Villa At Blue Ridge, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbia, Missouri.
- Location
- 701 Blue Ridge Road, Columbia, Missouri 65201
- CMS Provider Number
- 265251
- Inspections on file
- 18
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Villa At Blue Ridge, The during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, dementia, psychotic disturbance, and anxiety was verbally abused by a CNA who entered the room at night and repeatedly yelled, mocked, and demeaned the resident instead of using calm, supportive communication as outlined in the care plan. Video footage captured the CNA loudly confronting the resident about their actions, denying the resident's delusional perceptions, stating the resident had "no freaking clue" what they were doing or where they were, and ultimately yelling at the resident to go to sleep and slamming the door. The administrator, DON, law enforcement, and the resident's responsible party later agreed that the CNA's conduct on the video constituted verbal abuse.
Staff failed to follow facility policy for post-fall assessment and documentation after an unwitnessed fall involving a resident with moderate cognitive impairment and a history of prior falls. Video showed the resident on a fall mat beside the bed, and a CNA reported this twice to an LPN. The LPN delayed going to the room, did not complete a Report of Event Form, and only obtained vital signs more than an hour later without performing or documenting required neuro checks or range-of-motion assessments. The resident’s responsible party reported assisting the resident back to bed and remaining in the room for an extended period without any staff entering to assess the resident, and leadership confirmed that the expected post-fall procedures and documentation were not carried out.
Staff did not consistently follow facility policies requiring dual narcotic counts and timely medication ordering, resulting in missing documentation of controlled substance counts across multiple shifts and unavailability of ordered medications for three sampled residents. Narcotics were not always counted and signed by two staff at shift changes, and some shifts had no signatures at all. Additionally, medications were not reordered in advance as required, leading to situations where residents’ prescribed medications were not on hand and therefore not administered as ordered.
Staff failed to notify physicians when ordered medications were unavailable for three residents, despite facility policy requiring nursing to contact the prescriber if medication delivery is delayed or a drug is not available. One moderately cognitively impaired resident missed doses of antihypertensive and constipation medications, another cognitively intact resident missed multiple doses of supplements and other prescribed drugs, and a severely cognitively impaired resident missed repeated doses of medications for hyperlipidemia, dementia, anticoagulation, hypokalemia, cystitis, and vitamin deficiency. MARs showed numerous entries of medications marked as not available, while nurse notes lacked documentation of physician or pharmacy notification, and interviews with a CMT, the ADON, and the DON confirmed that nurses were expected, but failed, to contact the physician and pharmacy in these situations.
Staff failed to safeguard a cognitively intact resident’s $1700 in cash and did not promptly investigate repeated reports that the money was missing. At admission, an RN accompanied the resident to the business office, where the resident handed $1700 in cash to a staff member to be placed in an account, but no corresponding deposit was ever recorded. Over the following months, the resident and family repeatedly reported the missing funds to multiple staff, including social services and the Activity Director, who in turn informed the administrator. The administrator did not initiate an investigation or notify the state agency at that time, despite facility policy requiring thorough investigation and reporting of alleged misappropriation. Only after the Director of Operations was informed of the ongoing concern was an investigation started, confirming that the resident had given $1700 to a staff member and that the funds were never deposited.
Staff failed to ensure timely reporting of an allegation of misappropriation of a resident’s narcotic medication to the state agency. A resident with moderate cognitive impairment and PRN opioid orders had a bottle of liquid morphine that an LPN discovered with a broken seal and clear liquid instead of the expected pink solution, suggesting possible tampering or dilution. The LPN reported this to the ADON, who in turn informed the administrator. The pharmacist confirmed the medication should remain pink and that water would dilute the color. Although leadership acknowledged that the administrator was responsible for reporting such misappropriation allegations to the state within 24 hours, neither the administrator nor the ADON could confirm that the required report was made.
