Troy Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Troy, Missouri.
- Location
- 200 Thompson Drive, Troy, Missouri 63379
- CMS Provider Number
- 265702
- Inspections on file
- 24
- Latest survey
- May 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Troy Manor during CMS and state inspections, most recent first.
A CNA verbally abused a resident with dementia and schizophrenia by using loud, harsh, and profane language during personal care, despite the resident's care plan calling for a calm approach. The incident was witnessed by two other CNAs, who reported that the abusive language continued even after the resident was on the floor and visibly distressed. Staff interviews confirmed the behavior as verbal abuse, and it was noted that the CNA had a history of complaints regarding their demeanor.
A resident with dementia and schizophrenia was subjected to verbal abuse by a CNA, who was witnessed by two other CNAs using demeaning and profane language during care. The witnesses documented the incident in writing but did not immediately report it to the charge nurse or administration, resulting in a significant delay before the event was discovered and reported to the State Agency, contrary to facility policy and regulatory requirements.
A facility failed to promptly and thoroughly investigate an incident where a CNA was reported by two CNAs to have used demeaning and abusive language toward a resident with dementia and schizophrenia. The administrator did not discover the written reports until two days later, during which time the accused CNA continued to work with the resident and others. Required interviews with involved staff, the resident, and other residents were not conducted, and the investigation did not follow facility policy.
The facility was found deficient in providing food items at a safe and appetizing temperature, as determined through observation, interview, and record review. With a census of 87 residents, the facility did not meet the required standards for food safety and quality.
A resident with impaired cognition and behavioral disturbances caused harm to three other residents, resulting in injuries, including a shoulder fracture. Despite known behavioral issues, the facility's interventions were insufficient, leading to repeated incidents of abuse. Staff interviews confirmed the resident's aggressive behavior and the facility's failure to prevent harm.
The facility failed to provide hot water in resident rooms on the 200 hall, affecting at least two residents who required incontinence care. Staff reported the issue had persisted for two to three months, with water temperatures below the expected range. The maintenance director noted that the 100 and 200 halls shared a water heater, complicating temperature adjustments. The administrator and DON were unaware of the problem's extent until the survey.
The facility failed to serve food at safe and appetizing temperatures, as multiple residents reported receiving cold meals. Observations and temperature logs confirmed that food temperatures were below the required levels, with some items as low as 86 degrees Fahrenheit. The Dietary Manager was unaware of complaints and acknowledged issues with maintaining food temperatures, partly due to cold items being plated with hot items.
The facility failed to treat residents with dignity and respect, as evidenced by two incidents. A resident with legal blindness and dementia reported being handled roughly by an unknown staff member, causing pain and fear. Another resident with severely impaired cognition was frightened when a CNA yelled at them during care. These incidents were reported to the ADON and DON, who emphasized the importance of treating residents with dignity.
A resident with legal blindness and dementia alleged that a staff member yanked them out of their chair, causing pain and fear. This incident was witnessed by another resident and reported to the ADON and CMT, who informed the DON. However, the allegation was not reported to the administrator or state agency within the required timeframe, violating the facility's abuse reporting policy.
A resident with legal blindness and dementia reported being roughly handled by an unknown staff member, causing pain and fear. The incident was corroborated by the resident's roommate, who described the staff member's appearance. Despite these reports, the facility did not conduct a thorough investigation as required by their policy, failing to interview all relevant staff and provide a completed investigation form.
A resident with Alzheimer's and arm pain was improperly repositioned by staff using their arms under the resident's armpits, contrary to facility policy. This caused the resident discomfort and was due to a lack of proper training, as confirmed by interviews with the CNA, NA, and facility administrators.
The facility failed to ensure proper infection control procedures during resident care, as staff did not wash hands or change gloves when soiled while assisting two residents with incontinence care. This led to handling clean items and areas with contaminated gloves, compromising infection control standards.
The facility failed to follow proper infection control techniques for five residents, including improper sanitization of a glucometer used for blood glucose monitoring and inadequate hand hygiene and glove use during incontinence care. These actions increased the risk of cross-contamination and infection spread among residents.
The facility failed to respect and facilitate resident self-determination and choice regarding wake-up times. Staff were observed waking and dressing residents early in the morning based on a predetermined get-up list, without considering the residents' preferences. This practice affected several residents, including those with cognitive impairments, and was acknowledged by the DON as inappropriate.
The facility failed to provide necessary assistance with ADLs and oral hygiene for five residents, resulting in poor hygiene and unmet care needs. Observations revealed residents with unkempt hair, urine-soaked bedding, and poor oral hygiene, despite care plans indicating the need for substantial assistance.
The facility failed to provide an ongoing program of meaningful activities to meet the interests and well-being of residents. Several residents, including those with severe cognitive impairments and physical disabilities, were observed without engagement in scheduled activities. Staffing issues were cited as the primary reason for the lack of activities.
The facility failed to ensure the safety of six residents by not following care plan interventions for fall prevention, proper footwear, and the use of fall mats. Staff also failed to ensure residents were transported safely in their wheelchairs by not placing foot pedals on the wheelchairs prior to transport. Additionally, the facility did not prevent an elopement incident involving a resident who left the facility without approval and was found approximately one mile away. The facility also failed to protect two residents from another resident with a history of verbal and physical aggression.
