feeding regimen, including the amount and timing of feedings. However, review of the MAR showed multiple instances where the documented intake did not match the ordered amount, including days with significantly less or more than the prescribed volume, and days with no intake recorded. Staff interviews confirmed that these discrepancies were not consistently explained in the resident's record, and physician notification was not documented when variances occurred. Further, staff expressed confusion about the documentation process, with some admitting to not being trained on the specific unit or not understanding the MAR system. There was also a lack of clarity regarding when to notify the physician about deviations from the ordered tube feeding amounts, with some staff believing notification was only necessary if the variance persisted over several days. The facility's policies required documentation of changes in condition and physician notification, but these were not followed in practice, leading to a failure to provide appropriate care and monitoring for the resident receiving tube feedings.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Honor Resident Bathing Preferences and Promote Self-Determination
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not providing timely bathing in the form preferred by several residents. Multiple residents with varying degrees of cognitive impairment and physical limitations reported not receiving showers as requested, with some only receiving bed baths or going extended periods without any form of bathing. Documentation and interviews revealed inconsistencies in offering showers, lack of clarity on whether showers or bed baths were provided, and gaps of several days between bathing opportunities. One resident with a history of stroke, hemiplegia, and depression expressed a preference for showers over bed baths, but records showed reliance on family-provided bed baths and infrequent staff-provided bathing. Another resident with a leg fracture and impaired mobility reported receiving only occasional sponge baths, despite a care plan indicating the need for bathing or showering twice weekly. A third resident, with altered mental status, kept a personal calendar and noted significant gaps between showers, sometimes waiting up to eleven days, and reported feeling unclean and having requests for showers unmet. Staff interviews indicated confusion regarding shower schedules, documentation practices, and the process for handling refusals or preferences. Some staff were unaware of the frequency with which residents should be offered showers, and there was no consistent system for ensuring residents' bathing preferences were honored. The Director of Nursing and other staff assumed that showers were being offered as scheduled, but documentation and resident reports did not support this, leading to unmet resident preferences and a failure to support resident choice in personal care.
Failure to Maintain Cleanliness, Odor Control, and Comfortable Environment
Penalty
Summary
Multiple deficiencies were identified in the facility's ability to maintain a safe, clean, comfortable, and homelike environment for its residents. Surveyors observed unclean conditions in resident rooms and bathrooms, including strong urine odors, brown and black substances on floors and walls, sticky floors, and the presence of ants. Several rooms had peeling paint, damaged drywall, and holes in doors, while some bathrooms had loose or broken fixtures. In one case, a resident's over-bed table was left soiled after a meal, and a recliner in the dementia unit's sunroom was found with dried brown substances on multiple surfaces. These issues persisted over several days and were acknowledged by housekeeping and maintenance staff, who were sometimes unaware of the duration or cause of the problems. Odors were a recurring issue in several resident rooms and hallways, with strong urine smells noted both inside and outside rooms. Staff interviews confirmed awareness of these odors, and in some cases, staff attributed them to factors such as resident incontinence, pets, or infrequent cleaning due to resident preferences. Despite daily cleaning routines, staff reported ongoing complaints about sticky floors and persistent odors. Maintenance logs revealed delays or lack of documentation regarding repairs, such as broken lights, damaged doors, and malfunctioning air conditioning units. Temperature control was also problematic, with observations of resident rooms and common areas measuring above 80 degrees Fahrenheit, despite thermostats being set lower. Residents and staff reported discomfort due to excessive heat, and temporary solutions such as mini-air conditioners and fans were provided. However, temperature logs did not always reflect the higher temperatures observed during the survey. The facility census at the time was 149, and the deficiencies affected multiple residents with varying levels of cognitive impairment, including those who were cognitively intact and those with severe cognitive deficits.