Staff failed to conduct and document a thorough investigation into an allegation that a resident’s PRN liquid morphine, ordered as an opioid pain medication, had been tampered with. An LPN discovered during a narcotic count that the morphine bottle’s seal was broken and the liquid appeared clear instead of pink, despite the medication reportedly never having been used since receipt. The LPN reported this to the ADON, and a pharmacist later confirmed that the solution should remain pink and that dilution with water would change the color. Although administration reported that an investigation was completed and the allegation unsubstantiated, there was no documentation in the resident’s record or facility files to show that a required, thorough investigation of the alleged misappropriation was performed.
Staff did not notify the physician or family after changes in condition for three residents, including falls and significant weight loss. Documentation was lacking for required notifications, and family members expressed concerns about communication. Staff interviews confirmed the expectation to notify, but no policy was provided.
Staff did not consistently update or revise care plans after significant changes in residents' conditions, such as falls or notable weight loss, and failed to perform required quarterly care plan reviews. For example, a resident's care plan was not updated after a fall that led to an ER visit, and another resident's care plan lacked timely interventions for significant weight loss. The DON and administrator confirmed that care plans should be updated after such events and on a regular schedule, but acknowledged these updates were not completed as required.
Facility staff failed to follow required hiring protocols by employing a CNA with a Class A Felony conviction for First Degree Assault, a disqualifying offense. The initial background check did not identify the conviction because the mandated Family Safe Care Registry was not used, and the issue was only discovered during a later review.
Staff did not provide written bed hold policy notifications to three residents or their representatives during hospital transfers, as required by facility policy. Record reviews and resident interviews confirmed the absence of these notices, and staff interviews revealed a lack of oversight to ensure the notifications were consistently issued and documented.
Staff failed to ensure a resident received pain medications as ordered after a surgery was postponed, with missed doses due to lack of physician orders and poor communication about medication holds. Additionally, two residents who smoke were not re-assessed for smoking privileges after incidents, and staff were unclear about responsibility for completing smoking assessments.
Staff failed to enforce facility policies prohibiting residents from retaining smoking materials, resulting in two residents keeping cigarettes and lighters in their possession. One resident, assessed as cognitively intact, was observed smoking in a prohibited area and had no smoking interventions on the care plan. Another resident, whose care plan required supervised smoking and storage of smoking materials at the nurses' station, was found with cigarettes and a lighter in a public area. Staff interviews revealed confusion about which residents were allowed to keep smoking supplies, leading to inadequate supervision and increased accident risk.
Facility staff failed to complete quarterly MDS assessments for 19 residents within the required 92-day interval, as mandated by federal regulations. This deficiency was due to the previous MDS Coordinator's frequent absences, resulting in a backlog. The current MDS Coordinator is working to catch up, but the DON has been unavailable to assist due to other responsibilities. The administrator was unaware of the backlog, and corporate oversight had not reported the issue.
The facility failed to implement a comprehensive water management program, lacking policies, control measures, and testing protocols to prevent Legionella growth. Staff interviews revealed a lack of awareness and understanding of the program, contributing to a resident testing positive for Legionella after being hospitalized with respiratory distress.
The facility failed to conduct required CNA registry checks on five employees, including a Dietary Aide and a Registered Nurse, due to a lack of awareness by the assistant business office manager. Additionally, the facility did not investigate an injury of unknown origin for a resident with intact cognition and physical impairments, who was found with facial and wrist injuries. The ADON did not conduct a formal investigation or report the incident, and the Administrator was not informed, indicating a breakdown in communication and procedure adherence.
Facility staff failed to provide prescribed treatment for a resident with cognitive impairment and medical conditions, as Tubi grips were not consistently applied as ordered. Additionally, there were inconsistencies in code status documentation for two residents, with conflicting records of full code and DNR status. Staff interviews revealed a lack of awareness and understanding of the documentation discrepancies, and audits were not conducted frequently enough to ensure accuracy.
