Valley Manor And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Excelsior Springs, Missouri.
- Location
- 1410 Hospital Drive, Excelsior Springs, Missouri 64024
- CMS Provider Number
- 265356
- Inspections on file
- 16
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Valley Manor And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors identified multiple failures in food safety and sanitation, including improper hand hygiene, lack of hair restraints, incomplete temperature and sanitation logs, expired and unlabeled food items, and unclean kitchen conditions. Two residents expressed dissatisfaction with food presentation, specifically bowls touching other foods on their plates. These deficiencies had the potential to impact all residents.
Staff failed to follow infection prevention protocols by not changing gloves between clean and dirty tasks and not using required PPE, such as gowns, when providing care to two residents on enhanced barrier precautions. One resident had a surgical wound and a PICC line for IV antibiotics, requiring strict infection control. The facility also lacked an effective infection surveillance program.
Two residents did not have comprehensive care plans reflecting their current needs and interventions. One resident's care plan failed to address the use of a wheelchair seatbelt, while another resident's plan omitted essential care needs such as ADL support, diet, catheter care, and skin integrity interventions, despite these being documented elsewhere and discussed by staff. Staff interviews confirmed that care plans should include all required interventions and preferences, but these omissions resulted in incomplete guidance for care delivery.
Several dependent residents did not consistently receive the required two showers per week, as documented in their care plans and facility policy. Despite staff acknowledging that residents who requested two showers weekly should receive them, documentation and resident interviews revealed that some residents went up to ten days without a shower, leading to discomfort and embarrassment due to inadequate personal hygiene.
A resident with a documented religious restriction against pork was repeatedly served pork products and was not provided with a suitable substitute meal during a lunch service. Despite staff awareness of the restriction and the resident's preference for alternatives like grilled cheese and tomato soup, the only substitute offered was cold cereal, leading to resident frustration and a sense that their dietary needs were not respected.
A resident with multiple medical conditions and moderate cognitive impairment did not receive prescribed pregabalin for pain management as ordered, with several doses missed over a two-week period. The resident reported experiencing pain during this time, and staff interviews confirmed the medication was not administered according to physician orders.
The facility failed to maintain a clean and sanitary kitchen, with observations of grease and grime on surfaces, sticky floors, and improperly stored and labeled food items. The Dietary Manager acknowledged that cleaning tasks were not strictly followed, leading to unsanitary conditions. Additionally, refrigerator and freezer temperatures were not consistently monitored, and the dishwasher was not properly maintained, with logs not updated and the machine not cleaned as required.
The facility failed to implement proper infection prevention measures for several residents, including those with severe cognitive impairment, urinary catheters, and a history of MDRO infections. Staff were unaware of enhanced barrier precautions and proper PPE use, and hand hygiene practices were not followed during resident care.
The facility failed to implement an effective antibiotic stewardship program, lacking protocols for infection treatment and monitoring antibiotic use. The Director of Nursing, new to her role, was unaware of previous infection prevention management and current antibiotic data. The Administrator recognized the importance of stewardship but noted the Director's dual responsibilities. This lack of clarity and accountability led to the deficiency.
The facility failed to respect the rights of four residents, leading to deficiencies in care and dignity. One resident lacked oral care, resulting in dry, cracked lips and secretions in the mouth. Another resident had a dirty urinal placed next to their food and drinks. A resident reported long wait times for toileting assistance, leading to incontinence accidents. Additionally, a resident experienced long wait times for call light responses, especially on weekends.
The facility did not adequately address or communicate the concerns of resident council members, as reported by seven of eight residents in a group meeting. Issues such as inconsistent ice water delivery, food quality, and staff response times were documented in council minutes but not resolved or communicated back to residents. Residents were unaware of grievance procedures, and the Activity Director failed to document resolutions. The DON expected concerns to be addressed and documented, but this was not done, potentially affecting all 68 residents.
The facility failed to manage and reimburse residents' personal funds after discharge, affecting several residents. The facility lacked a refund policy, and checks for refunds were delayed, with some requests not processed promptly. Interviews revealed that the facility had specific timeframes for returning funds, but these were not met, leading to the deficiency.
The facility failed to document and clarify the code status for six residents, leading to inconsistencies between care plans, physician orders, and electronic medical records. Despite the facility's policy requiring advance directives to be respected and documented, several residents had missing or conflicting code status information. Interviews with the DON and Administrator confirmed the expectation for physician orders to be present and consistent across records.