Failure to Provide and Document Resident Activities
Penalty
Summary
The facility failed to provide activity programs that met the needs of all residents, as evidenced by missed scheduled activities, lack of documentation of activity participation, and failure to offer or complete meaningful activities for several residents. Observations showed that activities listed on the Special Care Unit (SCU) calendar, such as music and craft sessions, were not conducted at the scheduled times. Additionally, staff did not document attendance or the offering of group, independent, or one-on-one activities for multiple days for several residents. For one resident with severe cognitive impairment and osteoarthritis, records indicated that activity participation was unknown, and there was no documentation of activities being offered or attended over several days. Another resident with cognitive communication deficits, schizophrenia, and bipolar disorder had a care plan specifying preferred activities and the need for assistance to attend, but staff failed to document any activity participation or offerings during multiple periods. A third resident with multiple chronic conditions, including COPD, CKD, and CHF, preferred independent activities such as using a computer and reading, but there was no documentation of activity involvement, and the resident reported not seeing activity staff for one-on-one visits or being informed about available activities. Interviews with staff revealed inconsistent practices regarding the provision and documentation of activities, particularly on the dementia unit. Some staff admitted to not documenting one-on-one visits or not being instructed to provide such activities. The Activity Director and DON both acknowledged gaps in documentation and the need for one-on-one activities, while residents expressed a lack of engagement and awareness of available options. These findings demonstrate a failure to implement and document an activity program that supports the physical, mental, and psychosocial well-being of all residents as required by facility policy.
Failure to Document Medication Administration and Follow-Up on Prescriptions
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents by not ensuring proper documentation of medication administration or refusal on the Medication Administration Record (MAR) for multiple residents. For one resident with complex medical conditions including acute kidney failure, diabetes, and pressure ulcers, staff did not document the administration or refusal of several prescribed medications, such as anticoagulants, antidepressants, pain medications, gastrointestinal treatments, potassium supplements, and muscle relaxants, over several days. Interviews with staff revealed uncertainty about the reasons for missing documentation, with some staff indicating the resident was noncompliant or out of the facility, but these events were not properly recorded on the MAR as required by facility policy. Another resident, who had diagnoses of diabetes and morbid obesity, attended an outside dermatology appointment and reportedly received a new prescription for a topical medication. The resident reported discomfort and lack of access to the prescribed cream, stating that staff had not applied it and were unaware of its status. Interviews with nursing staff indicated a lack of follow-up with the outside provider and pharmacy to obtain the prescription, and there was no documentation of these follow-up attempts in the resident's progress notes. The Director of Nursing and other staff confirmed that the expected process was not followed, and the medication was not obtained or administered in a timely manner. A third resident with diagnoses including acute post-hemorrhagic anemia, diabetes, colon cancer, and atrial fibrillation also experienced multiple instances where staff failed to document the administration or refusal of several medications, including blood thinners, diabetes medications, gastrointestinal treatments, nerve pain medications, antidepressants, and antihypertensives. Staff interviews consistently indicated that all medications administered or refused should be documented on the MAR, and that blank areas on the MAR are not acceptable. The Director of Nursing and Administrator both confirmed that lack of documentation means the medication was not given, and that staff are expected to document all medication administration or refusals.
Medication Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5%, as required, resulting in a 20% error rate based on 5 errors out of 25 observed opportunities. Staff administered incorrect medication doses and wrong medications to several residents. Specifically, one resident with severe cognitive impairment was prescribed folic acid 1 mg daily but was given 800 mcg instead, as the correct dose was not available. Another resident with kidney failure and iron deficiency, who was ordered folic acid 400 mcg daily, received 800 mcg. Additionally, a resident with diabetes and vitamin D deficiency was ordered ferrous sulfate 325 mg daily but was given ferrous gluconate 27 mg instead. Staff interviews confirmed that medications and doses were not administered as ordered, and staff acknowledged that they should have sought clarification from the physician or ensured the correct medication was available before administration. The DON and Administrator both stated that staff should follow physician orders and not substitute medications or doses. The facility's policy required adherence to the five rights of medication administration, including the right drug and right dose, and staff failed to comply with these requirements in the observed cases. Further deficiencies were observed in the administration of insulin using prefilled pens. Two residents with diabetes were administered insulin without the required priming of the pen before each use, contrary to manufacturer guidelines and facility policy. Staff interviews revealed a lack of knowledge regarding the need to prime insulin pens before every injection, with some staff believing priming was only necessary for new pens. The DON, Administrator, and Corporate Nurse Consultant all confirmed that insulin pens should be primed before each use to ensure accurate dosing, but this was not consistently practiced by staff.