The facility failed to maintain RN coverage for at least eight consecutive hours per day, seven days a week, as required. The RN staff schedule showed multiple days without adequate coverage in July, August, September, and early October 2024. Interviews revealed that the facility had only one full-time RN, the DON, who worked night shifts and was on call. The ADON and administrator acknowledged the staffing shortfall and the requirement for RN coverage.
Facility staff failed to follow immunization policies for pneumococcal vaccines, resulting in two residents not being offered or documented as receiving the vaccines. The Infection Preventionist admitted to not maintaining the vaccination program, and the administrator acknowledged the oversight.
Facility staff did not complete a comprehensive discharge summary or post-discharge plan for a resident, as required by policy. The SSD, responsible for this task, admitted to not completing the necessary documentation. The ADON and administrator confirmed the SSD's role in ensuring discharge information is documented.
Facility staff failed to provide appropriate dialysis care for a resident, lacking necessary documentation and assessments as per professional standards. The resident's medical records did not include vital signs, shunt monitoring, or communication forms. Interviews revealed staff were unaware of the dialysis care policy, and there was a lack of oversight and education on proper procedures.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.45% error rate. A CMT crushed Metoprolol Succinate ER tablets, which should not be crushed, and administered Latanoprost eye drops to both eyes of a resident, contrary to the order for the left eye only. The errors were acknowledged by the CMT, and the importance of following medication orders was emphasized by the ADON and Charge Nurse.
Facility staff failed to document collaboration with hospice providers for two residents receiving hospice services. Despite expectations for regular communication and care plan documentation, records for a resident with cancer and another with kidney disease lacked necessary documentation. Interviews with staff, including an LPN, ADON, and the administrator, confirmed the expectation for documentation, which was not met.
Facility staff failed to secure medication and treatment carts, leaving them unlocked and unattended in public areas accessible to residents. Despite the facility's policy requiring carts to be locked, observations showed repeated instances of unsecured carts. Interviews with staff confirmed the carts should be locked unless directly attended, acknowledging the risk of resident access or drug misplacement.
Facility staff failed to document a physician-ordered wound care treatment for a resident, as required by professional standards. The resident's medical records did not include the physician's order for wound care, despite the resident being cognitively intact and having a specific treatment regimen prescribed. Interviews with staff revealed that both nurses and the DON were responsible for inputting and verifying orders, but the LPN was unaware of the wound care order. The administrator confirmed the expectation for accurate order entry and acknowledged the risk of infection if orders were not followed.
Facility staff failed to update care plans for three residents after falls, as required by policy. A resident with moderate cognitive impairment, another with severe cognitive impairment, and a cognitively intact resident all experienced falls, but their care plans lacked new interventions. Interviews revealed confusion about responsibility for updating and auditing care plans, with the MDS Coordinator admitting to missing updates due to health issues.
Verbal Abuse of Cognitively Impaired Resident by CNA
Penalty
Summary
Facility staff failed to protect a resident from verbal abuse when a CNA entered the resident's room during the night and repeatedly yelled at and mocked the resident. Video footage from the resident's room showed the CNA loudly confronting the resident about "leaving stuff alone" and questioning what the resident was doing. When the resident, who was experiencing delusional thinking about killing an animal, attempted to explain, the CNA loudly denied the resident's perceptions, repeatedly told the resident to leave things alone, and stated the resident had "no freaking clue" what they were doing or where they were. The CNA continued to argue with the resident, raised their voice, and ultimately yelled at the resident to go to sleep before slamming the door as they exited the room. The resident had a documented history of moderate cognitive impairment with diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance with hallucinations and delusions, and anxiety. The resident's care plan directed staff to calm the resident during distress related to decision making by talking slower and calmer, giving time to make decisions, and offering supportive measures such as contacting family. Instead of following these approaches, the CNA engaged in mocking and ridiculing behavior, used demeaning language, and failed to use calm communication techniques appropriate for a resident with dementia and psychotic symptoms. The administrator, DON, police officer, and the resident's responsible party all later characterized the CNA's behavior, as seen on the video, as verbal abuse toward the resident.