The facility failed to provide a safe, clean, and homelike environment for a resident and in common areas. A resident was found in an unkempt room with dirty floors, trash, and linens on the floor, and without adequate bed linens. Common areas had missing paint, strong odors, and maintenance issues. Staff interviews revealed challenges in maintaining cleanliness and addressing maintenance issues.
The facility did not ensure residents were informed about grievance procedures, as all interviewed residents were unaware of how to file a grievance. Despite the availability of grievance forms, the facility failed to adequately educate residents on their rights and the process, as evidenced by resident council minutes and staff interviews.
The facility failed to create individualized care plans for three residents, leading to unmet needs and preferences. One resident did not receive showers as often as desired due to staffing issues. Another resident's preferences for daily shaving and nail care were not addressed, resulting in irregular grooming. A third resident with advanced dementia lacked specific care interventions, leading to poor oral hygiene and unmet care needs. Staff interviews revealed a lack of awareness about care plans and supplies.
The facility failed to follow professional standards in medication and procedure administration, affecting several residents. A resident received incorrect Flonase dosage, another had improper eye drop administration, and two residents had blood sugar checks without proper drying time. Additionally, a resident received an incorrect Tylenol dosage. Staff acknowledged these deviations from prescribed orders.
The facility failed to provide adequate hygiene and grooming care for residents unable to perform ADLs independently. Observations showed incomplete perineal care and infrequent showers due to staffing shortages, affecting residents with conditions like paraplegia and Alzheimer's. Residents also reported dissatisfaction with irregular shaving and nail care.
A facility failed to ensure proper transfer techniques and supervision, affecting three residents. One resident's wheelchair was not locked during a transfer, another was moved with a Hoyer lift by a single CNA instead of two, and a third had the lift brakes locked against guidelines. These actions were inconsistent with facility policies and manufacturer instructions.
The facility failed to maintain proper hydration for several residents by not providing fresh ice water or thickened fluids as required. Observations showed that residents, including those with cognitive impairments and dietary restrictions, often lacked access to necessary fluids. Interviews with staff revealed inconsistencies in offering fluids, contrary to care plans that required regular hydration support.
The facility was found to have expired medications and biologicals in the medication room, including Calcium 600 mg with Vitamin D, Zinc Sulfate 220 mg, and Bisacodyl Suppositories. The facility's policy did not address expired medications, and the ADON believed the CMT was responsible for checking them. The Administrator stated that expired medications should be checked weekly by Medical Records or the CMT.
The facility failed to meet residents' nutritional needs and preferences, as staff did not follow dietician-approved recipes or dietary preferences, and did not post menu substitutions. A resident with dairy allergies had their preferences ignored, while others reported inconsistencies between the menu and meals served. Kitchen staff did not measure ingredients or follow recipes, and the dietary manager did not use formal tools to assess food preferences.
The facility failed to serve food at safe and appetizing temperatures, with residents receiving cold and burnt meals. Observations showed a lack of temperature documentation and inconsistent checks by dietary staff. Multiple residents reported dissatisfaction with the food's taste and temperature, highlighting a deficiency in the facility's food service quality.
The facility failed to serve meals on time, affecting a resident with paraplegia and potentially impacting all residents. Observations showed significant delays in meal service, with lunch trays served up to 39 minutes late and hall trays delayed by up to 55 minutes. Staff interviews confirmed that meals were consistently late, sometimes by two hours, despite expectations for timely service.
Widespread Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
Facility staff failed to adhere to professional standards for food service safety in multiple areas, as observed during kitchen inspections and interviews. Staff did not consistently perform proper handwashing or use hairnets and beard restraints while preparing and serving food. Handwashing stations were found without paper towels, and staff were seen changing gloves or touching their faces without washing hands before resuming food preparation. Additionally, staff were observed handling soiled gloves and then using the same hand to handle clean utensils, and some staff worked in the kitchen without appropriate hair coverings. Food storage and monitoring practices were also deficient. Several refrigerators and freezers lacked temperature logs for multiple days, and some units did not have thermometers. Food items, including frozen desserts and leftovers, were found without receipt or use-by dates, and expired food was present in storage. Food containers were sometimes unsealed or improperly labeled, and some food items were stored directly on the ground. The kitchen and food preparation areas were not maintained in a clean condition, with spills and food debris left unaddressed for extended periods, and sanitation buckets for cleaning surfaces were not consistently available or used. Food presentation did not meet facility policy or resident expectations. Meals were served with bowls of food placed directly on plates, causing the bowls to touch other food items, which residents found unappetizing and unsanitary. Residents expressed dissatisfaction with the appearance and arrangement of their meals. Additionally, logs for dishwasher sanitization were incomplete, and staff responsible for these tasks cited workload and staffing shortages as reasons for missed documentation. These failures had the potential to affect all residents in the facility.
