Superior Manor Of Festus, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Festus, Missouri.
- Location
- 12827 State Rd Highway Tt, Festus, Missouri 63028
- CMS Provider Number
- 265884
- Inspections on file
- 8
- Latest survey
- May 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Superior Manor Of Festus, Llc during CMS and state inspections, most recent first.
A resident with multiple diagnoses was verbally and physically abused by a dietary staff member during a smoke break. The staff member used derogatory language and excessive force on the resident's wheelchair, violating the facility's abuse policy. Witnesses confirmed the incident, and the staff member was removed from the facility.
The facility failed to check the NA Registry for five employees before hiring, as required by policy, potentially compromising resident safety. The Administrator confirmed that these checks should occur before hiring and quarterly thereafter.
The facility failed to provide a safe, clean, comfortable, and homelike environment, with surveyors noting persistent foul odors, damaged and dirty rooms, and inadequate housekeeping and maintenance practices. Housekeeping staff reported supply shortages and reduced hours, while nursing staff were uncertain about the maintenance of oxygen concentrators.
The facility failed to ensure that two CNAs received the required 12 hours of annual training. The facility assessment had not been updated since 2022, and there was no documentation of in-services related to the facility assessment and annual review. Both CNAs confirmed they had not received training on critical topics such as abuse/neglect, Alzheimer's, dementia, or behavioral health.
The facility failed to store and distribute food under sanitary conditions, leading to potential cross-contamination and food-borne illness risks. Observations revealed issues such as unlabeled and undated food items, improper hygiene practices by dietary staff, and a lack of cleanliness in the kitchen. Interviews confirmed these deficiencies, with the Dietary Manager admitting to the kitchen's poor state and the Administrator acknowledging unmet standards.
The facility failed to ensure the facility assessment was complete and reviewed annually. The assessment, dated 08/30/22, showed a census of only two residents, which did not reflect the current census of 49 residents. Additionally, the assessment was not updated to reflect the current resident needs and was not reviewed annually. There was no documentation that the QAA and QAPI committee reviewed the facility assessment. The Administrator acknowledged that the facility assessment should reflect the resident population and their needs and be updated annually.
The facility failed to develop a QAPI Plan, which is essential for guiding efforts in maintaining and improving care and services. The facility census was 49. The Regional Nurse could not find any documentation of a QAPI Plan, and the Administrator expected the facility to implement such a program with policies and procedures for data collection and monitoring.
The facility failed to ensure the QAA/QAPI committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. The facility did not provide a policy for a QAPI Plan or PIPs, and there was no documentation of maintaining the required documentation for a QAPI plan or PIPs. The Regional Nurse and Administrator confirmed the absence of a QAPI Plan and PIPs.
The facility failed to maintain quarterly QAPI committee meetings with the required members. The facility did not provide any policy or documentation related to QAPI, and there was no evidence of the required quarterly QAA meetings. Interviews with the Regional Nurse and Administrator confirmed the lack of QAPI activities.
The facility failed to maintain proper infection control practices, including improper glove changes, inadequate cleaning of a glucometer, lack of TB testing, and insufficient Legionella monitoring. An RN used soiled gloves for multiple tasks, and an ice scoop was improperly sanitized after falling on the floor.
The facility failed to ensure that the Infection Preventionist (IP) had completed specialized training in infection prevention and control, potentially affecting all 49 residents. The RN performing IP duties could not provide certification, and the Administrator and DON acknowledged the deficiency.
The facility failed to provide behavioral health training for nine staff members hired in the last year, despite having residents with significant behavioral health diagnoses. Interviews and record reviews confirmed the lack of training, and the Administrator and DON acknowledged the deficiency.
The facility failed to ensure resident funds were placed in a separate account from the operating account and did not provide timely refunds. One resident could not access funds for personal items, and housekeepers had to use personal money to assist. The facility also did not keep Medicaid resident funds over $50 in an interest-bearing account, and there were discrepancies in petty cash balances.
The facility failed to manage resident trust fund accounts according to proper accounting principles, including not reconciling accounts monthly, not maintaining accurate transaction records, and not providing quarterly statements. Additionally, resident petty cash was commingled with facility petty cash, and funds were transferred without proper documentation.
The facility failed to notify a resident when their trust account balance reached $200 less than the SSI resource limit. The Temporary Administrator/Business Office Manager admitted to not monitoring or notifying residents about their account balances, leading to a deficiency in compliance with facility policies.
The facility failed to maintain a sufficient surety bond to protect resident funds, with an average monthly balance of $11,894.63 and a bond of only $1,000.00, insufficient by $30,500.00. The Temporary Administrator/Business Office Manager was unsure about the correct method for determining the bond amount.
The facility failed to complete comprehensive MDS assessments within the required time frames for multiple residents. The assessments and CAAs were not completed within 14 days of admission, as mandated by federal regulations. The MDS Coordinator and Administrator acknowledged the delays and the absence of a current MDS Coordinator.
The facility failed to complete quarterly MDS assessments within the required 92-day timeframe for seven residents. The new MDS Coordinator found the assessments significantly behind schedule and had to code many items as not assessed due to missing information. The Administrator acknowledged the issue and stated that there was currently no MDS Coordinator for the facility.
The facility failed to transmit MDS assessments within the required 14-day period for ten residents, leading to significant delays in compliance with state and federal regulations. Staff interviews revealed that the MDS Coordinator position had been inadequately staffed, contributing to the backlog.
The facility failed to develop and implement comprehensive care plans for four residents, resulting in unaddressed CAAs and improper use of restraints. Diagnoses included diabetes, GERD, schizophrenia, dementia, and more, but care plans did not reflect these conditions accurately.
The facility failed to ensure sufficient nursing staff to meet the needs of its 49 residents, many of whom had complex medical and mental health diagnoses. The outdated facility assessment and reduced staffing levels led to long wait times for assistance, delayed medication administration, and insufficient care during the night. Both residents and staff expressed concerns about safety and quality of care.
The facility failed to implement procedures to ensure medications were accurately administered, documented, not expired, and reconciled for the Emergency Medication Kit (E-Kit). Observations revealed that the E-Kit was not locked with the required tags, and numerous medications were expired. Interviews with staff and pharmacy consultants confirmed that the facility did not have a process in place for monitoring and discarding expired medications, leading to several unaccounted-for narcotic medications.
The facility failed to securely store medications and monitor expired medications. A resident was found to have multiple pills on the bedside table without a physician's order for self-administration. Additionally, medication carts were frequently left unlocked and unattended, and expired medications were found in both the medication carts and storage room.
The facility failed to provide a dining room large enough to accommodate all residents, leading to congestion and insufficient seating, especially for those in wheelchairs. Staff and residents reported issues with space, and some residents had to sit in non-dining areas. Despite these concerns, the administration believed the dining area was adequate.
The facility failed to provide SNF ABN and NOMNC forms to two residents discharged from Medicare Part A services with benefit days remaining. Staff interviews revealed a lack of clarity and responsibility regarding the issuance of these forms, and the facility did not have a policy in place for this process.
The facility failed to assess and document the use of a lap tray for a resident, leading to its use as a physical restraint without appropriate justification or consent. The resident, with severe cognitive impairment and hemiparesis, was observed multiple times unable to remove the lap tray. The facility did not follow its policies on restraint assessment, documentation, and consent.
The facility failed to notify residents and/or their representatives in writing of transfers or discharges to a hospital, including the reasons for the transfer, and did not notify the Office of the State Long-Term Care Ombudsman. This deficiency was identified for multiple residents, and the Director of Nursing acknowledged the lack of required documentation.
The facility failed to inform residents and/or their legal representatives in writing of their bed hold policy during hospital transfers. Interviews revealed that the policy was communicated verbally, and no written documentation was provided, leading to the identified deficiency.