The facility failed to assess the need for bed rail use and obtain informed consent for three residents before installing and using bed rails. Observations and interviews revealed that bed rail assessments and consents were not documented as required, despite the residents' medical conditions and care plans indicating the need for such assessments.
The facility failed to ensure adequate staffing on the SCU, leading to residents being left unattended and incidents such as a verbal altercation and a near fall. Staff expressed concerns about insufficient monitoring, and the facility lacked a clear staffing policy, resulting in significant deficiencies.
The facility failed to ensure that three nurse aides completed their CNA training within four months of employment. Despite not being certified, these aides continued to work, with delays attributed to testing issues and lack of policy guidance.
The facility failed to ensure proper food storage and cleanliness, with scoops stored inside bulk containers, unsealed food items, a buildup of debris in the exhaust vent, and damaged microwaves. Staff interviews revealed a lack of adherence to cleaning and maintenance protocols.
The facility failed to complete regular inspections of bed frames, mattresses, and bed rails for three residents, leading to potential entrapment risks. Despite the residents' varying levels of cognitive impairment and dependence on assistive devices, there was no evidence of recent inspections in their medical records. The Administrator confirmed that these assessments were supposed to be done quarterly by the DON or management team.
The facility failed to ensure call lights were within reach for two residents, one of whom had contracted hands and could not use a traditional call light. Despite being cognitively intact and dependent on staff for mobility, the residents were observed multiple times with call lights on the floor out of reach, leading to long waits for assistance.
A facility failed to develop a comprehensive care plan for a resident with dementia and depression. The resident's frequent tearfulness, rejection of care, and use of antidepressants were not documented in the care plan, despite severe cognitive impairment and ongoing distress. Staff were unaware of the resident's behaviors and medication needs.
The facility failed to obtain orders for oxygen use and maintain equipment according to policy for two residents. One resident with heart failure had no physician orders for oxygen therapy, and staff did not consistently monitor or maintain oxygen levels. Another resident required weekly changes of oxygen tubing, but observations showed outdated tubing in use. The Director of Nursing confirmed the facility's policies were not followed.
A resident with severe cognitive impairment and insomnia received an incorrect dose of trazodone for ten days due to a transcription error. The new order to increase the dosage was not properly updated in the system, and the old medication card was not removed from the cart, leading to the continued administration of the incorrect dose.
The facility failed to ensure that residents on a pureed diet received food in the proper form as per their physician's orders. Observations showed that pureed corn and potatoes were served with visible chunks and no gravy, contrary to the facility's policy and diet spreadsheet menu. The Dietary Manager confirmed that pureed food should be smooth and pudding thick.
The facility failed to notify three residents or their representatives in writing of their transfer to the hospital, including the reasons for the transfer. Additionally, the facility did not send a copy of the transfer notice to a representative of the Office of State Long-Term Care Ombudsman. Interviews revealed a lack of awareness and adherence to the facility's policy on Discharge/Transfer of Resident.
The facility failed to provide written bed hold notices to residents and/or their representatives during hospital transfers. Three residents were transferred without receiving the required bed hold policy documentation. Interviews revealed that the Social Services Director was unaware of the follow-up requirement, and the administrator confirmed the lack of documentation.
Verbal Abuse of Resident by CNA on Dementia Unit
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) used derogatory and abusive language toward a resident on the dementia care unit. The resident, who had diagnoses including schizophrenia and unspecified dementia, was dependent on staff for personal hygiene and required substantial to maximal assistance for mobility. The resident's care plan indicated behavioral symptoms and recommended a calm, slow, and understandable approach, but did not document any history of aggressive behaviors toward staff, aside from occasional refusal of medications. On the day of the incident, the CNA attempted to change the resident's incontinence brief. The resident yelled and refused care, at which point the CNA responded with loud, harsh, and profane language directed at the resident, including calling the resident a "fucking bitch" and a "fucking witch." These actions were witnessed by two other CNAs, who reported that the CNA continued to use abusive language even after the resident was on the floor by the bed. The resident did not appear hurt, but was visibly distressed and accused the CNA of being a "monster" and causing harm. Interviews with staff confirmed that the CNA's behavior was considered verbal abuse and that the resident did not typically display aggression toward staff. The CNA involved had previously been counseled for speaking gruffly to others, and both staff and residents had made complaints about the CNA's demeanor in the past. The incident was reported to the administrator, who initiated an investigation after receiving written statements from the witnesses.
Failure to Timely Report Staff-to-Resident Verbal Abuse
Penalty
Summary
A staff-to-resident verbal abuse incident occurred involving a resident with schizophrenia and unspecified dementia, who was dependent on staff for personal hygiene and required substantial to maximal assistance for mobility. During care, a CNA was witnessed by two other CNAs yelling and using demeaning, derogatory, and profane language directed at the resident. The incident was observed by the two CNAs, who documented the event in written statements but did not immediately report the abuse to the charge nurse on duty. The written statements were left under the doors of the administrator and DON, but were not discovered until approximately two days after the incident. During this period, the alleged perpetrator continued to work and had further contact with the resident. The charge nurse on duty did not receive a direct report of the abuse, and other staff members who were aware of the written statements did not inquire further or escalate the report to administration as required by facility policy. Facility policy and federal and state regulations require that all allegations of abuse be reported immediately, but not later than two hours after the allegation is made, especially if the event involves abuse or results in bodily injury. In this case, the delay in reporting resulted in the State Agency not being notified until at least 40 hours after the occurrence of the alleged abuse. The failure to follow established reporting protocols led to a deficiency finding during the survey.
