Stonebridge Owensville
Inspection history, citations, penalties and survey trends for this long-term care facility in Owensville, Missouri.
- Location
- 1016 W Highway 28, Owensville, Missouri 65066
- CMS Provider Number
- 265670
- Inspections on file
- 22
- Latest survey
- November 26, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Stonebridge Owensville during CMS and state inspections, most recent first.
Staff failed to use a gait belt while transferring a resident who required substantial assistance, instead lifting the resident under the arms and by clothing, which resulted in a femur fracture. The facility's policies lacked clear direction on gait belt use, and staff interviews revealed inconsistent understanding of safe transfer procedures.
Staff failed to follow medication administration protocols when an LPN prepared insulin for one resident, but the ADON administered it to another resident who did not have a physician's order for insulin. The error was not documented in the medical record as required, and the incident was discovered when the resident's family questioned the insulin administration. Staff interviews confirmed the improper preparation and administration process, as well as the lack of documentation.
A resident ingested another resident's medications after a CMT left a cup of medications on top of the medication cart and became distracted by an LPN's request to check blood glucose. The resident, who was cognitively intact and independent, accessed and consumed medications not prescribed to them, including Haloperidol, Atorvastatin Calcium, and Clozaril. Facility policy required medications to be kept inaccessible and resident identity to be verified, but these procedures were not followed.
An LPN misappropriated a resident's Oxycodone and Lorazepam by removing medication cards from a locked narcotic box, failing to account for the medications, and discarding packaging, as confirmed by video footage and subsequent investigation. The resident, who was cognitively intact and receiving opioid and antianxiety medications for chronic pain, was discharged with fewer medications than documented, leading to the discovery of the deficiency.
Facility staff failed to maintain proper infection control practices during wound and incontinence care, and dietary staff did not adhere to hand hygiene protocols. An LPN placed wound care supplies on unclean surfaces, and both an LPN and a CNA did not change gloves or wash hands between tasks. Dietary staff washed hands inadequately, despite training. The DON and administrator confirmed the importance of proper hand hygiene and clean barriers.
The facility failed to complete baseline care plans within 48 hours for five residents, as required by policy. Interviews with staff, including the DON, an LPN, and the administrator, revealed confusion and lack of accountability regarding the completion of these plans. The admitting nurse was identified as responsible, but the plans were not completed, and nursing leadership was unaware of the issue.
The facility failed to develop comprehensive care plans for residents, neglecting to address critical needs such as oxygen therapy, contractures, PTSD, urinary catheter care, and pressure ulcer prevention. Observations and staff interviews revealed a lack of documentation and awareness, impacting the quality of care provided.
Facility staff failed to document medication administration for five residents, as required by policy. The MARs showed missing documentation for antibiotics, pain relief medications, and nutritional supplements. Interviews with a CMT, an LPN, and the DON confirmed that missing signatures indicate medications were either not given or not documented, potentially leading to incorrect dosages. Affected residents had conditions like osteomyelitis, arthritis, and cognitive impairment.
Facility staff failed to remove expired medications from medication carts and storage rooms. Observations revealed expired acetaminophen, nitroglycerin, and vaccines, among others. Interviews indicated inconsistent procedures for checking and removing expired medications, with staff unaware of the expired items.
A resident with a left hand contracture did not receive appropriate treatment to prevent further ROM decline. Despite hospital discharge notes recommending occupational therapy, the resident's care plan lacked documentation of the contracture and necessary interventions. Observations showed the resident's hand remained contracted without intervention, and staff interviews revealed a lack of awareness and action. The DON acknowledged the oversight, noting the contracture should have been care planned and communicated.
Failure to Use Gait Belt During Transfer Results in Resident Fracture
Penalty
Summary
Facility staff failed to safely transfer a resident, resulting in an accident and injury. Staff did not use a gait belt during the transfer, despite the facility's educational guide directing staff to always use a gait belt for safety. The resident, who was assessed as moderately cognitively intact and required substantial to maximal assistance with transfers, was being moved by two staff members who lifted the resident under the arms and by the clothing, rather than using a gait belt. During the transfer, a popping noise was heard, and the resident sustained a closed fracture of the left femur. The facility's policy on safe lifting and movement did not specify when to use a gait belt, and the resident's care plan did not provide direction regarding gait belt use during transfers. Interviews with staff revealed inconsistent understanding and implementation of safe transfer protocols. One CNA stated they were unsure if a gait belt was required and did not recall receiving in-service training on safe transfers, including during orientation. Other staff, including an LPN and the DON, confirmed that staff are directed to use a gait belt or other transfer equipment, and acknowledged the risk of injury when not using proper equipment. The incident report documented that the staff involved were counseled for not following fall protocol, which resulted in the resident's injury.