Failure to Implement and Maintain Infection Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple lapses in staff adherence to infection control protocols. Dietary staff did not change gloves between clean and dirty tasks, and facility staff failed to apply appropriate Personal Protective Equipment (PPE) when providing care and treatment to two residents. Specifically, staff did not don isolation gowns or change gloves and perform hand hygiene between clean and dirty tasks while caring for a resident on enhanced barrier precautions (EBP) due to a surgical wound and a peripherally inserted central catheter (PICC) line. Staff were observed entering the resident's room, applying gloves, and providing peri care without wearing gowns, and one staff member used gloved hands to retrieve items from a drawer without changing gloves or washing hands afterward. Interviews with staff and facility leadership confirmed that the expected protocol was not followed, as staff should have worn gowns and changed gloves with hand hygiene between tasks for residents on EBP. The facility also lacked an effective infection surveillance program, further contributing to the deficiency. The affected resident had a history of surgery, a PICC line for IV antibiotics, and was dependent on staff for all activities of daily living, including care that required strict adherence to infection control measures.
Failure to Maintain Comprehensive and Accurate Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive, person-centered care plans were accurately created and maintained for two residents. For one resident with a history of stroke and hemiplegia, the care plan did not address the use of a seatbelt on the resident's wheelchair, despite observations showing the resident regularly used a seatbelt. Both the MDS Coordinator and the Administrator confirmed that the use of a seatbelt should have been included in the care plan, but it was omitted. For another resident with diagnoses including diabetes, paraplegia, urine retention, and high blood pressure, the care plan lacked specific goals and interventions for activities of daily living and other care needs. The resident was dependent on staff for showering, toileting, and hygiene, and required a mechanical soft diet, urinary catheter care, blood glucose monitoring, pain monitoring, and skin integrity interventions. These needs were documented in the resident's order summary and progress notes but were not reflected in the care plan. The resident also reported inconsistent care regarding turning, hygiene, and shower frequency. Interviews with facility staff, including the MDS Coordinator, DON, ADON, RN, CNA, and Administrator, revealed that staff rely on care plans and the electronic Kardex to determine the care required for each resident. Staff acknowledged that all necessary care interventions, preferences, and significant changes should be included in the care plan, but in these cases, the care plans were incomplete and did not reflect the residents' current needs or preferences.
Failure to Provide Timely Showers for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically timely showers, to dependent residents who were unable to perform these tasks independently. Observations, interviews, and record reviews revealed that three sampled residents did not consistently receive two showers per week as outlined in their care plans and facility policy. Documentation showed gaps in shower provision, with some residents going up to eight to ten days without a shower, despite their preferences and care plans indicating a need for two showers weekly. One resident with intact cognition, diabetes, morbid obesity, and neuropathy reported only receiving one shower per week, sometimes with intervals of eight to ten days between showers, leading to feelings of embarrassment due to poor hygiene. Another resident with mild cognitive impairment, stroke, dementia, and diabetes, who required substantial assistance, also reported only receiving one shower per week, contrary to their care plan and expressed preferences. A third resident, dependent on staff for all ADLs due to paraplegia and other medical conditions, similarly reported not receiving two showers per week and expressed discomfort and embarrassment about their hygiene. Interviews with facility staff, including CNAs, the ADON, DON, and MDS Coordinator, confirmed that residents who requested two showers per week should have received them, and that resident preferences were to be care planned. However, documentation and resident interviews indicated that this standard was not consistently met, resulting in a failure to maintain good personal hygiene for these dependent residents.