Failure to Timely and Thoroughly Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into a reported incident of verbal abuse involving a resident with schizophrenia and unspecified dementia. Two CNAs witnessed another CNA using demeaning and derogatory language, including cursing, while providing personal care to the resident. The CNAs documented the incident and submitted written statements by placing them under the administrator and DON's door. However, the administrator did not discover these statements until two days later, resulting in a delay in initiating the investigation. During this period, the accused CNA continued to work on the dementia unit and had ongoing contact with the resident and others. Upon review, it was found that the administrator did not follow the facility's abuse investigation policy, which required immediate initiation of an investigation, interviews with all involved staff, attempts to interview the resident, and interviews with other residents who had received care from the accused staff member. The administrator did not interview the involved CNAs after reading their statements, did not attempt to interview the resident or other residents on the unit, and did not interview other staff who may have had relevant information. The DON was unaware of the incident until returning from vacation, and some staff were not immediately in-serviced on abuse and neglect following the event. The resident involved was dependent on staff for personal hygiene and mobility, had moderate hearing difficulty, and was rarely understood, according to the most recent MDS. The incident was witnessed by two CNAs, who reported that the accused CNA used harsh and abusive language multiple times. Despite these reports, the facility's response was delayed and incomplete, failing to meet its own policies for abuse investigation and resident protection.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to provide food items at a safe and appetizing temperature. This deficiency was identified through observation, interview, and record review. The facility had a census of 87 residents at the time of the survey. The report does not provide specific details about the residents affected or the exact nature of the temperature issues, but it highlights a general failure in maintaining food safety and quality standards.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving a resident with severely impaired cognition and behavioral disturbances. This resident physically harmed three other residents, resulting in significant injuries. The incidents included pulling a resident out of a wheelchair, causing a left shoulder fracture, hitting another resident in the face, and grabbing a third resident's arm, causing pain. These actions were documented in the resident's progress notes and were observed by staff members. The resident involved in these incidents had a history of behavioral issues, including agitation and aggression, as noted in their care plan. Despite this, the facility's interventions were insufficient to prevent harm to other residents. The care plan included behavior monitoring and interventions to prevent harm, but these measures were not effectively implemented, leading to repeated incidents of abuse. Interviews with staff members revealed that the resident's aggressive behavior was known, and there were attempts to manage it through medication and monitoring. However, the staff's inability to consistently supervise and intervene allowed the resident to continue causing harm. The Director of Nursing and the Administrator acknowledged that the incidents constituted resident-to-resident abuse, highlighting a failure in the facility's responsibility to ensure a safe environment for all residents.
Failure to Provide Hot Water in Resident Rooms
Penalty
Summary
The facility failed to ensure that residents on the 200 hall had access to hot water in their rooms, affecting at least two residents. Resident #9's care plan indicated the need for routine and as-needed perineal care due to incontinence. However, during an observation, a CNA informed the resident that there was no hot water, and the water used for care was cold. The CNA mentioned that the 200 hall had been without hot water for two to three months, and they had to obtain warm water from another hall. The water temperature in Resident #9's room was measured at 90.1 degrees Fahrenheit, below the expected range of 105-120 degrees Fahrenheit. Similarly, Resident #13, who required incontinence care after each episode, experienced cold water during care, which was bothersome. The water temperature in their room was recorded at 97.1 degrees Fahrenheit. The maintenance director acknowledged the issue, stating that the 100 and 200 halls shared a water heater, and adjusting it for the 200 hall would make the 100 hall's water too hot. Despite complaints from staff, the administrator and DON were unaware of the extent of the issue, with the administrator only learning about it on the day of the interview.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food items at a safe and appetizing temperature, as observed during a survey. The facility's policy requires hot food to be at least 120 degrees Fahrenheit when served to residents. However, multiple residents who ate in their rooms reported that their food was consistently cold. Temperature logs and observations confirmed that food temperatures were below the required levels, with recorded temperatures as low as 86 degrees Fahrenheit for soup and 90 degrees Fahrenheit for a hot dog. The Dietary Manager was unaware of resident complaints and acknowledged that the temperature of food decreases once plated and sent to residents' rooms. The Dietary Manager also noted that the cold salad plated with hot items likely contributed to the reduced temperature of the hot food. Despite the facility's policy, the Dietary Manager admitted that the plate warmer was not maintaining the desired temperature, as kitchen staff found the plates too hot to handle. The administrator was also unaware of any resident complaints regarding cold food, although the expectation was that food should be served at an appropriate and appetizing temperature.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that staff treated residents with dignity and respect, as evidenced by incidents involving two residents. Resident #4, who has legal blindness and dementia, reported that an unknown staff member entered their room without speaking, pulled back the covers, and yanked on their arm, causing pain and fear. This incident was corroborated by Resident #4's roommate, who reported the rough treatment to a Certified Medication Technician (CMT) B. The CMT reported the incident to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). In another incident, Resident #8, who has severely impaired cognition, was subjected to verbal aggression by a Certified Nurse Assistant (CNA) F. The CNA yelled the resident's name angrily during a care routine, which frightened the resident. A Nurse Assistant (NA) G witnessed the incident and intervened by asking CNA F to leave the room. The resident later confirmed that CNA F's behavior was frightening. The ADON was unaware of this incident, but the DON acknowledged that staff should not yell at residents and emphasized the importance of treating residents with dignity and respect.