Medication Administration Error and Failure to Document
Penalty
Summary
Facility staff failed to administer medications as ordered by the physician when an LPN prepared insulin intended for one resident, but the ADON administered it to a different resident who did not have a physician's order for insulin. The medication administration policy required staff to verify the right resident, medication, dosage, time, and route before administration, and to document any medication errors in the clinical chart. However, the insulin was prepared for one resident and given to another, and there was no documentation of this medication error in the resident's medical record. The resident who received the insulin was assessed as cognitively intact and had diagnoses including Alzheimer's, hypothyroidism, congestive heart failure, schizophrenia, and diabetes mellitus type II, but did not have a current physician's order for insulin. The error was discovered when the resident's family questioned the administration of insulin, leading to notification of the physician. Interviews revealed that staff were aware of the error but failed to document it as required, and that medication preparation and administration were improperly split between staff due to staffing shortages.
Resident Ingests Another Resident's Medications Due to Medication Cart Error
Penalty
Summary
Facility staff failed to prevent an accident when a resident ingested another resident's medications. The incident occurred when a certified medication technician (CMT) was preparing medications for one resident and placed the cup of medications for a second resident on top of the medication cart. While the CMT was distracted by a request from an LPN to check the LPN's blood glucose, the first resident reached over, picked up the cup containing the second resident's medications, and ingested them. The facility's medication administration policy required staff to verify resident identity three times before administering medication, ensure the right medication, dosage, time, and route, and to keep medications inaccessible to residents by not leaving them on top of the cart. In this case, the CMT did not follow these procedures, as the medications were left on top of the cart and accessible to residents, and the CMT was distracted by another task during medication administration. The resident who ingested the wrong medications was assessed as cognitively intact and independent with ambulation. The medications ingested included Haloperidol, Atorvastatin Calcium, and Clozaril, none of which were ordered for this resident. Following the ingestion, staff assessed the resident, monitored vital signs, and notified the appropriate medical personnel.
Misappropriation of Resident's Controlled Medications by LPN
Penalty
Summary
Facility staff failed to prevent the misappropriation of a resident's controlled medications when an LPN removed and failed to account for a significant quantity of Oxycodone and Lorazepam. The resident, who was assessed as cognitively intact and experiencing chronic pain with an intensity level of seven, had an active order for Oxycodone-Acetaminophen but no documented order for Lorazepam. Pharmacy records indicated that 120 tablets of Oxycodone were delivered, and upon discharge, staff documented releasing 49 tablets of Oxycodone and 25 tablets of Lorazepam to the resident. Subsequent investigation revealed discrepancies in the medication count and missing medications after the resident's discharge. Video footage showed the LPN removing three medication cards from a locked narcotic box, placing them in the medication cart, and then leaving the medication room with a full card and the medication sign-out sheet. The LPN was later observed disposing of items in a shred bin and trash, which were later identified as the top of the medication card and an empty medication card, respectively. The incident was brought to the facility's attention when the resident's spouse reported missing medications. The DON and administrator reviewed the video footage and confirmed the LPN's actions, which were also documented in a police report. The facility's policy clearly prohibits misappropriation of resident property, including medications, and directs staff to protect residents from such actions by anyone, including facility staff.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility staff failed to maintain proper infection prevention and control practices during wound care and incontinence care for several residents. Specifically, an LPN was observed placing wound care supplies directly on the beds of two residents without establishing a clean field, as required by the facility's policy. In one instance, the supplies were placed on a urine-soaked bed. The LPN acknowledged that supplies should be placed on a clean surface, such as a bedside table, but noted that these tables are often cluttered and inaccessible. Interviews with the Director of Nursing (DON) and the administrator confirmed that wound care supplies should always be placed on a clean barrier. Additionally, the facility staff did not adhere to approved hand hygiene practices during incontinence care. An LPN was observed failing to wash hands or change gloves between dirty and clean tasks while providing perineal care to a resident. Similarly, a CNA did not change gloves or wash hands after handling soiled linens and before touching clean items. Both staff members acknowledged the lapse in proper hand hygiene, and the DON and administrator reiterated the importance of washing hands and changing gloves between tasks to prevent infection. The dietary staff also failed to perform hand hygiene as often as necessary during food preparation and service. Several dietary aides and a cook were observed washing their hands inadequately, scrubbing for only a few seconds, and turning off faucets with bare hands. Despite being trained on proper handwashing techniques, staff admitted to rushing and not following the correct procedures. The Certified Dietary Manager and the administrator confirmed that staff should wash their hands for at least 20 seconds and use a towel to turn off the faucet, highlighting a gap between training and practice.