The facility failed to document accurate MDS assessments for five residents, leading to omissions and inaccuracies in diagnoses and treatments. The MDS Coordinator admitted to coding items as not assessed due to a backlog and lack of information.
The facility failed to provide a Level I PASARR for two residents admitted with mental health and intellectual disorder diagnoses. The DON confirmed the absence of PASARR documentation and stated that all residents should be screened before admission, especially those transferred from a closed facility.
The facility failed to implement baseline care plans within 48 hours of admission for five residents with various medical conditions. The baseline care plans were either not completed on time or were missing, and there was no documentation that the residents or their representatives received a written summary. Interviews revealed a lack of clarity and training on the requirements for new admissions.
The facility failed to develop comprehensive care plans within the required timeframe for six residents with various diagnoses, leading to incomplete assessments and care plans. The MDS and care plan coordinator reported significant delays, and the Administrator and DON confirmed the expectation for timely updates.
The facility failed to follow physician's orders for six residents, leading to various deficiencies in care. Issues included incorrect administration of nutritional supplements, failure to provide prescribed medications, lack of necessary suctioning, and improper use of wound vac equipment. The deficiencies were acknowledged by the DON and Administrator.
The facility failed to complete a comprehensive discharge summary for a resident. The policy requires a detailed discharge summary to be written and reviewed with the resident and family. However, for one resident, there was no documentation of a discharge summary. Interviews with the DON and ADON confirmed the absence of the discharge summary and the failure to chart the recapitulation of stay.
A facility failed to provide necessary care for a resident receiving chemotherapy, resulting in a malfunctioning infusion pump and medication leakage. Staff lacked training on managing chemotherapy and did not communicate with the infusion center, leading to potential harm to the resident.
The facility failed to ensure that the RD's recommendations for a resident's weight loss were communicated to the physician, resulting in inadequate nutritional management. The resident experienced significant weight fluctuations, and despite the RD's recommendations for interventions, these were not implemented. The DON acknowledged the communication gap and the lack of established protocols to address the issue.
The facility failed to ensure that residents diagnosed with dementia had personalized care plans to promote their highest level of functioning and psychosocial needs. Three residents with dementia did not have care plans addressing their condition, and observations showed them either unresponsive or inactive. Interviews revealed that the facility lacked a dementia policy and that MDS assessments were significantly behind schedule.
The facility failed to attempt a gradual dose reduction (GDR) for two residents on psychotropic medications, with no documentation of GDR attempts or contraindications. Observations showed one resident often unresponsive in bed and another pacing the hall and wearing the same suit for consecutive days. Interviews confirmed that GDRs should be attempted or documented as contraindicated, but this was not done.
The facility failed to maintain a medication error rate of five percent or less, resulting in a 14.29% error rate. Two residents experienced improper medication administration, including the crushing of medications that should not be crushed and issues with g-tube administration. Staff interviews revealed a lack of training and resources, contributing to the errors.
The facility failed to provide appealing alternative meal options of similar nutritive value to residents who chose not to eat the food initially served. Observations and interviews revealed that residents could only get a sandwich or cereal if they did not like the meal served, and the facility's rotating menu did not include alternative options.
The facility failed to ensure dumpsters were closed and maintained to keep pests out and garbage contained. Observations showed open dumpster lids with visible garbage. Staff interviews revealed that dumpsters were not emptied frequently enough, leading to overfilled dumpsters that could not be closed properly. The Administrator and DON confirmed that they expected the lids to be closed after trash disposal.
The facility failed to provide and document that residents received or declined appropriate immunizations for influenza and pneumonia. Five residents had no records indicating they were informed about or received the vaccinations, nor were there any records of refusals or contraindications. Interviews with the ADON and DON confirmed the lack of documentation and administration of the vaccines.
The facility failed to ensure that the COVID-19 vaccination was offered, administered, or refused by three residents. Medical records showed no documentation of education regarding the COVID-19 vaccination, nor any record of the vaccine being provided or refused. Interviews with the DON and Administrator confirmed the lack of documentation and the absence of a COVID-19 vaccination policy.
The facility failed to provide a safe environment by allowing items to be stored on overbed light fixtures in three rooms, creating a hazard of items potentially falling on residents. Observations included various items such as bottles, books, cards, and a foam cup placed on the light fixtures. The DON and Administrator acknowledged the potential hazard, and no policy for overbed lighting safety was provided.
The facility failed to ensure an effective training program for all new and existing staff members. The facility assessment had not been reviewed since 2022, and there was no evidence of a training schedule or tracking system. Interviews with the Administrator and DON revealed a lack of awareness regarding required training and tracking responsibilities.
The facility failed to provide required abuse and neglect training for five CNAs and one CMT hired in the last year. Employee files lacked documentation of this training, and staff interviews confirmed the absence of such training. The Administrator and DON acknowledged the deficiency and were compiling a list of necessary in-services and training.
The facility failed to provide the required twelve hours of annual in-service education and annual competencies in abuse prevention and dementia care for two CNAs. CNA K and CNA R did not receive the necessary training, and the Administrator and DON acknowledged the deficiency, stating that they were compiling a list of required in-services and training.
Verbal and Physical Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, resulting in a deficiency. The incident involved a resident who was cognitively intact and had multiple diagnoses, including schizophrenia, bipolar disorder, traumatic brain dysfunction, moderate protein calorie malnutrition, hypertension, and diabetes mellitus II. The resident became upset when a dietary staff member did not provide a cigarette quickly enough during a smoke break, leading to a verbal altercation. The facility's administrator witnessed the altercation and instructed the staff member to walk away. However, the staff member returned and continued the argument, using excessive force to jerk the resident's wheelchair. Witnesses, including CNAs, reported that the staff member used derogatory language and physically manipulated the resident's wheelchair in a rough manner. The staff member's actions were in direct violation of the facility's abuse policy, which prohibits verbal and physical abuse. The facility's investigation confirmed the staff member's inappropriate behavior, and the administrator took immediate action by removing the staff member from the facility. The staff member had previously signed the facility's abuse inservice policy, indicating awareness of the rules against abuse. Despite this, the staff member engaged in behavior that compromised the resident's right to be free from abuse, leading to the deficiency finding.
Failure to Check NA Registry Before Hiring Staff
Penalty
Summary
The facility failed to ensure that the Nurse Aide (NA) Registry was checked prior to hiring five employees, which included Dietary Staff A, a Registered Nurse (RN) F, an Activity Director G, a Housekeeping Supervisor H, and a Maintenance Supervisor I. This oversight was identified during an interview and record review, where it was found that there was no documentation indicating that the NA Registry was checked for these employees before their hire dates. The facility's policy, revised in January 2008, requires the Human Resources (HR) Director to conduct background investigations, including checking the NA Registry, to ensure applicants do not have a Federal Indicator for abuse or neglect. The Administrator confirmed during an interview that NA Registry checks should be completed on any new employee before they are hired and repeated quarterly. However, the personnel records for the five employees sampled showed no evidence of such checks being conducted prior to their employment. The facility's census at the time was 46, and the failure to adhere to the hiring policy potentially compromised the safety and well-being of the residents by not ensuring that employees were free from any history of abuse or neglect.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment, as evidenced by multiple observations of unsanitary and unsafe conditions. Surveyors noted a persistent musty and foul odor of urine and fecal material in the 100 and 200 Halls. Numerous rooms had visible damage, including scratches and holes in the drywall, broken drawers, and hanging vent covers. Additionally, floors in several rooms and hallways were sticky and littered with food particles, dirt, and other debris. Specific rooms had strong urine smells, and one room had a small medication cup with an unidentified yellow liquid that remained unattended for several days. The courtyard was also found to be in disrepair, with broken furniture and numerous cigarette butts scattered around the area. An oxygen concentrator used for multiple residents was observed with significant debris and lint on its filters, indicating a lack of proper maintenance and cleaning. The facility's shower rooms were also found to be in poor condition, with dirt, debris, mold-like substances, and various items left unattended. The Resident Council Meeting Minutes from March 2024 revealed that residents had voiced concerns about inadequate room cleaning and unmade beds. Housekeeping staff reported that their hours had been cut, and they had experienced multiple instances of missed supply orders due to unpaid bills. This resulted in rationing supplies and an inability to adequately perform their duties. Housekeeping staff also mentioned that they were instructed by the owner to limit their cleaning tasks to sweeping and mopping, and to avoid using chemicals on painted floors due to a reaction with the paint. Interviews with housekeeping staff and the Administrator confirmed that the facility had been without laundry help for an extended period, leading to further strain on housekeeping duties. Nursing staff were expected to clean and maintain oxygen concentrators, but there was uncertainty about the frequency of these tasks. The Administrator stated that maintenance tasks were prioritized based on need and importance, but the overall condition of the facility indicated a lack of timely and effective maintenance.