Failure to Document and Properly Administer Insulin Results in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically related to the administration and documentation of insulin for residents with diabetes. Staff did not document the administration of insulin or the checking of blood sugar levels for two residents over multiple days, as evidenced by blank entries in the Medication Administration Records (MARs) despite active physician orders for both blood glucose monitoring and insulin administration. Interviews with staff and leadership confirmed that if the MAR is blank, it is assumed that the medication or task was not completed, which constitutes a medication error. The Medical Director also confirmed that undocumented insulin administration is considered a significant medication error. Additionally, staff failed to follow manufacturer guidelines for insulin pen use by not priming the pens prior to each administration for two residents. Observations showed that registered nurses administered insulin using prefilled pens without priming them, contrary to both facility policy and manufacturer instructions, which require priming before every use to ensure accurate dosing. Interviews with nursing staff revealed a lack of awareness regarding the need to prime insulin pens with each use, with some staff believing priming was only necessary for new pens. Leadership, including the DON, Administrator, and Corporate Nurse Consultant, stated that priming is required every time, as per manufacturer guidelines. The residents involved had diagnoses of Type 2 diabetes and were cognitively intact or severely cognitively impaired, depending on the individual. Their care plans and physician orders required regular blood glucose monitoring and insulin administration, including sliding scale dosing. The failure to document administration and to properly prepare insulin pens directly contradicted facility policy and physician orders, resulting in significant medication errors for multiple residents.
Failure to Maintain Safe Kitchen Equipment Due to Missing Stove Knobs
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, as evidenced by three out of seven stove burner control knobs being missing on the kitchen cook stove. Observations on two separate dates confirmed the missing knobs, and interviews with dietary aides and the Dietary Manager revealed that staff were aware of the issue but continued to use the stove by turning the burners on and off without the knobs. The Dietary Manager acknowledged the missing knobs and indicated a need to order replacements. The Administrator also confirmed awareness of the deficiency, stating that all knobs should be present. The facility did not provide a policy regarding the upkeep of kitchen appliances.
Failure to Maintain Sanitary Kitchen Environment
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, as evidenced by multiple observations of unclean floors and walls. Surveyors noted black and white substances on the kitchen floors, particularly under sinks and the dishwasher, as well as food debris in these areas. The baseboards were observed to be black with dirt. Additional observations revealed a mold-like substance and brown stains along the backsplash above the sink, large brown splatters on the wall under the sink, a black substance under the dishwasher, and grease drops on the wall behind the stove. These conditions were present despite the facility's policy requiring a clean and sanitary work environment in nutritional services. Interviews with dietary aides and the dietary manager revealed inconsistencies and uncertainty regarding cleaning responsibilities and schedules. Staff reported that floors were swept and mopped each shift, with deep cleaning of walls occurring two to three times weekly, but there was a lack of clarity about the frequency and thoroughness of these tasks. The dietary manager and administrator both stated that floors and walls should be clean, but acknowledged that there should not be visible dirt, mold, or food debris. The dietary manager also indicated that maintenance and housekeeping were involved in cleaning, but was not aware of the presence of mold or the extent of the dirt observed.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to implement and maintain an effective pest control program, as evidenced by multiple observations of flies and gnats in several resident rooms affecting five residents. Surveyors observed flies landing on residents and their belongings, including pillows and food, and noted that residents found the flies to be bothersome. In one instance, a resident's pillow had a black substance on it, and flies were seen landing on it repeatedly. Another room had eight to ten live flies, gnats, and an unplugged pest control light, along with an uncovered bedside commode containing urine and debris on the floor. Additional observations revealed rooms with unpleasant odors detectable from the hallway, dirty floors with food debris, full trash cans, and personal items scattered about. In one room, a sticky fly trap was completely full of flies, and several live and dead flies were present. Residents reported that housekeeping cleaned their rooms every other day, but some did not want their belongings moved. Staff interviews confirmed the presence of flies, with some staff using fly swatters and others unsure about the frequency of pest control treatments. The facility did not provide a pest control policy for review, and staff interviews indicated inconsistent knowledge and practices regarding pest control measures. The maintenance director stated that pest control services were provided at least monthly or more often if needed, but had not received complaints about flies. The administrator described various methods used to address flies but was not aware of an ongoing issue. The lack of a documented pest control policy and the presence of pests in resident rooms contributed to the deficiency.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents with existing pressure ulcers did not consistently receive the necessary interventions to promote healing or prevent further skin breakdown. Additionally, preventive strategies for residents at risk of developing pressure ulcers were not adequately carried out, contributing to the occurrence of new ulcers.