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report a staff-to-resident allegation of abuse to the state agency as required by their policy. On the morning of September 30, 2024, Resident #4, who has legal blindness and unspecified dementia, alleged that an unknown staff member yanked them out of their chair and rushed them around, causing pain and fear. This incident was witnessed and reported by Resident #12, who described the staff member as a short, blonde-haired individual with a ponytail. Both residents reported the incident to the Assistant Director of Nursing (ADON) and Certified Medication Technician (CMT) B, who then informed the Director of Nursing (DON). However, neither the ADON nor the DON reported the allegation to the administrator or the state agency within the required timeframe. The facility's policy mandates that all alleged violations involving abuse or mistreatment be reported immediately, but not later than two hours after the allegation is made if it involves abuse or results in bodily injury. Despite this, the DON did not report the incident, as she believed the resident's statement only indicated that they had been rushed, not that they had been yanked. The DON had not spoken with either Resident #4 or Resident #12 and did not inform the administrator of the incident. The administrator was unaware of the situation and expected that staff would have reported any issues to her. The failure to report the allegation of abuse within the required timeframe constitutes a deficiency in the facility's adherence to its abuse reporting guidelines. The administrator acknowledged that an allegation of yanking on a resident's arm would be considered abuse and should have been reported to the state agency within two hours. This oversight highlights a breakdown in communication and adherence to established protocols for reporting suspected abuse within the facility.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident with legal blindness and unspecified dementia. The resident reported that an unknown staff member entered their room early in the morning, pulled back the covers, and yanked on their arm, causing pain and fear. The resident could not identify the staff member due to their impaired vision. The incident was documented in a statement initialed by the resident, and the resident's care plan noted the report of a Certified Nurse Assistant (CNA) being disrespectful and rough. Another resident, who was the roommate of the affected resident, corroborated the incident. This resident reported that a short, blonde-haired staff member entered the room, stated they were running late, and then roughly pulled the affected resident out of bed. This account was documented in a statement signed by the roommate. The roommate reported the incident to the Assistant Director of Nursing (ADON), who then informed the Director of Nursing (DON). Despite these reports, the facility did not conduct a thorough investigation as required by their policy. The facility failed to provide a completed investigation form with the necessary elements, such as interviews with all relevant staff and documentation of findings. The DON and Administrator, who were responsible for investigating abuse allegations, did not suspend any staff pending investigation and did not interview all potential witnesses, including night aides and the night nurse. The facility did not provide the state agency with an investigation within five working days of the incident.
Improper Repositioning Technique Causes Resident Discomfort
Penalty
Summary
The facility failed to ensure proper repositioning of a resident, identified as Resident #9, which led to discomfort and potential harm. Resident #9, who has diagnoses including pain in the right arm and Alzheimer's disease, was observed being repositioned in bed by a CNA and a NA. The staff members stood on opposite sides of the bed and pulled the resident up by placing their arms under the resident's armpits, contrary to the facility's policy which requires the use of a draw sheet and two staff members to lift the resident. This improper technique was confirmed by the resident, who reported shoulder pain and discomfort from being pulled up by the arms. Interviews with the staff involved revealed a lack of proper training and understanding of the correct repositioning techniques. CNA C admitted to using the method of locking arms with the resident to pull them up, while NA D was unsure of what a draw sheet was and had been taught to reposition residents by placing arms under the resident's arms. The Director of Therapy and the Director of Nursing both stated that the correct method involves using a pad or draw sheet, and not lifting under the arms due to the risk of causing pain. The Administrator also confirmed that the expected practice is to use a draw sheet for repositioning.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to ensure proper infection control procedures were followed during resident care, specifically in handwashing and glove use. For Resident #9, the care plan indicated bladder incontinence and required toileting assistance. During an observation, CNA C and NA D performed incontinent care without washing hands before or after the procedure. They also failed to change gloves after they became soiled with urine and feces, and continued to handle clean items and assist the resident with soiled gloves. Similarly, for Resident #10, who also required assistance due to bladder and bowel incontinence, NA J and CNA K did not adhere to proper infection control protocols. They performed perineal care without changing gloves or washing hands between tasks. They touched the resident's clean areas and items with soiled gloves, further compromising infection control standards. Interviews with the involved staff and the Director of Nursing confirmed the lapses in infection control practices. Staff acknowledged the need for handwashing before and after care, and the necessity of changing gloves when soiled. The Director of Nursing reiterated the expectation for staff to follow these protocols, highlighting the importance of changing gloves and washing hands after perineal care and before touching clean areas or items.