Failure to Provide Required Annual Training for CNAs
Penalty
Summary
The facility failed to ensure that two Certified Nurse Assistants (CNAs), identified as CNA K and CNA R, received the required 12 hours of annual training. The facility, which had a census of 49 residents, did not provide a policy regarding annual training. The facility assessment had not been reviewed since 2022, when the facility had only two residents. The assessment should have included staff competencies and annual training requirements on various topics such as abuse, neglect, exploitation, advance directives, behavioral health, communication, compliance and ethics, CPR, dementia care management, equipment and assistive device training, infection control, emergency preparedness, facility policies and procedures, resident rights, and assessing nutritional needs for individuals with mental illness, intellectual disability, or developmental delays. Review of CNA K's and CNA R's employee files showed no documentation of in-services related to the facility assessment and annual review. During interviews, both CNAs confirmed they had not received annual training on critical topics such as abuse/neglect, Alzheimer's, dementia, or behavioral health. The Director of Nursing (DON) and the Administrator acknowledged the lack of documentation and stated that they were in the process of compiling a list of necessary in-services and trainings. The Administrator also noted that the facility assessment should reflect the resident population and their needs, and that annual trainings should align with this assessment.
Facility Fails to Maintain Sanitary Food Storage and Handling Conditions
Penalty
Summary
The facility failed to store and distribute food under sanitary conditions, which increased the risk of cross-contamination and food-borne illness. Observations revealed multiple issues, including a significant buildup of frost/ice in the freezer, unlabeled and undated food items, and unwrapped vegetables directly on refrigerator shelves. The dry food storage room contained various items on the floor, scattered dirt and debris, and multiple unlabeled or undated food items. The kitchen itself was found to be in a state of disrepair, with grime buildup on equipment, debris on floors and surfaces, and improperly stored utensils and cookware. The dietary staff did not follow proper hygiene protocols, such as sanitizing hands or changing gloves between tasks, and wearing appropriate hair restraints. Observations showed staff handling food with soiled gloves, not covering their hair or beards properly, and leaving food uncovered while waiting to be served. Additionally, the facility lacked a policy for managing food brought in from outside, and there were no logs maintained for steam table temperatures for the past eleven months. Interviews with the Dietary Manager (DM) and other staff confirmed these deficiencies. The DM admitted to knowing the kitchen was dirty but cited a lack of time to clean it. The Administrator acknowledged the expectations for food storage, cleanliness, and staff hygiene but noted that these standards were not being met. The facility's failure to maintain sanitary conditions and proper food handling practices had the potential to affect all residents served by the kitchen.
Incomplete and Outdated Facility Assessment
Penalty
Summary
The facility failed to ensure the facility assessment was complete and reviewed annually. The assessment, dated 08/30/22, showed a census of only two residents, which did not reflect the current census of 49 residents. Additionally, the assessment was not updated to reflect the current resident needs and was not reviewed annually. There was no documentation that the Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee reviewed the facility assessment. During an interview, the Administrator acknowledged that the facility assessment should reflect the resident population and their needs and be updated annually.
Failure to Develop a QAPI Plan
Penalty
Summary
The facility failed to develop a Quality Assurance and Performance Improvement Plan (QAPI), which is a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved. The facility census was 49. Review showed the facility did not have a QAPI plan containing the necessary policies and protocols describing how they will identify and correct their quality deficiencies, track and measure performance, and establish goals and thresholds for performance measurement. During an interview, the Regional Nurse was unable to find any documentation that the facility had a QAPI Plan and did not believe the facility had been doing anything related to QAPI. The Administrator also stated that she would expect the facility to implement a QAPI Program and Plan with policies and procedures for data collection and monitoring.
Failure to Implement QAPI Plan
Penalty
Summary
The facility failed to ensure the Quality Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. The facility census was 49. The facility did not provide a policy for a QAPI Plan or Performance Improvement Plans (PIPs). Review showed no documentation that the facility maintained the minimum required documentation for a QAPI plan or PIPs. During an interview, the Regional Nurse was unable to find any documentation that the facility had a QAPI Plan or PIPs in place and did not believe the facility had been doing anything related to QAPI. The Administrator also stated that she would expect the facility to have a QAPI Plan in place and implement PIPs to address identified issues.
Failure to Maintain Quarterly QAPI Meetings
Penalty
Summary
The facility failed to maintain quarterly Quality Assurance and Improvement Program (QAPI) committee meetings with the required members. The facility census was 49. The facility did not provide a policy or any documentation related to QAPI. Review showed no documentation that the facility maintained the minimum required quarterly QAA meetings with the required members. During an interview, the Regional Nurse stated that he/she was unable to find any documentation that the facility had any QAPI meetings and did not believe the facility had been doing anything related to QAPI. The Administrator also stated that she would expect the facility to have QAPI meetings at least quarterly with the required members present.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices in several instances. During wound care for a resident, an RN used soiled gloves to handle various items, including wound dressings, a spray bottle, and personal items like a cell phone. The RN did not change gloves or wash hands between tasks, leading to potential cross-contamination. The RN also failed to use barriers under the resident's legs and did not clean scissors between uses, further compromising infection control standards. In another instance, the facility did not properly clean and disinfect a glucometer between resident uses. An RN cleaned the glucometer for only five seconds instead of the recommended 30 seconds to a minute, and did not allow it to air dry for the required time. Additionally, the RN did not wash hands before and after checking blood sugar levels and changing gloves, which is against the facility's policy. The facility also failed to implement a risk management process for Legionella disease and did not have a water management program in place. There was no documentation of TB testing or screening for two residents, and the facility lacked sufficient tuberculin for testing. Furthermore, an ice scoop that had fallen on the floor was rinsed with water and placed back into the clean ice container without proper sanitization, posing a risk of contamination.