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete baseline care plans within 48 hours of admission for five residents out of a sample of 25, as required by their policy. The policy, dated December 2016, mandates that a baseline care plan be developed to meet the resident's immediate needs within 48 hours of admission. This plan is intended to be used until a comprehensive assessment and an interdisciplinary person-centered care plan can be developed. However, the medical records for Residents #1, #2, #6, #28, and #65 did not contain these baseline care plans, indicating a lapse in adherence to the policy. Interviews with facility staff, including the Director of Nursing (DON), Licensed Practical Nurse (LPN) S, and the administrator, revealed a lack of clarity and accountability regarding the completion of baseline care plans. The DON acknowledged that the baseline care plans should be completed by the admitting nurse as part of the admission process, but noted that the Assistant Director of Nursing (ADON) had been unable to conduct recent chart reviews. LPN S mentioned that baseline care plans are typically completed and reviewed with the medical chart or primary care and family, but was unsure of who was responsible for ensuring their completion. The administrator, who had been at the facility for five months, also stated that the admitting nurse is responsible for completing the care plan, with nursing leadership ensuring its completion, but was unaware of the missing care plans.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their specific medical and psychosocial needs. For Resident #14, the care plan did not include necessary interventions for oxygen use despite the resident having a diagnosis of respiratory failure and COPD. Observations showed the resident's oxygen concentrator was not being used properly, and interviews with staff revealed a lack of documentation and awareness regarding the resident's oxygen therapy needs. Resident #64's care plan failed to address the resident's contractures, despite observations of the resident's left hand being contracted and causing pain. Interviews with staff indicated that contractures should be documented in the care plan to guide care, but this was not done. Similarly, the care plans for Residents #66, #71, #1, and #17 did not include interventions for their PTSD diagnoses, leaving staff unaware of potential triggers and behaviors to monitor. Additionally, Resident #2's care plan did not include specific instructions for urinary catheter care, leading to inconsistent care practices. Resident #65's care plan lacked details on pressure ulcer prevention and the management of an external fixator, which are critical for the resident's mobility and skin integrity. Interviews with staff and the Director of Nursing highlighted the absence of these essential care components in the care plans, which are necessary for providing appropriate and individualized care to the residents.
Medication Administration Documentation Deficiency
Penalty
Summary
The facility staff failed to document the administration of medications for five residents, as required by the facility's policy. The policy mandates that a Nurse or Medication Aide must document all medications administered to each resident on the Medication Administration Record (MAR) immediately after administration, including the signature and title of the person administering the medication. However, the MARs for several residents showed missing documentation for various medications, including antibiotics, pain relief medications, and nutritional supplements, on multiple occasions throughout August 2024. Interviews with facility staff, including a Certified Medication Technician (CMT), a Licensed Practical Nurse (LPN), and the Director of Nursing (DON), confirmed that the absence of a signature on the MAR indicates that the medication was either not administered or not documented. This lack of documentation could potentially lead to residents receiving incorrect dosages. The residents affected by this deficiency had various medical conditions, such as osteomyelitis, arthritis, severe cognitive impairment, and stroke, which required consistent medication management.
Expired Medications Found in Facility
Penalty
Summary
The facility staff failed to remove and destroy expired medications and biologicals in two of four sampled medication carts and one of two medication rooms. Observations revealed that the charge nurse's medication cart contained expired liquid pain relief acetaminophen, and the 400 hall medication cart contained several expired items, including lubricant eye gel, nitroglycerin, fecal occult blood test developing solution, laxative tablets, and a dressing change kit. Additionally, the medication storage room was found to contain expired Novolog insulin Flex Pen and prefilled syringes of influenza vaccines. Interviews with facility staff indicated a lack of consistent procedures for checking and removing expired medications. A Certified Medication Technician mentioned that pharmacy staff used to check for expired medications but no longer do so. The Licensed Practical Nurse stated that nurses and CMTs are supposed to check for expired medications weekly but was unaware of any expired items. The Director of Nursing mentioned that the pharmacist conducts monthly cart audits and that any nurse can dispose of expired medications, yet was unaware of the expired items found during the survey. This lack of awareness and inconsistent practices contributed to the presence of expired medications in the facility.
Failure to Address Resident's Contracture and ROM Needs
Penalty
Summary
The facility staff failed to provide appropriate treatment and services to prevent further decrease in range of motion (ROM) for a resident with a contracture in the left hand. The facility's policy required that residents with limited ROM receive treatment to prevent further decline, and that care plans include specific interventions and therapies. However, the resident's care plan did not document the contracture, goals, or interventions, despite the resident's hospital discharge documentation indicating the need for occupational therapy focused on contracture prevention. Observations over several days showed the resident's left hand remained contracted without any intervention, such as a washcloth, which the resident reported as helpful. Interviews with staff, including CNAs and LPNs, revealed a lack of awareness and action regarding the resident's contracture. Staff did not perform ROM exercises or provide any therapy, and there was no communication or documentation in the care plan regarding the contracture. The Director of Nursing (DON) acknowledged the oversight, stating that the contracture should have been included in the care plan and communicated to the MDS Coordinator. The DON also noted that physical therapy determines who receives restorative services, but there was no indication that the resident had been evaluated for such services. The lack of documentation and communication led to the resident not receiving necessary interventions for the contracture.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