Infection Control Deficiencies in Blood Glucose Monitoring and Incontinence Care
Penalty
Summary
The facility failed to ensure proper infection control techniques were followed for five residents in a sample of 23. Specifically, the staff did not appropriately sanitize the glucometer machine after use, which was used for blood glucose monitoring. This failure was observed with Resident #27 and #29, where the glucometer was cleaned with an alcohol wipe instead of the required bleach wipes. Resident #29 had Hepatitis C, and the same improperly disinfected glucometer was used on Resident #59, posing a risk of cross-contamination. The facility identified that this multi-resident use glucometer was utilized for five residents on the 300 hall, including Resident #29, #59, #501, #502, and #503. The staff's improper cleaning practices were based on outdated training and incorrect instructions provided by the facility, despite the availability of proper disinfectant wipes. Additionally, the facility's policy and CDC guidelines were not followed, which required the use of EPA-registered disinfectants and adherence to manufacturer guidelines for cleaning and disinfecting glucometers between uses. The staff's actions were contrary to these guidelines, leading to potential exposure to bloodborne pathogens for multiple residents. The facility also failed to use appropriate infection control procedures for hand hygiene and changing gloves during incontinence care for two residents, Resident #12 and #27. Observations showed that staff did not perform hand hygiene or change gloves when moving from dirty to clean tasks, such as cleaning the resident's perineal area and then handling clean linens and clothing. This lack of proper hand hygiene and glove use increased the risk of spreading bacteria and other infection-causing contaminants. The staff's actions were inconsistent with the facility's policy on standard and transmission-based precautions, which required handwashing and changing gloves to prevent cross-contamination. Interviews with staff, including the LPN and DON, revealed a lack of awareness and adherence to proper infection control practices. The LPN admitted to using alcohol wipes based on outdated training, and the DON acknowledged that bleach wipes were the appropriate disinfectant but were not being used. The facility's failure to ensure proper training and adherence to infection control policies contributed to the deficiencies observed. The administrator and DON were unaware of the specific residents with bloodborne viruses and the need for individualized glucometers, further highlighting the gaps in infection control practices and oversight within the facility.
Failure to Respect Resident Wake-Up Preferences
Penalty
Summary
The facility failed to respect and facilitate resident self-determination and choice, particularly regarding wake-up times, for several residents. Staff were observed waking and dressing residents early in the morning based on a predetermined get-up list, without considering the residents' preferences. This practice was noted for four residents (Residents #6, #34, #58, and #70) who were cognitively impaired and dependent on staff for assistance with activities of daily living, as well as one additional resident (Resident #89) who was also cognitively impaired. The facility's policy for resident rights emphasized the importance of respecting residents' dignity and individuality, yet this was not reflected in the observed practices. For instance, Resident #34, who had Alzheimer's disease and other cognitive impairments, was woken up at 5:15 A.M. by a nurse aide who turned on the light and dressed the resident while they remained mostly unresponsive. Similarly, Resident #89, who had severe cognitive impairment, was told it was time to get up at 5:30 A.M. despite expressing a preference for not waking up so early. Resident #70, who was cognitively intact but dependent on staff for mobility and dressing, reported being woken up at 5:00 A.M. daily, despite preferring to sleep until closer to 8:00 A.M. Resident #58, who had moderate cognitive impairment, was also observed being dressed and moved to the dining room early in the morning against their preference. The Director of Nursing acknowledged that residents' rights regarding wake-up times should be honored and that 4:30 A.M. was too early for staff to start waking residents for breakfast. Despite this acknowledgment, the facility's practices did not align with the stated policies and residents' preferences, leading to a failure in creating an environment respectful of the residents' rights to make choices about significant aspects of their lives.
Failure to Provide Adequate ADL Assistance and Oral Hygiene
Penalty
Summary
The facility failed to ensure that five residents who required assistance with activities of daily living (ADL) received the necessary support. Resident #28, who had diagnoses including urinary tract infection, overactive bladder, and panic disorder, was found to have received inadequate assistance with showering and toileting. The resident's shower records showed significant gaps, with no documentation of showers for extended periods. Observations revealed the resident lying in urine-soaked bedding and with greasy, unkempt hair. The resident reported not having had a shower for two weeks and that staff did not assist with sponge baths, leading to distress and discomfort. Resident #4, diagnosed with schizophrenia and dementia, required supervision for oral hygiene but was observed with poor oral hygiene, including missing and broken teeth. Staff failed to provide oral care before meals, and the resident's care plan did not address dental status or assistance needed for dental care. Similar issues were observed with Resident #34, who had Alzheimer's disease and dementia, and Resident #27, who had dementia. Both residents required assistance with oral hygiene but were not provided with the necessary care, resulting in poor oral hygiene and unaddressed dental needs. Resident #1, with severe intellectual disabilities, dysphagia, and quadriplegia, was dependent on staff for oral hygiene. Observations showed the resident with dry, cracked lips, plaque-covered teeth, and uncombed hair. Despite the care plan indicating the need for frequent oral care, staff did not provide the required assistance. Interviews with staff, including the Director of Nursing, confirmed that the expected care routines were not followed, leading to the deficiencies observed in the residents' care.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of meaningful activities on a daily basis to meet the interests and the physical, mental, and psychosocial well-being of several residents. Specifically, the facility did not adhere to its own activity schedule, and there were significant lapses in the provision of activities for residents in both the general population and the special care unit (SCU). For instance, Resident #1, who had severe intellectual disabilities and quadriplegia, was observed in bed without any of the sensory stimulating activities outlined in their care plan. Similarly, Resident #58, who had moderate cognitive impairment and preferred one-on-one activities, reported that staff did not provide such activities, and observations confirmed that the resident was often left staring at the wall without engagement from staff. In the SCU, the activity schedule was not followed, and residents were often left without any structured activities. For example, Resident #82, who had severe cognitive impairment and enjoyed group activities, was observed walking up and down the hall without any engagement in the scheduled activities. The same was true for Resident #34, who also had severe cognitive impairment and enjoyed group activities but was observed self-propelling in their wheelchair without any engagement from staff. Additionally, Resident #4, who had schizophrenia and dementia, was observed in bed without any one-on-one activities as required by their care plan. Interviews with staff, including the Activity Director and nursing aides, revealed that the lack of activities was due to staffing issues. The Activity Director admitted that there was no activity aide on the SCU on the days in question, and the scheduled activities were not conducted. Nursing aides also confirmed that they were too busy with other tasks to conduct activities. The Director of Nursing and the Administrator both acknowledged that activity staff should always be present in the SCU and that one-on-one visits should be completed as indicated in the residents' care plans.