Failure to Accommodate Religious Dietary Restrictions
Penalty
Summary
The facility failed to honor a resident's religious dietary preferences by not providing a suitable substitute meal when pork was served, despite documentation indicating the resident could not consume pork products. During a lunch meal service, the Dietary Manager initially prepared a tray containing breaded pork for the resident. After being informed by the Assistant Director of Nursing that the resident could not eat pork, the pork was removed, but the plate was returned with only rice and green vegetables and no substitute entrée. The resident was then offered cold cereal as a substitute, which was not their preferred choice. The resident later expressed frustration, stating that pork is regularly served to them despite their religious restrictions and that they are not always aware of what substitutes are available. Record review showed that pork was frequently included in the facility's menu, and the resident's menu card clearly indicated a restriction against pork. Interviews with staff revealed that while a preference list is maintained and residents are expected to annotate substitutes, the kitchen staff did not always catch dietary restrictions, and suitable alternatives were not always prepared in advance. The resident, who is cognitively intact and has a diagnosis of liver cell carcinoma, reported feeling that their preferences and religious needs were not respected during meal service.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
Facility staff failed to administer pain management medication as ordered for a resident with moderately impaired cognition and multiple diagnoses, including pain, debility, anxiety, depression, and lung disease. The resident's physician had prescribed pregabalin 150 mg by mouth three times daily for pain, and the resident's care plan included both scheduled and PRN pain medications. Review of the medication administration record for April showed multiple missed doses of pregabalin on specific dates, with no documentation that the medication was given. During interviews, the resident reported not receiving pregabalin as prescribed during the last two weeks of April and experiencing pain while waiting for the medication. The ADON was unable to explain the gaps in administration and noted that the pharmacy was waiting for the physician to sign the order, while the Administrator confirmed that medications are expected to be administered as ordered. Facility policy requires implementation of the medication regimen as ordered and immediate provider contact if pain is not controlled, but these procedures were not followed, resulting in unnecessary pain for the resident.
Facility Fails to Maintain Sanitary Kitchen and Proper Food Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by observations of grease and grime on condiment baskets, recipe menu books, and food carts. The kitchen floors were sticky, and garbage and debris were found on the floor and food storage racks. The Dietary Manager acknowledged that cleaning tasks were assigned to staff, but the cleaning lists were not strictly followed, leading to unsanitary conditions. Additionally, the facility did not ensure that food preparation surfaces were cleaned and sanitized before use, as expected by the Administrator. The facility also failed to properly store and label food items. Observations revealed undated and unlabeled food items in the refrigerator, including applesauce, meat in marinade, and various soups and gravies. Spices were also found to be opened and undated, and some food items were stored directly on the floor. The Dietary Manager and staff were aware of the requirement to date and label food items, but this was not consistently done, leading to potential food safety risks. Furthermore, the facility did not adequately monitor refrigerator and freezer temperatures, as logs were found to be incomplete or missing. The Dietary Manager admitted to having only one thermometer in use, and the temperature logs for several days were blank. The Administrator expected temperatures to be checked daily on each shift, but this was not consistently done. Additionally, the dishwasher was not properly maintained, with logs not updated and the machine not cleaned as required. The Dietary Manager and staff were aware of the need to test and log the dishwasher's sanitizer levels, but this was not consistently performed.
Inadequate Infection Control and Precautions
Penalty
Summary
The facility failed to implement proper infection prevention measures for several residents, as observed during a survey. Three residents were not placed on enhanced barrier precautions despite having conditions that warranted such measures. Resident #34, with severe cognitive impairment and a gastric feeding tube, had no care plan addressing the risk of multidrug-resistant organism (MDRO) infections or the use of personal protective equipment (PPE). Similarly, Resident #63, who had a urinary catheter and a history of repeated urinary tract infections, also lacked a care plan for MDRO infection risk and PPE use. Resident #23, with a history of MDRO infections and impaired cognition, was not identified for enhanced precautions, and staff were not alerted to the necessary PPE for care. The facility's staff demonstrated a lack of awareness and understanding of enhanced barrier precautions. Interviews with nursing assistants revealed that they were unsure about which residents required enhanced precautions and what PPE should be used. This lack of knowledge extended to the Director of Nursing and the Assistant Director of Nursing, who were also uncertain about the current criteria and recommendations for enhanced precautions. This indicates a systemic issue in the facility's infection control practices and staff training. Additionally, the facility failed to maintain proper hand hygiene practices during resident care. An observation of Resident #58's care showed that a certified nursing assistant did not wash hands between glove changes while providing care for a resident with a urinary catheter. This was contrary to the facility's hand hygiene policy, which emphasizes handwashing as a primary means to prevent healthcare-associated infections. The deficiency in hand hygiene practices further highlights the facility's failure to adhere to infection prevention protocols.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, specifically lacking a comprehensive antibiotic stewardship program. The program was supposed to include protocols for optimizing infection treatment, reducing adverse events from inappropriate antibiotic use, and implementing a system to monitor antibiotic usage and resistance data. However, the facility did not provide documentation of ongoing monthly surveillance and monitoring, nor did it have designated staff accountable for overseeing antibiotic stewardship. The facility's revised Antibiotic Stewardship policy from December 2016 outlined the need for monitoring antibiotic use and educating staff, but these measures were not effectively implemented. During interviews, the Director of Nursing, who started in May, admitted to being unaware of who previously managed infection prevention and was unsure of the current antibiotic usage and monitoring data. The antibiotic tracking book was found to be lacking in information. The Administrator acknowledged the importance of antibiotic stewardship but noted that the Director of Nursing was new to her role and now also responsible for managing infection control and antibiotic stewardship. This lack of clarity and accountability contributed to the deficiency in the facility's antibiotic stewardship program.