Failure to Complete and Document Required Post-Fall Assessment
Penalty
Summary
Facility staff failed to meet professional standards of care by not completing and documenting a fall assessment as required by facility policy after an unwitnessed fall involving one resident. The facility’s Event Investigation policy directed staff to complete a Report of Event Form as soon as possible for unexpected events such as falls, and to document the event location and type, vital signs, mental/neurological status, range of motion, and pain assessment. The resident’s admission MDS showed moderate cognitive impairment and a history of two or more non-injury falls since admission. Video footage from the resident’s room showed a CNA entering the room twice with the resident’s lower body on the fall mat/mattress next to the bed. The CNA reported to the nurse on two occasions that the resident was on the fall mat/mattress. The EMR for the date of the incident did not contain documentation that the LPN completed a Report of Event Form or performed and documented the required post-fall assessments, including neurological status and range of motion. The LPN stated that the CNA reported the unwitnessed fall but the LPN was busy and did not immediately assess the resident, and that approximately 10 minutes later the resident’s family arrived and assisted the resident back to bed. The LPN did not enter the room until after the family left over an hour later, at which time the resident was asleep; the LPN obtained vital signs but did not initiate neurological or range of motion checks and only believed a progress note had been documented. The administrator and DON both stated they expected completion of an event form, vital signs, neurological checks, range of motion, pain assessment, and documentation per policy for an unwitnessed fall. The resident’s responsible party reported arriving, assisting the resident from the fall mat/mattress to bed, remaining for about an hour and a half, and not seeing any staff enter the room or assess the resident during that time.
Failure to Perform Dual Narcotic Counts and Ensure Medication Availability
Penalty
Summary
Facility staff failed to follow professional standards and facility policy for controlled substance management and medication administration. Review of the facility’s policies showed narcotics were to be physically counted at each shift change by both the incoming and outgoing licensed nurse or CMT, with both staff signing the Shift Verification of Controlled Substance Count form. From 12/08/25 through 12/31/25, multiple shifts lacked the required two staff signatures, and on some shifts there were no signatures at all, indicating that the required dual narcotic counts were not consistently completed or documented. Interviews with an LPN, the administrator, the ADON, and the DON confirmed that staff were required to perform and document narcotic counts at the beginning and end of each shift, and that the DON/ADON were responsible for auditing these forms. They also stated that failure to complete these counts could result in an inability to determine why a narcotic count was incorrect or who might be responsible for missing medication. The facility’s Medication Ordering and Receiving from Pharmacy policy required staff to reorder medications four days in advance of need, and at least seven days in advance for medications requiring special processing, to ensure an adequate supply. The Medication Administration Guidelines policy required that residents receive medications on a timely basis and in accordance with established policies. Despite these policies, surveyors determined that medications were not available as ordered for three sampled residents, and medications were not administered as ordered when unavailable. The report identifies that these failures occurred for three residents out of three sampled, in the context of a facility census of 90.1, but does not provide additional clinical details about the residents’ diagnoses or conditions at the time of the deficiency.