Lack of Specialized Training for Infection Preventionist
Penalty
Summary
The facility failed to ensure that at least one person had completed specialized training in infection prevention and control for the Infection Preventionist (IP) position. This deficiency had the potential to affect all 49 residents in the facility. The facility's policy outlined that the Infection Control Nurse should stay informed of relevant health regulations, direct and maintain an infection control program, contribute to inservices and staff meetings, monitor immunizations, and act as the facility's IP. However, the facility did not provide documentation for any staff members who had completed the specialized training required for the IP position. During an interview, a Registered Nurse (RN) who was performing the IP duties stated that they thought the certification had been completed but did not have the certificate to prove it. The Administrator and Director of Nursing (DON) confirmed that they would expect to have an IP with the appropriate qualifications and certification, but acknowledged that the RN currently holding the IP position did not have the necessary documentation to confirm their specialized training.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide behavioral health training for nine out of nine sampled staff hired in the last year, despite having a census of 49 residents, many of whom had significant behavioral health diagnoses. The medical diagnoses of the residents included schizophrenia, bipolar disorder, anxiety, depression, schizoaffective disorder, history of suicide attempts or suicidal ideations, agoraphobia, neurocognitive disorder with Lewy bodies, personality disorders, PTSD, psychosis, and disruptive mood dysregulation disorder. The lack of behavioral health training was confirmed through interviews and record reviews, which showed no documentation of such training in the employee files of the sampled staff. During interviews, several staff members, including a Certified Medication Technician (CMT) and multiple Certified Nursing Assistants (CNAs), confirmed that they had not received any behavioral health training since being employed at the facility. The Administrator and Director of Nursing (DON) acknowledged the deficiency, stating that they were in the process of compiling a list of in-services and training that needed to be done, as it had not been completed. The facility also failed to provide a policy regarding behavioral health training, further highlighting the gap in compliance with regulatory requirements.
Failure to Properly Manage Resident Funds
Penalty
Summary
The facility failed to ensure resident funds were placed in an account separate from the facility operating account and did not provide residents with refunds of their personal funds in a timely manner. This affected six residents, with amounts ranging from $35 to $3,685 held in the operating account. Additionally, one resident reported not being able to access their funds to purchase personal items and was only given partial amounts when requesting money. Housekeepers had to use their personal money to purchase underwear for this resident due to a lack of resident trust petty cash. The facility's process for accessing funds was limited to weekdays and required approval, causing delays and inconvenience for residents needing money during evenings or weekends. The facility also failed to keep resident funds over $50 for Medicaid recipients in an interest-bearing account, as evidenced by one resident having $200 in petty cash, which was $150 more than allowed. The facility's bank statements showed that interest was not accrued in the resident trust account. The Temporary Administrator/Business Office Manager was unaware of how interest was paid to each resident and could not explain discrepancies in the petty cash balance. These deficiencies indicate a lack of proper management and oversight of resident funds, potentially affecting all residents whose funds were managed by the facility.
Failure to Properly Manage Resident Trust Fund Accounts
Penalty
Summary
The facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles. Specifically, the facility did not reconcile the resident trust fund account monthly, did not maintain accurate accounting records for each transaction, and failed to provide quarterly resident trust statements. Additionally, the facility commingled resident petty cash with facility petty cash. These deficiencies affected 46 residents out of a census of 49. The facility's bank statements from February 2023 through March 2024 showed no documentation of reconciliations, and the Owner confirmed that reconciliations were not completed. The Temporary Administrator/Business Office Manager admitted to balancing the books only as needed and was unaware of the status of previous petty cash logs or the reasons for discrepancies in the petty cash balance. Further, the facility did not provide quarterly reports of transactions to residents as required. The Owner and the Temporary Administrator/Business Office Manager both confirmed that resident trust statements were not provided. Additionally, facility staff transferred resident funds from the resident petty cash to the facility petty cash box on at least two occasions, totaling $900, without proper documentation or receipts. The Temporary Administrator/Business Office Manager acknowledged these transfers but could not provide a valid reason or documentation for them.
Failure to Notify Resident of Trust Account Balance
Penalty
Summary
The facility failed to notify a resident when their trust account balance reached $200 less than the Supplemental Security Income (SSI) resource limit. Specifically, Resident #22's account balance was consistently above the threshold from 02/15/24 through 04/04/24, but no notification was provided. The facility managed funds for 46 out of 49 residents, indicating a systemic issue in monitoring and notifying residents about their account balances. During interviews, the Temporary Administrator/Business Office Manager admitted that they were supposed to write a list of residents needing notification for spend-down but had not done so. The manager also revealed that they did not have access to view resident account balances until recently and that no resident notices had been sent out. This lack of action and oversight led to the deficiency in notifying Resident #22 about their account balance, as required by the facility's policies and regulations.
Insufficient Surety Bond for Resident Funds
Penalty
Summary
The facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility's Resident Trust Bank Statements for the period from April 2023 through March 2024 showed an average monthly balance of $11,894.63, and the Accounts Receivable Aging Report dated April 8, 2024, indicated a balance of resident funds amounting to $9,577.14. However, the Department of Health and Senior Services approved bond list revealed that the facility only had a $1,000.00 approved bond, which was insufficient by $30,500.00. During interviews, the Temporary Administrator/Business Office Manager admitted to being unsure about the correct method for determining the bond amount and acknowledged that the bond should be sufficient to cover the resident funds.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required time frames for 10 residents out of 13 sampled residents and two additional residents outside the sample. The MDS assessments and Care Area Assessments (CAAs) were not completed within 14 days of admission as mandated by federal regulations. This deficiency was observed in the medical records of residents who were admitted on various dates, with the MDS and CAA completion dates significantly delayed beyond the required timeframe. The facility's policy, as outlined in the MDS Coordinator's job description, mandates tracking and scheduling required resident assessments, completing all MDS assessments and CAAs, and ensuring compliance with state and federal requirements. However, the review of the medical records showed that none of the sampled residents had their comprehensive admission MDS assessments and CAAs completed within the stipulated 14 days of admission. This lapse in timely assessment was confirmed through interviews with the MDS Coordinator and the facility Administrator. During interviews, the MDS Coordinator acknowledged that the MDS assessments were significantly behind schedule when they started in March 2024. The Coordinator had to code many items as not assessed due to missing information and had to rely on assistance from nursing staff and the Social Services Designee to complete the assessments. The Administrator confirmed the expectation for timely and accurate MDS assessments per the RAI Manual and acknowledged the absence of a current MDS Coordinator for the facility.
Failure to Complete Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required 92-day timeframe for seven residents out of 13 sampled residents. The residents affected were identified as Residents #2, #18, #32, #33, #38, #40, and #42. The review of the facility's policy and the Resident Assessment Instrument (RAI) Manual indicated that the MDS assessments were not completed timely, which is a requirement to monitor residents' status and ensure quality care. Specific instances included Resident #2's quarterly MDS assessment being in progress beyond the 92-day limit, and similar delays were noted for the other residents mentioned. Interviews with the MDS Coordinator and the Administrator revealed that the MDS assessments were significantly behind schedule when the new MDS Coordinator started in March 2024. The MDS Coordinator had to code many items as not assessed due to missing information and required assistance from nursing staff and the Social Services Designee to complete the assessments. The Administrator acknowledged the issue and stated that there was currently no MDS Coordinator for the facility, which contributed to the delay in completing the assessments as per the RAI Manual requirements.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to electronically transmit Minimum Data Set (MDS) assessments in a timely manner for ten residents out of a sample of thirteen. The MDS assessments, which are federally mandated, were not transmitted within the required 14-day period for various types of assessments, including comprehensive admission assessments, quarterly assessments, and entry tracking records. This failure was observed in the records of Residents #6, #16, #18, #32, #33, #35, #36, #38, #40, and #42. The facility's policy mandates that these assessments be completed and transmitted in compliance with state and federal regulations, but this was not adhered to in multiple instances. For example, Resident #6 had a discharge-return anticipated MDS completed on 02/01/24 but was not transmitted until 03/15/24, well beyond the 14-day requirement. Similarly, Resident #18 had multiple instances of delayed transmissions, including an entry MDS tracking record dated 11/01/22 that was not transmitted until 05/18/23. These delays were consistent across other residents as well, indicating a systemic issue within the facility's process for handling MDS assessments. Interviews with staff revealed that the MDS Coordinator position had been vacant or inadequately staffed, contributing to the backlog. RN AG, who served as the MDS Coordinator from 03/01/24 to 04/10/24, acknowledged that the assessments were significantly behind schedule when they started. The Administrator also confirmed awareness of the issue, noting that the previous MDS Coordinator's services had been paused and that there was currently no MDS Coordinator for the facility.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans with specific interventions to meet individual needs for four residents. Resident #1's medical record showed diagnoses of diabetes and GERD, with triggered CAAs for functional abilities, urinary incontinence, nutritional status, and pressure ulcer/injury, but the care plan did not address these CAAs. Resident #6 had diagnoses of schizophrenia, GERD, and hyperlipidemia, with triggered CAAs for cognitive loss/dementia, functional abilities, urinary incontinence, falls, fluid maintenance, psychotropic drug use, and pain, but the care plan only addressed functional performance without listing any goals or other CAAs. Resident #16, diagnosed with dementia, anxiety disorder, hemiparesis, and hemiplegia following a stroke, had a comprehensive care plan that did not address the use of a lap tray as a restraint. Observations showed the resident frequently restrained by the tray, which the resident was unable to remove. The Director of Nursing confirmed that the lap tray was considered a restraint and should only be used during meals. Resident #29, diagnosed with dementia with behavioral disturbance, altered mental status, and pain, had an admission MDS assessment that triggered CAAs for dementia, urinary incontinence, falls, pressure ulcer, and psychotropic drug use, but there was no comprehensive care plan in place. Interviews with staff revealed that the MDS and care plans were significantly behind or incomplete, affecting the accuracy and comprehensiveness of the care plans. The MDS Coordinator and Social Services Designee were responsible for creating and revising the care plans, but the care plans did not accurately reflect the residents' conditions. The Assistant Director of Nursing acknowledged the need for appropriate interventions and activities for dementia residents, but these were not implemented in the care plans reviewed.