Deficiencies in Resident Care and Dignity
Penalty
Summary
The facility failed to respect the rights of four residents, leading to deficiencies in care and dignity. One resident, who was severely cognitively impaired and required total assistance for all activities of daily living, was observed with a lack of oral care, resulting in dry, cracked lips and a buildup of secretions in the mouth. The care plan for this resident did not address grooming or oral care needs, and staff interviews revealed a lack of knowledge about oral care supplies. Another resident, who was not cognitively intact and had a history of urinary tract infections, was observed with a dirty urinal placed next to their food and drinks, compromising their dignity and hygiene. A resident who was cognitively intact but required assistance for personal hygiene and mobility reported long wait times for toileting assistance, leading to embarrassing incontinence accidents. The resident expressed frustration with the lack of timely assistance, particularly during nighttime hours, which was attributed to staffing shortages. Interviews with staff confirmed that residents should be taken to the bathroom before meals and checked every two hours, but the resident's experience indicated these protocols were not consistently followed. Additionally, another resident with intact cognitive skills but significant physical impairments reported waiting over an hour and a half for staff to respond to call lights. The resident noted that staff shortages on weekends exacerbated the issue. Interviews with staff and the facility's administration revealed discrepancies in the expected response times for call lights, with the administrator and DON stating that call lights should be answered within a few minutes, yet the resident's experience suggested otherwise.
Failure to Address and Communicate Resident Council Concerns
Penalty
Summary
The facility failed to adequately address and communicate the concerns and recommendations of the resident council members, as reported by seven of the eight residents who participated in a group meeting. The facility's policy for recording and investigating grievances, revised in April 2017, outlines a process for investigating and resolving grievances, but the facility did not follow through with this process. The resident council minutes from meetings held in April, May, and June 2024, documented various concerns such as inconsistent ice water delivery, issues with food quality, and inadequate response times from staff. However, these minutes did not indicate how the concerns were addressed or if they were resolved to the residents' satisfaction. During interviews, residents expressed that they did not receive any follow-up on their concerns voiced during the resident council meetings and were unaware of how to fill out a grievance or who to contact. The Activity Director mentioned that resolutions were discussed in subsequent meetings but were not documented in the minutes. The Director of Nursing expected that residents' concerns would be addressed and documented in the following meeting, but this was not done. This lack of communication and documentation had the potential to affect all 68 residents in the facility.
Facility Fails to Timely Reimburse Residents' Funds Post-Discharge
Penalty
Summary
The facility failed to properly manage and reimburse residents' personal funds after discharge, affecting nine out of 17 sampled residents. The facility did not have a policy on refunds, and the Resident Rights Policy indicated that residents have the right to manage their financial affairs and that the facility must act as a fiduciary for residents' funds. The facility's Interim Aged Analysis Report showed negative balances for several discharged residents, indicating that refunds were not issued in a timely manner. Checks for these refunds were delayed, with some requests submitted to the corporate office but not processed promptly. Interviews with the Business Office Manager and Administrator revealed that the facility had a 30-day timeframe to return funds for Medicaid residents and a five-day timeframe for private pay residents. However, the Business Office Manager noted delays in processing refund requests, with some requests not submitted or processed due to previous management issues. The Administrator expected timely returns of funds, but the facility's actions did not align with these expectations, leading to the deficiency in managing residents' financial affairs.