Deficient Bowel/Bladder and Catheter Care Practices
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder. It also notes failures in providing appropriate catheter care and in implementing measures to prevent urinary tract infections. The deficiency is based on observations or findings that the facility did not consistently ensure proper care practices for these residents, as required by regulatory standards.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Document and Provide Catheter Care per Standards and Orders
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received care in accordance with standards of practice and physician orders. Staff did not consistently document the completion of catheter care, monitoring of urinary output, or assessment for signs and symptoms of infection as required by the resident's care plan and physician orders. There were multiple instances across several months where documentation was missing for catheter care and output monitoring on both day and night shifts, and staff did not provide reasons for these omissions. Additionally, orders for catheter changes and care were not always transcribed or updated in the resident's records, and the care plan was not revised to reflect changes in the resident's catheter management, including involvement by urology specialists. The resident in question had a complex medical history, including chronic indwelling catheter use due to obstructive and reflux uropathy, a history of recurrent urinary tract infections, and episodes of hematuria and urinary obstruction. The resident was dependent on staff for most activities of daily living and required close monitoring and care of the catheter to prevent complications. Despite this, staff interviews revealed confusion about documentation responsibilities, with some CNAs unaware that they needed to document catheter care and others unsure about the presence of relevant orders in the electronic medical record. Nurses and administrative staff acknowledged that standard protocols required regular catheter care, output monitoring, and care plan updates, but these were not consistently followed or documented. Observations and record reviews further indicated that the facility did not maintain clear communication or coordination with the resident's urology providers regarding catheter changes and care. Orders from urology were not always incorporated into the resident's care plan, and there was a lack of documentation regarding urology visits and procedures. The failure to document catheter care, output monitoring, and care plan updates, as well as the lack of clear orders and communication with external providers, contributed to the deficiency identified by surveyors.
Delayed Urinalysis Collection Following Change in Condition
Penalty
Summary
The facility failed to ensure that a resident received care in accordance with professional standards of practice when staff did not obtain an ordered urinalysis (UA) in a timely manner. The resident, who had diagnoses including COPD, muscle weakness, heart failure, and chronic pain syndrome, was noted to have a change in mental status, including hallucinations. Following this change, a nurse practitioner ordered a stat CBC, CMP, and later a UA with culture and sensitivity, with permission to use a catheter if needed. Despite these orders, the UA was not collected until ten days after the order was received. Facility policy required that staff obtain labs as ordered, document on the lab scheduling/tracking form, and notify the physician if there were issues or delays. However, review of the resident's treatment administration record showed inconsistent documentation, with checkmarks indicating the UA was obtained on multiple occasions, but the actual collection did not occur until much later. There was no documentation in the progress notes explaining the delay, nor was there evidence that the provider was notified about the ongoing inability to obtain the sample. Interviews with staff revealed confusion about the process, with some staff indicating that a checkmark on the record did not always mean the task was completed, and others unsure why the delay occurred. The delay in obtaining the UA was confirmed by both the lab results, which showed the sample was collected ten days after the order, and by staff and provider interviews, all of whom agreed that this timeframe was excessive. The resident was known to be difficult to catheterize and sometimes refused care, but there was no documentation of refusals or provider notification during the period in question. The facility's failure to follow its own policies and ensure timely communication and documentation led to the deficiency.
Failure to Timely Report Allegation of Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all allegations of possible abuse were reported immediately to management and within two hours to the state licensing agency, as required by both facility policy and regulation. On the day in question, a resident with significant medical needs, including paraplegia, cancer of the larynx, and cognitive communication disorder, reported to an LPN that a CNA had jerked and broken their leg during a transfer. The LPN assessed the resident and discussed the incident with the involved CNAs, who denied any rough handling. The LPN did not consider the resident's statement to be an allegation of abuse and did not report it to the Administrator or the state agency within the required timeframe. Multiple staff interviews revealed that several employees were aware of the resident's complaint, but the information was not escalated to facility leadership or reported to the state as an abuse allegation. Staff members, including CNAs, LPNs, and the Social Service Director, indicated in interviews that such statements from a resident should be considered abuse and reported according to policy. However, the DON and Administrator both stated they were not informed that the resident had accused staff of jerking or breaking their leg, and thus no report was made to the state. Facility records and interviews confirmed that the required self-report to the Department of Health and Senior Services was not made. The failure to recognize and report the resident's statement as a potential abuse allegation resulted in non-compliance with both facility policy and regulatory requirements for timely reporting of suspected abuse.