Failure to Ensure Resident Safety and Follow Care Plans
Penalty
Summary
The facility failed to ensure the safety of six residents by not following care plan interventions for fall prevention, proper footwear, and the use of fall mats. Staff also failed to ensure residents were transported safely in their wheelchairs by not placing foot pedals on the wheelchairs prior to transport. Additionally, the facility did not prevent an elopement incident involving a resident who left the facility without approval and was found approximately one mile away. The resident's elopement risk assessment was scored incorrectly, and staff did not provide the required protective oversight. The facility also failed to protect two residents from another resident with a history of verbal and physical aggression. The aggressive resident had altercations with other residents, including hitting and punching incidents. Despite these behaviors, the facility did not implement any interventions other than instructing the residents to stay away from each other. The aggressive resident had not been evaluated by psychiatry, and there was no policy regarding behavioral and resident safety. Furthermore, the facility did not follow its policy for wheelchair use, which required footrests to be in place during transport. Observations showed that residents were transported without foot pedals on their wheelchairs, and some residents were not wearing proper footwear. One resident, who was at high risk for falls, was observed multiple times without proper footwear and without foot pedals on the wheelchair. Another resident, who required a fall mat as per the care plan, was observed without a fall mat in place. Staff interviews confirmed that they were unaware of the care plan requirements or did not follow them.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess the need for bed rail use and obtain informed consent for three residents before installing and using bed rails. Resident #25 had Alzheimer's disease, falls, and weakness, and was observed using U-bars on both sides of the bed without documented assessment or consent. Despite the resident's physical decline and increased need for assistance, there was no documentation of a bed rail assessment or consent in the resident's electronic medical record. Resident #62 had generalized weakness, ataxic gait, history of falls, and dementia, and was observed with a U-bar on the left side of the bed. The last documented bed rail assessment was dated 8/5/22, with no subsequent assessments recorded. The resident's care plan indicated the need for quarterly assessments, but these were not completed as required. Resident #58 had diagnoses including cerebral infarction, contracture, muscle weakness, reduced mobility, and seizures, and was observed with U-bars on both sides of the bed. The resident's responsible party confirmed that no consent was obtained for the use of bed rails. The facility's Director of Nursing and Administrator confirmed that bed rail assessments were to be completed quarterly, but this was not done for the residents in question.
Inadequate Staffing on Special Care Unit
Penalty
Summary
The facility failed to ensure adequate staffing on the Special Care Unit (SCU), which housed residents with impaired cognition and at risk for falls and behaviors, including resident-to-resident altercations. Observations revealed that the SCU was often staffed with only two nurse aides (NAs) and occasionally an activity aide, without the presence of a certified nurse assistant (CNA). On multiple occasions, residents were left unattended, leading to incidents such as a verbal altercation between two residents and a resident almost falling out of their wheelchair while unsupervised. Interviews with staff indicated that the facility's staffing policy was unclear, and there was confusion about the appropriate staffing levels for the SCU. Staff members, including NAs and LPNs, expressed concerns about the inability to monitor all residents adequately, especially when providing care behind closed doors. The staffing coordinator and Director of Nursing (DON) acknowledged that the SCU should ideally have a CNA working with NAs and that having only one staff member on the night shift was insufficient for proper resident oversight. The administrator confirmed that NAs should not be working alone and that the facility should adjust staffing times to ensure residents are not left unattended during morning care. Despite these acknowledgments, the facility continued to operate with inadequate staffing, leading to potential risks for resident safety and well-being. The lack of a clear staffing policy and the failure to provide sufficient certified staff on the SCU were significant deficiencies identified during the survey.
Failure to Ensure Timely CNA Certification for Nurse Aides
Penalty
Summary
The facility failed to ensure that three nurse aides (NAs) completed a certified nurse aide (CNA) training program within four months of their employment. NA E was hired on 7/5/21 and had not completed the CNA training program within the required timeframe. NA E was scheduled to take the knowledge portion of the certification test on 3/29/24 but had not yet scheduled the skills test. NA N, hired on 1/16/23, and NA O, hired on 2/13/23, also did not complete the CNA training program within four months of their hire dates. Both NA N and NA O had failed their previous tests and were waiting for retest dates. Despite these deficiencies, all three NAs continued to be scheduled and work as NAs in March 2024. During interviews, the staffing coordinator and the nurse educator/CNA instructor confirmed that the NAs should have been certified within four months and should not have been working without certification. The nurse educator mentioned delays in testing due to scheduling issues from the testing site and noted that NA E was scared to test. The Administrator acknowledged that NAs should be certified within four months and should not be working if they had not tested and/or passed the certification test. The facility did not have a policy on Nursing Assistant and Certified Nursing Assistant training programs, as confirmed by the Administrator.