Failure to Document and Clarify Code Status for Residents
Penalty
Summary
The facility failed to clarify and document the code status of six residents, which is a critical aspect of respecting residents' rights to make decisions about their treatment preferences. The facility's Advance Directive Policy requires that advance directives be respected and documented in accordance with state law and facility policy, including obtaining physician orders for Do Not Resuscitate (DNR) or Full Code status. However, the review revealed that the code status was not documented in the medical records or care plans for several residents, and there were no corresponding physician orders. For Resident #63, the face sheet and physician orders lacked a code status, despite the resident's complex medical history, including cognitive impairment and chronic conditions. Similarly, Resident #6's care plan indicated a DNR status, but there was no corresponding physician order, and the electronic medical record showed conflicting information. Resident #18's care plan indicated a Full Code status, but the electronic medical record and code status book showed a DNR status, highlighting inconsistencies in documentation. Other residents, such as Resident #29 and Resident #33, also had discrepancies between their care plans, physician orders, and electronic medical records regarding their code status. Resident #22 had a signed OHDNR order, but the physician order was missing from the resident's POS. Interviews with the Director of Nursing and the Administrator confirmed that the facility's practice should include having a physician order for each resident's code status, which should be reflected on the face sheet and care plan, but this was not consistently done for the sampled residents.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for Resident #23 and in common areas on the 200 and 300 halls. Resident #23, who was readmitted from the hospital with infected hardware from hip repair and had a history of multi-drug resistant organisms, was observed multiple times in an unkempt room with dirty floors, trash, and linens on the floor. The resident's call light was often out of reach, and the resident was found without adequate bed linens, shivering in a cold room. Staff failed to ensure the call light was accessible and did not offer assistance or bed linens during tray delivery. The facility's common areas also showed significant deficiencies. Observations revealed missing wood chunks and varnish on handrails, missing paint on resident room doors, and a strong odor of urine in the 300 hall. The kitchen ceiling had chipping paint, and drywall patches were unsanded and unpainted. The dining room had exposed food trays with flies, and several rooms had sticky floors, strong odors of urine, and missing paint from walls. Maintenance issues were noted, including a black spot on the floor from a shower leak and difficulties in matching wall paint colors for repairs. Interviews with staff highlighted challenges in maintaining cleanliness and addressing maintenance issues. The housekeeping supervisor mentioned a lack of a floor tech and no current schedule for stripping and waxing floors, while the maintenance director noted ongoing pest control issues and difficulties in matching paint colors. A CNA reported that strong odors of urine were due to inadequate incontinent care and infrequent bed checks. These observations and interviews indicate systemic issues in maintaining a clean and safe environment for residents.
Failure to Inform Residents on Grievance Procedures
Penalty
Summary
The facility failed to ensure that residents were informed about how to file a grievance, which is a violation of their rights. The review of the resident rights documentation indicated that federal regulations guarantee residents certain rights, including the right to voice grievances without fear of discrimination or reprisal. The facility is required to make information on how to file a grievance available to residents and establish a grievance policy to ensure prompt resolution of grievances. However, during a group interview, all eight residents in attendance expressed that they were unaware of how to fill out a grievance or who to contact for assistance. The resident council minutes from April to June did not show any discussion on how to file grievances, focusing instead on other rights such as confidentiality, privacy, respect, and communication. Interviews with the Activity Director and the Director of Nursing revealed that grievance forms were available at nurse's stations and in front of the Activity Director's office, but it was assumed that residents knew this information. This lack of awareness among residents indicates a failure in the facility's responsibility to educate and inform them about their grievance rights and procedures.
Failure to Develop Individualized Care Plans
Penalty
Summary
The facility failed to develop individualized, person-centered comprehensive care plans for three residents, leading to unmet needs and preferences. Resident #18, who was cognitively intact and dependent on a wheelchair, required substantial assistance with bathing due to multiple sclerosis and other conditions. However, the care plan did not include the resident's shower preferences, resulting in showers being provided less frequently than desired. The resident expressed dissatisfaction with the frequency of showers, which were scheduled twice a week but often delayed due to staffing issues. Resident #43, also cognitively intact and dependent on a wheelchair, required assistance with personal hygiene and grooming. The care plan did not address the resident's preferences for daily shaving and nail care, leading to irregular grooming practices. The resident reported irritation from the facility's razors and overgrown nails, which were not consistently addressed. Observations confirmed the resident's facial hair and nail condition, and interviews with staff revealed a lack of awareness and documentation regarding the resident's grooming preferences. Resident #34, with severely impaired cognition and advanced dementia, was on hospice care and required total assistance for all activities of daily living. The care plan lacked specific interventions for comfort care, grooming, oral care, repositioning, and skin integrity. Observations showed the resident with poor oral hygiene and unmet care needs, while interviews with staff indicated a lack of knowledge about care plans and oral care supplies. The facility's failure to update and individualize care plans resulted in inadequate care for these residents.