Failure to Investigate and Protect After Allegation of Abuse
Penalty
Summary
Facility staff failed to immediately initiate an investigation and take protective measures following an allegation of possible abuse involving a resident. According to the facility's abuse prevention policy, any finding of potential abuse or neglect requires an immediate investigation and steps to protect the alleged victim. However, after a resident alleged that a certified nurse aide (CNA) was rough and broke their leg during a transfer, staff did not follow the policy. The CNA continued to work the remainder of the shift, though not with the resident, and there was no documentation of a written investigation or evidence that the accused staff was suspended pending investigation. The resident involved had significant medical conditions, including cancer of the larynx, spinal stenosis, muscle weakness, cognitive communication disorder, and paraplegia, and was dependent on staff for all activities of daily living. The incident occurred after a transfer, during which the resident reported to staff and family that the CNA had been rough and broke their leg. Despite these allegations, staff interviews revealed that the incident was not reported to administration as abuse, and no formal investigation was conducted as required by policy. Multiple staff members, including LPNs, CNAs, and the Social Service Director, indicated in interviews that such allegations should be reported and investigated, with the accused staff suspended. However, both the Director of Nursing and the Administrator stated they were not made aware of the specific abuse allegation and therefore did not initiate an investigation. Facility records and Department of Health and Senior Services records confirmed the absence of a written investigation into the allegation.
Deficiencies in Wound Care and Medication Administration
Penalty
Summary
The facility failed to provide care for residents according to standards of practice and physician orders, resulting in deficiencies in wound care and medication administration. For Resident #6, the facility did not obtain wound care orders for all wounds, specifically for the open area on the buttock and left heel. Additionally, wound care was not documented on several occasions, indicating a lack of adherence to the prescribed treatment plan. Resident #7 also experienced incomplete documentation and execution of wound care orders, with staff failing to include the full physician's order for the right leg and not documenting the reason for holding treatment on specific dates. Resident #5's medication administration was inconsistent, with multiple instances of staff failing to document the administration of various medications, including antidepressants, blood thinners, and pain medications. This lack of documentation suggests that the medications may not have been administered as prescribed, potentially impacting the resident's health and treatment outcomes. Similarly, Resident #9 experienced numerous instances where staff did not document the administration of prescribed medications, including those for anxiety, depression, and pain management, further highlighting the facility's failure to adhere to physician orders and maintain accurate medical records. Interviews with facility staff, including a Certified Medication Technician and an LPN, revealed that if a medication is not documented as given, it is possibly not administered. The facility's Administrator and DON acknowledged that staff should follow physician orders and document wound care completion or provide a note explaining why it was not done. The facility's failure to ensure proper documentation and adherence to physician orders for wound care and medication administration represents a significant deficiency in providing standard care to residents.
Significant Medication Errors Due to Lack of Documentation
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the lack of documentation for the administration of multiple medications for three residents. The facility's policies require that medications be administered as prescribed and documented immediately after administration. However, staff failed to document the administration of various medications, including those for critical conditions such as congestive heart failure, diabetes, and schizophrenia, for Residents #8, #9, and #5. Resident #8, who had a complex medical history including congestive heart failure, diabetes, and schizophrenia, had multiple instances where medications were not documented as administered. These included blood pressure medications, antipsychotics, and insulin, among others. The lack of documentation spanned several days and involved critical medications that required monitoring of vital signs, such as blood pressure and blood sugar levels, which were also not documented. Similarly, Resident #9, who was cognitively intact and had diagnoses including COPD and diabetes, had numerous instances of undocumented medication administration. This included antidiabetic medications, thyroid medications, and anticonvulsants. Resident #5, with a history of bacterial meningitis and sepsis, also had several undocumented doses of antibiotics and blood pressure medications. Interviews with facility staff confirmed that if a medication is not documented as given, it was possibly not administered, indicating a significant lapse in medication management and documentation practices.