Insufficient Nursing Staff
Penalty
Summary
The facility failed to ensure there was a sufficient number of nursing personnel to provide care and respond to each resident's basic and individual needs. The facility's assessment had not been reviewed since 2022 when the facility had only two residents, and the staffing levels were based on that outdated assessment. The facility's census had increased to 49 residents, many of whom had complex medical and mental health diagnoses requiring significant care and attention. Despite this, the facility often operated with only one RN and one CNA during night shifts, which was insufficient to meet the residents' needs, especially for those requiring assistance with transfers and those with behavioral issues. Interviews with residents and staff revealed that the lack of adequate staffing led to long wait times for assistance, delayed medication administration, and insufficient care during the night. Residents reported waiting up to an hour for call lights to be answered and receiving their medications late. Staff members expressed concerns about the safety and quality of care, noting that it was dangerous to have only two staff members in the building at night, especially in the event of a medical emergency. Housekeeping staff also reported being unable to keep up with cleaning and laundry due to reduced hours and staffing cuts. The Director of Nursing (DON) and the Administrator acknowledged the staffing issues and stated that the facility should have a minimum of two nurses and three CNAs during the day shift and one nurse and two CNAs during the night shift for a census over 40. However, the facility's reliance on agency staff and the need for owner approval for staffing changes further complicated the situation. The deficiency in staffing levels had a significant impact on the quality of care provided to the residents, as evidenced by the numerous complaints and observations documented in the report.
Failure to Implement Medication Management Procedures
Penalty
Summary
The facility failed to implement procedures to ensure medications were accurately administered, documented, not expired, and reconciled for the Emergency Medication Kit (E-Kit). The facility's policy required that emergency medications be logged, monitored, and replaced as needed, but these procedures were not followed. Observations revealed that the E-Kit was not locked with the required tags, and there were no E-Kit removal or verification forms available. Additionally, numerous medications in the E-Kit were found to be expired, including various pain medications, antibiotics, and other essential drugs. During an interview, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that they were new to the facility and had only been there for two weeks. They admitted that the facility did not appear to have a process in place for monitoring and discarding expired medications. Further observations showed that a Registered Nurse (RN) removed a pain medication from the E-Kit without filling out the required form, and the Administrator instructed the DON to log it on the supply log instead. This indicated a lack of adherence to the facility's policies and procedures for medication management. Interviews with the Pharmacy Consultant and Pharmacy RN confirmed that the facility had not received a new E-Kit since the initial delivery and that the E-Kit was not being checked or replenished as required. The Pharmacy Consultant stated that the facility should check the E-Kit weekly, but this was not being done. As a result, several narcotic medications were unaccounted for, including temazepam, oxycodone, hydrocodone/acetaminophen, clonazepam, and alprazolam. The Administrator and DON admitted that there was no way to reconcile when and to whom these narcotic medications were administered, highlighting a significant deficiency in the facility's medication management practices.
Failure to Securely Store Medications and Monitor Expired Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were securely stored in accordance with currently accepted practices and facility policy. Specifically, the facility did not have a physician's order for one resident to keep and self-administer medications at the bedside. Observations showed that the resident had multiple pills on the bedside table on several occasions, and the resident confirmed that they took the medications without staff supervision. The facility policy requires a physician's order and an assessment to determine if a resident is capable of self-administering medications safely, which was not followed in this case. Additionally, the facility failed to ensure that medication carts and medication rooms were free from expired medications. Observations revealed that medication carts were frequently left unlocked and unattended, and expired medications were found in both the medication carts and the medication storage room. Specific expired medications included Hepatitis A and B vaccines, a Ventolin HFA inhaler, liquid bandage, and loperamide hydrochloride tablets. The facility policy mandates that medications be monitored by the unit nurse, charge nurse, and consultant pharmacist to ensure they are not expired, contaminated, or unusable, which was not adhered to. Interviews with staff, including the Director of Nursing (DON) and the Administrator, confirmed that they expected medication carts to be locked when not in use and for expired medications to be discarded per facility policy. However, the observations and interviews indicated that these expectations were not met, leading to the deficiencies noted in the report.
Inadequate Dining Room Space
Penalty
Summary
The facility failed to provide a dining room large enough to accommodate all residents, affecting one resident out of 13 sampled and two additional residents outside the sample, with the potential to affect all 49 residents. Observations showed that several residents had to leave the dining area before others could be brought in to eat, and some residents had to sit in areas not designated for dining due to lack of space. The dining room had nine round tables and four rectangle tables with twenty-seven chairs, which were insufficient for the number of residents, especially those in wheelchairs. Interviews with various staff members, including the Dietary Manager, Certified Nurse Aides, Certified Medication Technicians, and Housekeeping Staff, confirmed that the dining room was congested and not large enough to accommodate all residents at mealtimes. Residents expressed fear of not having a place to sit if they left the dining room, indicating the inadequacy of the space. Despite these observations and staff feedback, the Administrator and Director of Nursing believed the dining area was sufficient for the residents to eat together.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) to two residents who were discharged from Medicare Part A services with benefit days remaining. Resident #203 was discharged from Medicare Part A services on 11/23/23 and remained in the facility without receiving the required notices. Similarly, Resident #204 was discharged from Medicare Part A services on 10/04/23 and also remained in the facility without receiving the necessary documentation. The facility did not have a policy for issuing SNF ABN or NOMNC forms, and staff were unable to locate these forms when searched for by the Physical Therapy Assistant (PTA) and other managerial/office staff. Interviews with various staff members, including the Social Services Designee (SSD), Administrator, Director of Nursing (DON), and Regional Director of Therapy, revealed a lack of clarity and responsibility regarding the issuance of SNF ABN and NOMNC forms. The SSD admitted to not documenting these forms and was unsure who was responsible for this task. The Administrator and DON expected the forms to be completed and signed by the resident or their representative, but this was not done. The Regional Director of Therapy confirmed that both residents were discharged from Medicare Part A services with benefit days remaining, having reached their maximum potential, and that the discharges were not resident-initiated.