Medication and Procedure Administration Deficiencies
Penalty
Summary
The facility failed to ensure that staff followed professional standards in administering medications and performing procedures, affecting several residents. One resident did not receive the correct dosage of Flonase nasal spray as prescribed, with only one spray administered in each nostril instead of the required two. The Certified Medication Technician (CMT) did not instruct the resident to administer the correct dosage, despite acknowledging the need to follow the physician's order. Another resident experienced improper administration of eye drops, where the CMT allowed the tip of the eye dropper to touch the resident's eyelashes, contrary to the facility's policy. Additionally, the resident applied lacrimal pressure for only eight seconds, whereas the policy required one minute. This deviation from the procedure was acknowledged by both the CMT and the Director of Nursing (DON). The facility also failed to obtain a physician's order for blood sugar checks for one resident, and the Licensed Practical Nurse (LPN) did not allow the alcohol to dry completely before obtaining blood sugar readings for two residents. Furthermore, another resident received an incorrect dosage of Tylenol, with two tablets administered instead of the prescribed one. The CMT involved admitted to not following the physician's orders, and the DON confirmed the expectation to adhere to the prescribed dosage.
Deficiencies in Resident Hygiene and Grooming Due to Inadequate Care
Penalty
Summary
The facility failed to provide adequate care for residents who were unable to perform activities of daily living (ADLs) independently, resulting in deficiencies in personal hygiene and grooming. Observations revealed that staff did not provide complete perineal care for several residents, including not cleaning all necessary areas and using the same area of a wipe for different parts of the body. This affected multiple residents who were dependent on staff for toileting and personal hygiene due to conditions such as paraplegia, Alzheimer's disease, and multiple sclerosis. Additionally, the facility did not ensure that residents received showers as scheduled, with some residents receiving significantly fewer showers than planned. This was partly due to staffing shortages, as shower aides were often pulled to work on the floor, leaving residents without the necessary hygiene care. Residents expressed dissatisfaction with the infrequency of showers, and some reported feeling embarrassed due to oily hair and inadequate cleanliness. The facility also failed to provide regular shaving and nail care for residents, with documentation showing that these tasks were often not completed during scheduled shower days. Residents reported preferences for daily shaving and expressed discomfort with the facility's shaving methods, which sometimes caused skin irritation. The lack of consistent grooming and hygiene care was attributed to insufficient staffing and inadequate scheduling, leading to unmet resident needs and dissatisfaction.
Improper Transfer Techniques and Inadequate Supervision
Penalty
Summary
The facility failed to ensure proper techniques were used to reduce the possibility of accidents or injuries during resident transfers. Specifically, staff did not lock residents' wheelchairs during transfers, did not close the base of lift legs during movement, and performed transfers with only one staff member present when two were required. These deficiencies affected three residents, including one who was cognitively intact and dependent on a wheelchair, another with moderately impaired cognition and multiple physical impairments, and a third with memory problems and dependency on staff for all activities of daily living. For Resident #31, staff used a mechanical lift to transfer the resident from a recliner to a toilet and back to a wheelchair. During this process, the lift's legs were locked when they should have been free to roll, and the wheelchair was not properly locked, leading to potential instability. Staff members involved were unaware of the correct procedures, indicating a lack of training or adherence to facility policies. Resident #6, who required substantial assistance and had multiple diagnoses including cerebral palsy and hemiplegia, was transferred using a Hoyer lift by a single CNA, contrary to the care plan that required two staff members. This was reportedly due to staffing shortages, with staff acknowledging they often performed transfers alone. For Resident #25, staff locked the brakes on the mechanical lift during a transfer, which was against the manufacturer's guidelines, further demonstrating inconsistencies in following proper procedures.
Failure to Maintain Resident Hydration
Penalty
Summary
The facility failed to maintain the hydration status of five residents by not providing fresh ice water or offering thickened fluids as required. Observations revealed that Resident #1, who was cognitively impaired and at risk for dehydration due to a urinary tract infection, did not have fluids within reach on multiple occasions. Despite being on a puree diet with nectar thick liquids, the resident was often found without any liquids in their room, indicating a lack of adherence to the care plan that required encouragement of fluid intake. Resident #10, who was cognitively intact but required assistance for daily activities, reported that their water cup was sometimes filled only once a day, and there were days when it was not filled at all. Observations confirmed that the resident's ice water was refilled only upon request, and the water cup was often less than a quarter full. This neglect in providing adequate hydration was contrary to the care plan, which required staff to prompt fluid intake with meals and in between. Other residents, such as Resident #25, who was severely impaired and dependent on staff for all activities, were also found without the necessary thickened fluids in their rooms. Interviews with staff revealed a lack of consistent practice in offering fluids every two hours, as expected. Resident #63, with a history of urinary tract infections, was observed with untouched beverages and no water available, while Resident #58 expressed a desire for more frequent ice water refills, which were not consistently provided. These observations and interviews highlight a systemic issue in the facility's hydration management practices.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to discard expired medications and biologicals stored within the medication room, as observed during a survey. The facility's policy for the storage of medications was undated and did not address the handling of expired medications. During an observation and interview, it was found that the central supply cabinet contained an unopened bottle of Calcium 600 mg with Vitamin D supplement expired since June 2024, an unopened bottle of Zinc Sulfate 220 mg expired since March 2024, and a box of Bisacodyl Suppositories expired since November 2022. The Assistant Director of Nursing (ADON) indicated a belief that the Certified Medication Technician (CMT) was responsible for checking expired medications, which should be destroyed and not used. In an interview, the Administrator stated that either Medical Records or the CMT should check for expired medications every Tuesday, and there should not be expired medications in the room. Staff had been trained to check expiration dates when pulling medications.