Failure to Notify Physicians When Ordered Medications Were Unavailable
Penalty
Summary
Facility staff failed to notify physicians when ordered medications were not available for three residents, contrary to the facility’s Medication Orders policy requiring nursing to contact the prescriber when delivery of a medication will be delayed or the medication is not or will not be available. For a moderately cognitively impaired resident, the physician had ordered hydrochlorothiazide for hypertension and MiraLAX for constipation; the MAR showed multiple dates in which these medications were marked as not available, and nurse notes for the same period contained no documentation that the physician or pharmacy had been contacted. A cognitively intact resident had multiple ordered medications, including hydrochlorothiazide, cyclobenzaprine, Boost, lemon drops, ferrous gluconate, rosuvastatin, and vitamin B12. The MAR documented several of these medications as not available on multiple dates, yet nurse notes did not show any physician notification. A severely cognitively impaired resident had orders for colestipol, donepezil, Eliquis, potassium chloride, methenamine hippurate, and vitamin C; the MAR documented repeated instances of these medications being unavailable across many days, including Eliquis and potassium chloride, without corresponding documentation in nurse notes that the physician was contacted when the medications were not administered. In interviews, a CMT stated staff would report unavailable medications to the charge nurse, and the ADON and DON stated nurses should contact the physician and pharmacy when medications are not available, indicating this did not occur as required.
Failure to Safeguard Resident Funds and Investigate Reported Misappropriation
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from misappropriation of funds and did not follow required abuse/misappropriation reporting and investigation protocols. The resident’s quarterly MDS documented that the resident was cognitively intact. At admission, the resident had $1700 in cash, described as $100 bills, which the resident reported giving to a staff member in the business office to be placed in an account for the resident’s use. RN A, who completed the admission, stated that he/she took the resident to the Business Office Manager’s (BOM) office, witnessed the resident hand the $1700 in cash to a staff member, and heard the staff member tell the resident the money would be put into an account for the resident. Review of the resident’s funds account showed no deposit of $1700 during the period reviewed. Multiple staff and family reports about the missing $1700 were made over several months without a timely or thorough investigation by the administrator. The Activity Director reported that in early August, during an admission activity assessment, the resident stated he/she had given $1700 in cash to a staff member on the day of admission and did not know what happened to the money; the Activity Director reported this concern to the administrator. The Social Service Director (SSD) D stated that shortly after starting in September, the resident’s family member asked about the missing $1700, and a former staff member told them the facility was investigating it. SSD D further reported that in October, he/she and the resident’s family member spoke directly with the administrator, in front of the receptionist, about the missing money. The receptionist confirmed witnessing SSD D and the family member inform the administrator about the missing funds and stated the administrator had been made aware of the issue even before that conversation. Despite these reports, the administrator did not initiate an investigation or notify the state agency when first informed of the missing money. The Assistant Director of Nursing (ADON) stated that he/she was aware of the resident’s report of missing money several months earlier and had asked the administrator if assistance was needed, but the administrator responded, “the less you know the better,” and the ADON heard nothing further. The administrator later acknowledged being told about the missing money, though not the exact amount, and admitted he/she did not investigate or report the allegation to the Department of Health and Senior Services at that time, stating he/she should have done so. The facility’s Abuse Prohibition Protocol required that allegations of abuse, neglect, misappropriation, or exploitation be thoroughly investigated with documented resident, staff, and witness statements, environmental review, physical assessment, and a timeline of events. These required investigative steps were not initiated when the allegation was first reported, leading to a prolonged period during which the resident’s missing funds were not addressed in accordance with facility policy and regulatory expectations. When the Director of Operations (DOP) was later informed by SSD D that the resident and family had repeatedly reported the missing $1700 and that the administrator had been previously notified without action, the DOP began an investigation and notified the state agency. The DOP determined through interviews that the resident had $1700 in cash at admission and had given it to a staff member, but the funds were never deposited into the resident’s account. The corporate financial representative and BOM also interviewed the resident, who again reported bringing $1700 in cash at admission, taking it to the office, and giving it to a staff member whose name he/she could not recall, though the resident could identify the office location. Former SSD E denied receiving any cash from the resident and stated that if he/she had, it would have been secured in the facility safe with a witness. Overall, the documented events show that the facility failed to safeguard the resident’s funds and failed to promptly and thoroughly investigate and report the allegation of misappropriation as required by its own abuse and misappropriation protocols.