Infection Control Lapses in Diabetes Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to proper hand hygiene and equipment sanitization protocols. Specifically, staff did not sanitize multi-use resident equipment between uses, did not place appropriate barriers for supplies, and failed to perform hand hygiene according to standards of practice while checking resident blood sugar levels and administering insulin. These deficiencies were observed in the care of four residents, all of whom had diabetes mellitus and were at risk for complications related to their condition. In one instance, an LPN was observed entering a resident's room to obtain a blood sugar reading without using a barrier for supplies, potentially contaminating the resident's table. The LPN also failed to perform hand hygiene after removing gloves and did not clean the glucometer before using it on another resident. Similar lapses were noted with other residents, where the LPN did not perform hand hygiene before or after resident contact, did not use gloves, and placed used equipment on surfaces without barriers, increasing the risk of cross-contamination. Interviews with staff, including CNAs, CMTs, and LPNs, revealed a lack of adherence to the facility's infection control policies. Staff acknowledged the importance of hand hygiene, using barriers, and cleaning equipment between uses, yet these practices were not consistently followed. The facility's administrator and DON also confirmed the expectations for hand hygiene and equipment sanitization, highlighting a disconnect between policy and practice.
Failure to Provide Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer care according to standards of practice for one resident. The resident, who was admitted for seven weeks of chemotherapy and radiation treatment, had a diagnosis that included a pressure ulcer in the sacral region. Despite having a physician's order to cleanse the coccyx wound with normal saline, apply Mepilex border, and change the dressing every three days or as needed, the staff did not document the completion of this treatment on several occasions, specifically on 12/05/24, 12/06/24, 12/07/24, 12/08/24, and 12/09/24. Additionally, the resident's care plan was not updated to include the pressure ulcer or the redness of the coccyx, which is a critical component of managing and preventing further deterioration of the wound. Interviews with the LPN and the facility's administrative staff confirmed that the staff should have followed the physician's orders for wound treatment and documented any changes or pertinent information regarding the wound. The failure to adhere to these protocols resulted in a deficiency in the care provided to the resident.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage and administration protocols, as evidenced by two main deficiencies. Firstly, a resident was observed with medication left at their bedside without a physician's order, which is against the facility's policy. The resident, who is cognitively intact and dependent on staff for various activities, reported that staff routinely left potassium supplements at their bedside for them to take later. Interviews with staff, including a Certified Medication Technician (CMT) and a Licensed Practical Nurse (LPN), confirmed that medications should not be left at the bedside and that there were no physician orders permitting such practice. Secondly, multiple observations revealed that medication carts were left unlocked and unattended, with medications accessible to unauthorized individuals. Specific instances included an Ozempic pen and insulin vials left on top of an unlocked cart, and several occasions where medication carts were left with drawers open and unattended. Staff interviews, including those with a CMT and the Administrator and Director of Nursing (DON), reiterated that medication carts should always be locked when not attended by authorized personnel.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for residents, as evidenced by multiple observations of unclean and disorganized conditions in various areas. On the 200 hall, a shower room was found with used towels, plastic gloves, and a bucket containing a rusty, dirty substance. The floor was soiled with an unknown substance. Similarly, the 600 hall shower room had a dirty spa tub with discolored water residue, stains, and bits of paper, along with a smear of dried substance resembling feces on the tub's edge. Used plastic gloves and paper towels were also found on the floor. Further observations revealed unsanitary conditions in other areas. The 500 hall shower room had a dirty whirlpool tub and brown/rusty stains on the shower walls. A resident's bathroom was found with soiled clothing and fecal matter on the floor, which had not been addressed by staff despite being reported. The 400 hall shower room had feces on a shower chair and dried fecal matter on the walls, with a noticeable odor. Additionally, the 300 hall shower room had rust/black substance around the shower tiles, a missing tile section, and feces under a shower chair. Interviews with housekeeping staff and supervisors indicated a lack of awareness and communication regarding the cleaning needs. Housekeepers followed a checklist but faced interruptions and were not always informed of priority cleaning situations. The Housekeeping Supervisor was unaware of specific issues, such as stains or rust in the showers, and there was no written policy for maintaining cleanliness. The facility's failure to provide sufficient housekeeping and maintenance services resulted in unsanitary conditions in resident access areas.
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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