Deficiencies in Meal Preparation and Dietary Preferences
Penalty
Summary
The facility failed to ensure that meals were served to meet the nutritional needs and preferences of residents, as evidenced by several deficiencies observed during the survey. Staff did not prepare food according to the registered dietician-approved recipes, failed to follow dietary preferences, and did not post a list of available menu substitutions for residents. This affected five of the seventeen sampled residents. For instance, Resident #22, who is allergic to dairy products and whey, reported that their allergies were not noted on their meal ticket, and their dietary preferences were not addressed. Additionally, Resident #21 expressed that they did not always receive the meals they ordered, and Resident #48 was unable to have cranberry juice with all meals as requested, with the facility only offering juice at breakfast. Resident #31 noted the absence of salt and pepper, which used to be provided with meals. Furthermore, Resident #32 expressed frustration during a resident council meeting about inconsistencies between the menu and the meals served, such as being served breaded chicken nuggets instead of BBQ chicken thighs as listed on the menu. Observations in the kitchen revealed that staff did not measure ingredients or follow recipes when preparing meals, such as quick oats, farina, and pancakes. The dietary manager admitted to not using a formal assessment tool for determining food preferences and acknowledged that the a-la-carte menu was not posted in the dining room. The dietician expected staff to follow menus and complete dietary preference assessments upon admission and annually, but these expectations were not consistently met.
Deficiency in Food Service Quality and Temperature Control
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that hot food was not served at the appropriate temperature, and burnt food was provided to 10 out of 17 sampled residents. The facility's policy required food to be stored, prepared, distributed, and served in accordance with professional standards for food service safety, including maintaining specific temperature ranges for different types of food. However, the facility did not adhere to these standards, as evidenced by the lack of temperature logs for July and the failure to document food temperatures during meal service. Multiple residents reported receiving cold meals, with some describing the food as tough or burnt. For instance, one resident mentioned receiving burnt bacon and cold food, while another complained about the difficulty in cutting and chewing cold meat. Additionally, residents expressed dissatisfaction with the taste of the food, noting that it was sometimes overcooked or undercooked. The dietary staff did not consistently check or document food temperatures, and there were instances where burnt food, such as pancakes and baked goods, was served to residents. Interviews with staff members, including dietary aides and nurse aides, confirmed that there were frequent complaints from residents about cold and burnt food. The dietary manager acknowledged that food temperatures should be checked multiple times during meal service, but this was not consistently done. The facility's failure to maintain proper food temperatures and serve palatable meals resulted in a deficiency in providing quality care to the residents.
Consistent Delays in Meal Service
Penalty
Summary
The facility failed to serve meals according to scheduled meal times, affecting one of 17 sampled residents and potentially impacting all residents in the community. The facility's policy required timely distribution of meals and snacks, but observations showed significant delays in meal service. For instance, lunch service on multiple days was delayed, with the first tray served 24 minutes after the posted meal time and the last tray served 39 minutes late. Hall trays were also delayed, with the first cart leaving the kitchen 55 minutes after the scheduled time. Interviews with staff, including the Dietary Manager and Certified Nurse Aides, confirmed that meals were consistently served late, sometimes by up to two hours. Resident #22, who had intact cognitive skills but required assistance for meals due to paraplegia and other health conditions, reported that their food was often late. The Dietary Manager was unaware of the consistent delays, although they acknowledged that meal service took longer when residents had a-la-carte orders. The facility's dietician and administrator both expected meal service to be completed within one hour, but this expectation was not met. The consistent delays in meal service were observed and reported by multiple staff members, indicating a systemic issue within the facility's meal distribution process.
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Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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