Failure to Properly Assess and Document Lap Tray Use as Restraint
Penalty
Summary
The facility failed to properly assess and document the use of a lap tray for a resident, leading to its use as a physical restraint without appropriate justification or consent. The facility did not assess whether the lap tray was a restraint, did not document it in the care plan, and did not identify a medical symptom that supported its use. Additionally, there was no documentation of the least restrictive use for the lap tray or ongoing re-evaluation for its necessity. The resident involved had severe cognitive impairment, hemiparesis, and hemiplegia following a stroke, and was observed multiple times unable to remove the lap tray, indicating it was indeed a restraint. The facility's policies on restraints require a thorough assessment, documentation of alternatives tried, informed consent, and ongoing re-evaluation, none of which were followed in this case. The resident's medical record lacked an assessment for the lap tray, documentation of alternatives, and consent for its use. The resident's care plan also did not address the lap tray or restraint use. Observations showed the resident frequently had the lap tray attached and was unable to remove it, contradicting the facility's policy that the tray should only be used during meals. Interviews with the DON and the Administrator confirmed that they were aware of the requirements for restraint use, including documentation and consent, but these were not followed. The Regional Director of Therapy noted that different chairs had been tried for the resident, but the resident was non-compliant with the plan of treatment. Despite this, the facility did not follow its own policies to ensure the resident's safety and compliance with restraint regulations.
Failure to Notify Residents and Ombudsman of Transfers
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of transfers or discharges to a hospital, including the reasons for the transfer, and did not notify the Office of the State Long-Term Care Ombudsman. This deficiency was identified for five residents out of 13 sampled residents and one resident outside the sample. Specifically, the medical records of Residents #6, #16, #18, #35, #36, and #43 showed multiple instances of hospital transfers without the required written notifications to the residents, their representatives, or the Ombudsman. During interviews, the Director of Nursing (DON) acknowledged the lack of documentation for transfer and bed hold notifications. The Administrator and DON confirmed that they would expect staff to notify the resident or resident representative in writing of the reason for transfer and to send a copy to the Ombudsman, but this was not being done. The facility's policy on discharges, which was undated, indicated that the Social Services department was responsible for notifying the resident and family in accordance with federal regulations, but this policy was not being followed in practice.
Failure to Provide Written Bed Hold Policy
Penalty
Summary
The facility failed to inform residents and/or their legal representatives in writing of their bed hold policy at the time of transfer to the hospital. This deficiency was identified for four residents within the sample and one resident outside the sample. Specifically, Residents #6, #16, #35, #36, and #43 were transferred to the hospital on multiple occasions, but there was no documentation indicating that they or their representatives were informed in writing about the facility's bed hold policy during these transfers. Interviews with the facility's Administrator and Director of Nursing (DON) revealed that the facility did not provide written bed hold policies to residents or their representatives. The Administrator admitted that the policy was communicated verbally, while the DON confirmed the absence of any written documentation regarding bed hold policies. Despite the expectation that staff should inform residents or their representatives in writing, this practice was not followed, leading to the identified deficiency.
Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to document accurate Minimum Data Set (MDS) assessments for five residents out of a sample of 13. Resident #6's MDS entry tracking record inaccurately indicated that the resident entered from a skilled nursing facility instead of a hospital upon readmission. Additionally, the resident's admission MDS failed to reflect a serious mental illness diagnosis, despite a Level II PASARR indicating such a condition. Resident #16's quarterly MDS assessment did not document the use of a wheelchair with a lap tray, which the Director of Nursing confirmed was considered a restraint. Resident #18's quarterly MDS assessment omitted several diagnoses, including GERD, aphasia, and cerebrovascular disease, and failed to document the administration of antibiotics, despite medical records indicating these conditions and treatments. Resident #36's quarterly MDS assessment did not include diagnoses of pulmonary embolism and GERD, even though the resident had physician orders for medications to treat GERD. Similarly, Resident #42's quarterly MDS assessment failed to document a GERD diagnosis and incorrectly included a diagnosis of pneumonia. During an interview, the MDS Coordinator admitted that the MDS assessments were significantly behind schedule when they started in March 2024. Due to the backlog, the coordinator had to code many items as not assessed because the necessary information was unavailable. The coordinator also mentioned that nursing staff and the Social Services Designee assisted with interviews to complete the assessments as much as possible, following the Resident Assessment Instrument (RAI) manual.
Failure to Provide PASARR Screening
Penalty
Summary
The facility failed to provide a Level I Preadmission Screening and Resident Review (PASARR) for two residents out of 13 sampled residents. Resident #2, who was admitted with diagnoses of major depressive disorder, anxiety disorder, and schizophrenia, did not have a Level I PASARR in their medical record. Similarly, Resident #26, admitted with diagnoses of schizophrenia, anxiety disorder, and dementia, also lacked a Level I PASARR. During an interview, the Director of Nursing (DON) confirmed the absence of PASARR documentation for these residents and stated that all residents should be screened before admission. These two residents had been admitted from a previous facility that closed emergently and should have been screened if the appropriate paperwork was not located after admission.
Failure to Implement Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to implement a baseline care plan within 48 hours of admission for five residents out of 13 sampled residents. These residents had various medical conditions, including diabetes mellitus, high blood pressure, high cholesterol, major depressive disorder, anxiety disorder, schizophrenia, chronic obstructive pulmonary disease (COPD), severe protein-calorie malnutrition, aphasia, bipolar disorder, cerebrovascular disease, gastroesophageal reflux disease (GERD), seizures, anemia, neuromuscular dysfunction of the bladder, gastrostomy status, insomnia, multiple pressure ulcers, and mild intellectual disabilities. The baseline care plans were either not completed within the required timeframe or were missing entirely, and there was no documentation that the residents or their representatives received a written summary of the baseline care plans. This deficiency was identified through interviews and record reviews conducted by the surveyors, who noted that the nursing staff and the Director of Nursing (DON) were responsible for completing the care plans, but there was a lack of clarity and training on the requirements. During interviews, a Registered Nurse (RN) admitted to not receiving adequate orientation and being unsure of the requirements for new admissions. The Director of Nursing (DON) stated that she expected baseline care plans to be completed within 48 hours of admission, while the Administrator believed they should be completed within 10 days but preferred within three days. The Administrator was unaware that baseline care plans should be completed within 48 hours, signed by the resident or their representative, and available for review for all new admissions. The facility also failed to provide a policy related to baseline care plans, contributing to the deficiency in meeting the residents' immediate needs upon admission.
Failure to Develop Timely Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans within seven days after the completion of the comprehensive assessment and no more than 21 days after admission for six residents out of 13 sampled residents. The residents involved had various diagnoses, including severe protein-calorie malnutrition, aphasia, bipolar disorder, cerebrovascular disease, GERD, seizures, anemia, neuromuscular dysfunction of the bladder, gastrostomy status, insomnia, multiple pressure ulcers, suicidal ideations, mild intellectual disabilities, dysphasia following cerebral infarction, asthma, major depressive disorder, generalized anxiety, pain, hemiplegia and hemiparesis, atherosclerotic heart disease, chronic embolism and thrombosis of unspecified deep veins in bilateral legs, pulmonary embolism, hypertension, chronic viral hepatitis C, paraplegia, malignant neoplasm of connective and soft tissue, COPD, and other genetic-related intellectual disabilities. The care plans for these residents were not completed within the required timeframe, with delays ranging from several weeks to months past the mandated deadlines. Interviews with the MDS and care plan coordinator revealed that when they started in March 2024, the MDS assessments and care plans were significantly behind schedule or not completed at all. This lack of timely assessments and care plans meant that many items in the assessments had to be left blank, which affected the care plans as there were no triggers from the assessments. The Administrator and Director of Nursing confirmed that they expected care plans to be created and updated in a timely manner per the RAI Manual and reflect the current status of the resident. They acknowledged that the MDS coordinator or the Social Service Director should complete the revisions and that care plans should be revised as needed.