Improper Food Storage and Cleanliness Issues
Penalty
Summary
The facility failed to ensure proper food storage and cleanliness in the kitchen and other areas. Observations revealed that scoops were stored inside bulk containers with food items such as sugar, oats, and breadcrumbs, which were not labeled or sealed properly. Additionally, containers of ground white pepper and lemon and pepper seasoning salt were found with open and unsealed lids. The exhaust vent over the dish machine had a heavy buildup of dark fuzzy debris, and two microwaves were found with significant food debris and damage, making them difficult to clean. One microwave had a buildup of melted, burnt, and peeling black coating, while the other had heavy food debris on the door and glass plate. The light bulb in the walk-in freezer was also found to be unshielded and unprotected from breakage. Interviews with staff revealed a lack of awareness and adherence to cleaning and maintenance protocols. The Dietary Manager confirmed that food scoops should not be stored inside food containers and that lids on spices should be sealed after use. The Maintenance Supervisor was unaware of the missing light bulb shield in the freezer and the damage to the microwave in the kitchen. The Dietary Manager also mentioned that the damage to the microwave had been present for three years, and the microwave needed to be replaced. The facility's policies on receiving and storing food, cleaning workspaces, and maintaining equipment were not followed, leading to these deficiencies.
Failure to Inspect Bed Frames, Mattresses, and Bed Rails for Entrapment Risks
Penalty
Summary
The facility failed to complete regular inspections of bed frames, mattresses, and bed rails to identify areas of possible entrapment for three residents. Resident #25, who had moderately impaired cognition and required assistance with bed mobility and transfers, was observed with assist bars on both sides of the bed. There was no evidence in the resident's medical record that staff conducted an inspection of the bed frame, mattress, or assist bars for potential entrapment risks. Resident #62, who had severely impaired cognition and required a U-bar side rail for assistance with positioning and transfers, had not had bed rail assessments, including entrapment zone measurements, completed since 8/5/22. Despite the resident's need for the U-bar due to chronic pain and other medical symptoms, there was no documentation of recent inspections in the resident's electronic medical record. Resident #58, who had moderately impaired cognition and was dependent on staff for bed mobility and transfers, was observed with assist rails in the upright position on both sides of the bed. Similar to the other residents, there was no evidence in the medical record that staff conducted inspections of the bed frame, mattress, or assist bars to identify areas of possible entrapment. The Administrator confirmed that the Director of Nursing and/or the management team were responsible for completing these assessments at least quarterly, but this had not been done.
Failure to Ensure Call Lights Were Accessible for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of individual needs by ensuring call lights were within reach at all times for two residents. Resident #31, who was cognitively intact but had functional limited range of motion in both upper extremities and was dependent on staff for bed mobility and transfers, was observed multiple times with the call light on the floor out of reach. Despite the resident's inability to use a traditional call light due to contracted hands, no alternative means to contact staff was provided, forcing the resident to holler for assistance, which was ineffective and led to long waits for help. Interviews with the resident and staff confirmed the resident's inability to use the call light and the lack of an alternative solution. Similarly, Resident #70, who was cognitively intact and required assistance for bed mobility and transfers, was observed multiple times with the call light on the floor and out of reach. The resident confirmed that he/she could use the call light if it was within reach, but staff frequently left it on the floor. Interviews with staff, including an LPN and the Director of Nursing, acknowledged that call lights should be within reach at all times and that Resident #31 should have a soft touch call light due to hand contractures. The facility's failure to ensure call lights were accessible and to provide an alternative for Resident #31 led to deficiencies in accommodating the residents' needs and preferences.
Failure to Develop Comprehensive Care Plan for Resident with Depression
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident diagnosed with dementia and depression. The resident's care plan did not address their depression, rejection of care, or the use of an antidepressant, despite the resident exhibiting severe cognitive impairment and frequent tearfulness. Observations and interviews revealed that the resident cried frequently, felt that nobody cared about them, and resisted care, yet these behaviors were not documented in the care plan. The resident's admission and quarterly Minimum Data Set (MDS) assessments indicated severe cognitive impairment and frequent feelings of depression. Despite these assessments and a physician's order for an antidepressant, the care plan was not updated to reflect the resident's needs. Staff observations and family interviews confirmed the resident's ongoing distress and resistance to care, but these issues were not addressed in the care plan. Interviews with facility staff, including the Care Plan Coordinator and the Director of Nursing, revealed a lack of awareness regarding the resident's behaviors and medication needs. The Care Plan Coordinator admitted that the resident's behaviors and use of antidepressants should have been documented in the care plan but were not. The Director of Nursing also acknowledged that the resident's tearfulness, rejection of care, and use of antidepressants should have been included in the care plan.