Failure to Follow Physician's Orders for Multiple Residents
Penalty
Summary
The facility failed to follow physician's orders for six residents, leading to various deficiencies in care. Resident #12, who had multiple diagnoses including malnutrition, schizophrenia, and diabetes, was supposed to receive Jevity or Isosource HN through a gastrostomy tube. However, RN C administered Glucerna instead and failed to flush the g-tube after feeding. This discrepancy was due to RN C mistaking Glucerna for Jevity. Additionally, Resident #16, diagnosed with dementia and major depressive disorder, did not receive the prescribed Trintellix medication for an extended period due to issues with prior payment authorization and lack of communication between the pharmacy and the nursing home. The resident only received the medication after being switched from Medicare Part A to Medicaid, which allowed the pharmacy to bill for it and dispense it. Resident #18, who had severe protein-calorie malnutrition and multiple other diagnoses, required suctioning as per the care plan. However, there was no order for suction, and the equipment was found undated and containing yellow and brown-green substances. The DON and Administrator acknowledged that there should have been an order for suctioning and that staff should assess the need for it regularly. Resident #26, diagnosed with malnutrition and schizophrenia, had an order for fortified foods and health shakes, but was not on the list of residents to receive them. Similarly, Resident #33, who had bipolar disorder and dysphasia, had orders for Boost and Ensure health shakes and continuous oxygen, but was observed not receiving the shakes and not wearing oxygen as prescribed. Resident #40, with diagnoses including hypertension and a stage IV pressure ulcer, had an order for a wound vac, but the device was often found not working or not connected. The resident reported that the wound vac frequently malfunctioned and that facility staff often lacked the necessary supplies to perform dressing changes. The Administrator and DON confirmed that residents should receive diets, supplements, oxygen, and other items according to physician orders and that nursing staff should have the appropriate competencies to provide specialized care.
Failure to Complete Comprehensive Discharge Summary
Penalty
Summary
The facility failed to complete a comprehensive discharge summary for one resident out of two discharged residents. The facility's policy requires a detailed discharge summary to be written by the unit nurse after a discharge care conference, which includes various aspects of the resident's status and is to be reviewed with the resident and family. However, for Resident #50, who was discharged to another facility, there was no documentation of a discharge summary. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the absence of the discharge summary and the failure to chart the recapitulation of stay. The Administrator and DON acknowledged that they would expect a recapitulation to be completed upon discharge.
Failure to Provide Appropriate Chemotherapy Care
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards of practice for a resident receiving chemotherapy. The resident, diagnosed with malignant neoplasm of connective and soft tissue, COPD, hypertension, chronic pain, and intellectual disability, was observed with an infusion pump that had malfunctioned. The resident reported that the pump started beeping at 4:00 A.M., and some of the infusion had leaked onto their sweatshirt and hands. Despite notifying the nurse, the issue was not resolved, and the resident's infusion pump remained off and not running the following morning. The facility's staff, including the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Registered Nurses (RNs), demonstrated a lack of knowledge and training regarding the management of chemotherapy and infusion pumps. Interviews revealed that the staff had not received any training on how to handle chemotherapy medications, manage infusion pumps, or use spill kits. The DON admitted that the facility did not have a spill kit and that the staff did not know how to handle chemotherapy-related issues. The resident's care plan also did not address the chemotherapy treatment or provide any direction on how to care for the resident after returning from the infusion center. The facility's failure to provide appropriate care was further evidenced by the lack of communication with the infusion center. The infusion center staff reported that they had not been notified about the pump malfunction and that the facility did not answer their calls. The resident's infusion pump issue was not addressed promptly, and the staff did not follow the necessary protocols to manage the chemotherapy medication, leading to potential harm to the resident.
Failure to Implement Dietician's Recommendations for Weight Loss
Penalty
Summary
The facility failed to ensure that the Registered Dietician's (RD) recommendations for weight loss were provided to the physician, affecting one resident out of 13 sampled residents. The resident, who had diagnoses including mild protein calorie malnutrition, dementia, and gastroesophageal reflux disease (GERD), experienced significant weight fluctuations over several months. Despite the RD's recommendations for interventions such as double protein, health shakes, weekly weights, and Prostat supplements, these were not communicated to or implemented by the physician, leading to a lack of appropriate nutritional management for the resident. The resident's medical record showed a series of weight measurements indicating a 14.58% weight loss over three months, which was severe for the time frame. The RD made several recommendations to address the resident's nutritional needs and wound healing, but these were not converted into physician orders. The resident's care plan included monitoring and evaluating weight loss, providing supplements and snacks, and ensuring the dietician and physician were aware of lab results and weight changes. However, the facility did not follow through on these protocols. During an interview, the Director of Nursing (DON) acknowledged the communication gap between the dietician and nursing management. The DON expected dietician recommendations to be implemented as physician orders but had not seen a dietician report in the three weeks of her tenure. The facility had not yet established weekly weight meetings, and there was a lack of mandatory meetings and education to address these issues. This failure to act on the RD's recommendations resulted in inadequate nutritional care for the resident.
Failure to Provide Personalized Dementia Care Plans
Penalty
Summary
The facility failed to ensure that residents diagnosed with dementia had personalized care plans to promote their highest level of functioning and psychosocial needs. Specifically, three residents with dementia did not have care plans addressing their condition. Resident #20, diagnosed with severe cognitive impairment and dementia with behavioral disturbance, had no care plan addressing dementia or related activities. Observations showed the resident consistently lying in bed with eyes closed and covered with a blanket. Similarly, Resident #29, also with severe cognitive impairment and dementia with behavioral disturbance, lacked a comprehensive care plan. Observations indicated the resident was unresponsive and often covered their head or face while in bed. Resident #45, diagnosed with moderate cognitive impairment and dementia with agitation, had no care plan addressing dementia or related activities, despite being observed in various locations around the facility, including the dining room and outside smoking area. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the MDS Coordinator, revealed that the facility did not have a dementia policy and that MDS assessments were significantly behind schedule. The MDS Coordinator admitted to coding many items as not assessed due to missing information and relied on assistance from nursing staff and the Social Services Designee to complete assessments. The Administrator and Director of Nursing acknowledged that residents with dementia should have personalized care plans to ensure their highest practicable physical, mental, and psychosocial well-being.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for two residents, which had the potential to keep any resident on a psychoactive medication from receiving the lowest possible dosage. Resident #29 had diagnoses of dementia with behavioral disturbance and altered mental status and was prescribed paroxetine and quetiapine. Despite a behavior note indicating spitting behavior and a progress note mentioning a Medication Regimen Review (MRR) with a GDR request, there was no documentation of GDR attempts or contraindications for medication adjustments. Observations showed Resident #29 often unresponsive and lying in bed with a shirt covering their face. Resident #43 had multiple diagnoses, including schizophrenia, depression, bipolar disorder, and anxiety, and was prescribed Latuda, lorazepam, and sertraline. There was no documentation of GDR attempts or contraindications for medication adjustments. Observations showed Resident #43 lying in bed with a mask over their face, pacing up and down the hall, and wearing the same suit for consecutive days. Interviews with the pharmacist and the Director of Nursing (DON) confirmed that monthly medication reviews are conducted, and GDRs should be attempted or documented as contraindicated, but this was not done for the two residents in question.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less, resulting in a 14.29% error rate. This deficiency affected two residents, one of whom had a gastrostomy tube (g-tube) and required specific medication administration protocols. The facility's policy on medication administration and feeding tubes was not followed, leading to multiple medication errors. For Resident #12, a gabapentin capsule was improperly opened and mixed with water, which then leaked from the g-tube port onto the bed sheet during administration. For Resident #36, several medications, including desvenlafaxine ER, hydroxyurea, and Reglan, were crushed and administered through the g-tube, causing frequent clogging and improper medication delivery. Interviews with staff revealed a lack of knowledge and training regarding which medications could be crushed and administered through g-tubes. RN B admitted to crushing medications without verifying if they could be safely administered in that form. The Administrator and Director of Nursing (DON) acknowledged that staff were expected to follow physician orders and medication guidelines but did not provide adequate resources or training to ensure compliance. The pharmacist confirmed that certain medications, such as extended-release forms and hydroxyurea, should not be crushed and required special handling. The facility's failure to adhere to its own policies and ensure proper medication administration practices led to a significant medication error rate. The lack of training and resources for nursing staff contributed to the improper handling of medications, particularly for residents with g-tubes. This deficiency highlights the need for improved staff education and adherence to established protocols to ensure the safe and effective administration of medications to residents.