Failure to Maintain Oxygen Therapy Orders and Equipment
Penalty
Summary
The facility failed to obtain an order for oxygen use and maintain equipment according to the facility policy for two residents. Resident #54, diagnosed with systolic congestive heart failure, returned from the hospital on continuous oxygen at 3 liters/minute via nasal cannula. However, there were no physician orders for oxygen frequency, liter flow, or changing tubing/cannulas. Multiple observations showed the resident with an oxygen cannula in place but with the oxygen tank either set to 0 liters/minute or empty. Staff members, including a nurse aide and a licensed practical nurse, were observed not addressing the empty oxygen tank promptly, and the resident's oxygen saturation levels were not consistently monitored or maintained as required by the facility's policy. Resident #28, with moderately impaired cognition, required continuous oxygen therapy. The resident's care plan indicated the use of an oxygen concentrator in the room and portable oxygen tanks when out of the room, with tubing to be changed weekly. However, observations showed the resident using oxygen tubing dated 2/28, despite the facility's policy requiring weekly changes. Interviews with staff revealed inconsistencies in following the schedule for changing oxygen supplies and labeling them appropriately. The Director of Nursing confirmed that oxygen tubing should be labeled, stored in a bag, and changed weekly or as needed. The facility's failure to adhere to its policies for oxygen administration and equipment maintenance resulted in deficiencies in providing safe and appropriate respiratory care for the residents involved.
Failure to Transcribe New Medication Order Correctly
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when staff did not transcribe a new order to increase the resident's trazodone dosage. The resident, who had severe cognitive impairment, depression, and insomnia, was supposed to have their trazodone increased from 25 mg to 50 mg at bedtime. However, due to a transcription error, the resident continued to receive the incorrect dose of 25 mg for ten days. This error was observed through the resident's Electronic Medication Administration Record (EMAR) and confirmed by staff interviews and medication cart inspections. The error occurred because the new order was not properly updated in the computer system, and the old medication card was not removed from the medication cart. The Director of Nursing (DON) admitted to missing the removal of the special instruction section on the computer, which led to the continued administration of the incorrect dose. The resident expressed ongoing difficulty sleeping, and the Nurse Practitioner expected the new dosage to begin within two days of the new order. The facility's policy on medication administration was not followed, leading to this significant medication error.
Failure to Provide Properly Prepared Pureed Diet
Penalty
Summary
The facility failed to ensure that residents on a pureed diet received food in the proper form as per their physician's orders. The facility's policy for a pureed diet specifies that food should be blended to a mashed potato consistency or altered to meet the needs of the resident, using as little liquid as possible. However, during an observation, the Dietary Cook did not measure the amount of corn or hot water used and the resulting mixture was chunky and not smooth. Additionally, the pureed potatoes had visible red chunks, and no gravy was served with any of the pureed items, contrary to the diet spreadsheet menu for the lunch meal. During the lunch meal service, the Dietary Manager served pureed corn and potatoes that were not smooth and contained visible chunks. The Dietary Manager also failed to prepare or serve gravy with any of the pureed food items. An interview with the Dietary Manager confirmed that pureed food items should be pudding thick and smooth, and staff should follow the menu and diet spreadsheet to ensure all food items are prepared correctly. The facility census was 95, and two residents had a physician-ordered pureed diet during the period reviewed.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to notify three residents or their representatives in writing of their transfer to the hospital, including the reasons for the transfer. Additionally, the facility did not send a copy of the transfer notice to a representative of the Office of State Long-Term Care Ombudsman. This deficiency was identified during a review of 23 sampled residents, with a facility census of 95. The facility's policy on Discharge/Transfer of Resident was not followed, as it mandates explaining the transfer and providing a signed transfer or discharge notice to the resident and/or representative, even in emergency situations as soon as possible. Resident #48 was transferred to the hospital twice, once on 11/17/22 and again on 6/4/23, due to severe health issues including high blood sugar levels and low oxygen saturation. In both instances, there was no documentation that the resident or their representative received a written notice of transfer. Similarly, Resident #24 was transferred to the hospital on 7/1/23 for a stroke workup, and there was no documentation of a written notice of transfer being provided. Resident #4 experienced a sudden change in condition on 12/29/23 and was transferred to the hospital, but again, no written notice of transfer was documented. Interviews with the facility's administrator and Social Service Director (SSD) revealed a lack of awareness and adherence to the policy. The administrator admitted that transfer notices could not be located and that the charge nurses were responsible for providing them, with the SSD supposed to follow up. However, the SSD was unaware of her responsibility to follow up on transfer notices and notify the State Ombudsman of transfers/discharges. This lack of communication and adherence to policy led to the deficiency in notifying residents and their representatives of hospital transfers.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide a written notice of bed hold with required information to the resident and/or resident representative when the facility initiated a transfer to the hospital for three residents. Resident #48 was transferred to the emergency department on two occasions, and there was no documentation that the facility provided the bed hold policy to the resident or their representative during either transfer. Similarly, Resident #24 was transferred to the hospital for a stroke work-up, and there was no documentation that the bed hold policy was provided. Resident #4 experienced a sudden change in condition and was transferred to the emergency room, but again, there was no documentation that the bed hold policy was provided. During interviews, the Social Services Director (SSD) stated she was unaware that she needed to follow up to ensure bed hold notices were provided. The administrator confirmed that there was no documentation to show that bed hold notices were provided and stated that charge nurses were supposed to provide the bed hold policies, with the SSD following up to ensure completion. The facility's undated policy on Discharge/Transfer of Residents indicated that staff were to explain and give a copy of the bed hold form to the resident and/or representative, which was not adhered to in these cases.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