Failure to Provide Appealing Alternative Meal Options
Penalty
Summary
The facility failed to provide appealing alternative options of similar nutritive value to residents who chose not to eat the food that was initially served. Observations showed that the menu for dinner and lunch on specific dates did not include alternative options. For instance, a resident who did not like the meal being served was given a bowl of cereal with milk because no other alternatives were available. The facility's four-week rotating menu also showed only the main meal served with no alternative options. During interviews, several residents expressed that there wasn't a specific alternative food menu available for meals, and they could only get a sandwich or cereal if they did not like the meal served. The Resident Council Meeting minutes indicated that residents had requested more food options. The Dietary Manager confirmed that there were no specific alternative menus available, and the Administrator stated that she expected dietary services to have an alternative food option of equal nutritional value available for residents who did not like the main meal served.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that dumpsters were closed at all times and maintained to keep pests out and to keep the garbage contained. Observations showed that on multiple occasions, the dumpster lids were left open with visible garbage, including cardboard boxes and other miscellaneous items. Interviews with the Dietary Manager and a housekeeper revealed that staff were instructed to close the lids, but nursing staff often left them open. Additionally, the housekeeper mentioned that the dumpsters were not emptied frequently enough, leading to overfilled dumpsters that could not be closed properly. The Administrator and Director of Nursing confirmed that they expected the dumpster lids to be closed after trash disposal.
Failure to Document and Administer Influenza and Pneumonia Vaccinations
Penalty
Summary
The facility failed to provide and document that residents received or declined appropriate immunizations for influenza and pneumonia. This deficiency was identified for five residents out of a sample of five, with a facility census of 49. The facility's policies for influenza and pneumonia vaccinations required documentation of education, administration, or refusal of the vaccines, as well as monitoring by the Infection Control (IC) Nurse. However, the medical records for the sampled residents showed no documentation of education, administration, or refusal of the vaccines. Specifically, Residents #1, #8, #26, #35, and #102 had no records indicating they were informed about or received the influenza and pneumococcal vaccinations, nor were there any records of refusals or contraindications noted. Interviews with the Assistant Director of Nurses (ADON) and the Director of Nursing (DON) confirmed the lack of documentation and administration of the vaccines. The ADON mentioned that the pneumonia vaccine had not been given at the facility, while the DON stated that they were waiting for the pneumonia vaccine to arrive, as it required approval from the owner due to its cost. Both the Administrator and the DON acknowledged that they would expect vaccinations to be given per CDC guidelines and that declinations should be signed if refused, but this was not reflected in the residents' records.
Failure to Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccination was offered, administered, or refused by three residents out of five sampled residents. Specifically, the medical records for Residents #1, #26, and #102 showed no documentation of education regarding the COVID-19 vaccination, nor any record of the vaccine being provided or refused. Resident #1 had diagnoses including diabetes mellitus, bradycardia, and high blood pressure. Resident #26 had diagnoses of anxiety, schizophrenia, and heart failure. Resident #102 had diagnoses of kidney disease, chronic obstructive pulmonary disease (COPD), and a history of COVID-19. During interviews, the Director of Nursing (DON) confirmed that there was no documentation of vaccination consents or refusals for COVID-19. The Administrator and DON stated that they would expect vaccinations for COVID-19 to be given per CDC guidelines and declinations signed if refused. The facility also did not provide a COVID-19 vaccination policy, further contributing to the deficiency.
Unsafe Storage on Overbed Light Fixtures
Penalty
Summary
The facility failed to provide a safe and functional environment for residents by allowing items to be stored on top of overbed light fixtures in three rooms. This practice created a hazard of items potentially falling on residents and did not utilize the light fixtures as intended. Specific observations included a bottle containing artificial flowers, a bottle of shampoo, a book, six cards, a decorative gift bag, a decorative plaque, and a foam cup placed on the light fixtures above the beds. During an interview, the Director of Nursing (DON) and Administrator acknowledged that items should not be placed on the light fixtures due to the potential hazard. The facility census was 49, and no policy for overbed lighting safety was provided.
Failure to Implement Effective Staff Training Program
Penalty
Summary
The facility failed to ensure an effective training program for all new and existing staff members. The facility assessment had not been reviewed since 2022, when the facility had only two residents. The assessment did not address the training needs or frequency of training for staff, nor did it specify which individuals or departments were responsible for conducting and tracking the training. The facility's policy on abuse required that all newly hired employees read the policy during orientation and attend yearly in-service training on abuse, but there was no evidence that this was being tracked or implemented effectively. Interviews with the Administrator and the Director of Nursing (DON) revealed a lack of awareness regarding an education calendar or schedule for the year, a list of required training, or a list of training identified in the facility assessment. The Administrator was unsure if there was a calendar or what training was required or had been completed, while the DON, who had only been at the facility for two weeks, was unaware of who was responsible for tracking education and in-service hours. Both the Administrator and DON acknowledged that they would expect all facility staff to receive the required education to ensure adequate care for the residents, but they were still compiling a list of necessary in-services and training.
Failure to Provide Abuse and Neglect Training
Penalty
Summary
The facility failed to provide abuse and neglect training for five Certified Nursing Assistants (CNAs) and one Certified Medication Technician (CMT) out of eight sampled staff hired in the last year. The facility's policy mandates that all newly hired employees receive abuse training during orientation and attend yearly in-service training on abuse. However, a review of employee files revealed that none of the six staff members had documentation of receiving this required training. Interviews with the staff confirmed that they did not remember receiving any abuse or neglect training since their employment began. During an interview, the Administrator and Director of Nursing (DON) acknowledged that they would expect all CNAs to have abuse and neglect training upon hire. The DON mentioned that they were in the process of compiling a list of in-services and training that needed to be completed, as it had not been done. This lack of training is a significant deficiency, as it directly contravenes the facility's policy and potentially compromises the safety and well-being of the residents.
Deficiency in CNA Training and Annual Competencies
Penalty
Summary
The facility failed to conduct at least twelve hours of nurse aide in-service education per year and did not provide the required annual competencies in abuse prevention and dementia care for two Certified Nursing Assistants (CNAs) sampled. CNA K, hired on 03/17/23, attended only 30 minutes of in-services, lacking an additional 11 hours and 30 minutes, and did not attend any annual competency in-services on abuse prevention or dementia care. Similarly, CNA R, hired on 02/28/23, showed no documented time for in-services and did not attend any annual competency in-services on abuse prevention or dementia care. During interviews, CNA K confirmed the lack of annual training on abuse/neglect, Alzheimer's, dementia, or behavioral health, stating that employees only sign a paper upon hire regarding abuse without any orientation or training. The Administrator and Director of Nursing (DON) acknowledged the deficiency, stating that they would expect all CNAs to have 12 hours of continuing training each year, including abuse/neglect and dementia care training. They mentioned that they were compiling a list of in-services and training that need to be done, as it had not been completed.
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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.