Failure to Timely Report Alleged Misappropriation of Narcotic Medication
Penalty
Summary
Facility staff failed to report an allegation of misappropriation of a resident’s narcotic medication to the state agency within the required 24-hour timeframe. The facility’s Abuse Prohibition Protocol Manual requires the Administrator or designee to report allegations to the State Survey Agency within two hours if abuse or serious bodily injury is involved, or within 24 hours if the event did not involve abuse or serious bodily injury. Resident #1’s quarterly MDS dated 12/25/25 showed the resident was moderately cognitively impaired, received PRN pain medication during the seven-day look-back period, and used an opioid medication. The resident’s POS for 10/01/25–10/31/25 included an order for Morphine concentrate solution 100 mg/5 ml every four hours as needed for pain. During a narcotic count in October, an LPN observed that Resident #1’s liquid Morphine bottle, received in June, had a broken seal and the liquid appeared clear instead of the expected pink color, leading the LPN to believe the bottle was full of water. The LPN reported this to the ADON. The pharmacist later confirmed that the Morphine solution should remain pink and that water entering the bottle would dilute the color. The ADON stated that the LPN reported the potential missing doses and possible misappropriation to him/her, and that he/she then reported this potential misappropriation to the Administrator. The Administrator and ADON both acknowledged that the Administrator was responsible for reporting allegations of misappropriation of property to the Department of Health and Senior Services within 24 hours, but the Administrator did not remember if DHSS was contacted, and the ADON did not know if the allegation was reported. The DON, who was not employed at the time of the incident, confirmed that staff are directed to report abuse and neglect immediately to a supervisor or the Administrator and that the Administrator is responsible for reporting misappropriation allegations to DHSS within 24 hours.
Failure to Investigate Alleged Misappropriation of Narcotic Medication
Penalty
Summary
Facility staff failed to initiate and complete a thorough investigation into an allegation of misappropriation of a resident’s narcotic medication. The facility’s Abuse Prohibition Protocol Manual requires that all alleged violations of abuse, neglect, misappropriation, or exploitation be thoroughly investigated with documented evidence such as resident, witness, and staff statements, environmental review, resident physical assessment, and a clear timeline of events. The facility’s Narcotic Count policy further requires that any narcotic count discrepancy be reconciled with the off‑going nurse remaining on duty, the DON notified, and an investigation initiated to determine the cause of the discrepancy. Despite these policies, the medical record for the period reviewed contained no documentation that an investigation was conducted regarding the alleged misappropriation of the resident’s liquid morphine. The resident involved was assessed on a quarterly MDS as moderately cognitively impaired, having received PRN pain medication in the look‑back period, and using an opioid medication. The resident had an order for morphine concentrate solution 100 mg/5 ml to be given every four hours as needed for pain. An LPN reported that during a narcotic count, the seal on the resident’s liquid morphine bottle—received months earlier and reportedly never used—was found broken and the liquid appeared clear instead of the expected pink, leading the LPN to believe the bottle contained water. The LPN reported this to the ADON. The pharmacist later confirmed that morphine solution should remain pink and that dilution with water would lighten the color. The administrator stated that he and the ADON were responsible for thorough investigations of misappropriation allegations and that the ADON had investigated and found the allegation unsubstantiated; however, the ADON reported being unable to locate any paperwork related to this investigation, and the resident’s record contained no evidence of a completed investigation.
Failure to Notify Physician and Family After Resident Change in Condition
Penalty
Summary
Facility staff failed to notify residents' representatives and/or physicians after significant changes in condition for three out of five sampled residents. For one resident with severe cognitive impairment, staff did not document notification to the physician or family after two separate falls, and the family later reported not being informed about the fall or subsequent hospital transfer. Progress notes also indicated the family expressed concerns about lack of communication regarding one of the falls during a care plan meeting. Another resident, assessed as cognitively intact, experienced a fall, but there was no documentation that the physician or family were notified. Event reports and progress notes for these incidents lacked evidence of required notifications. A third resident experienced a significant weight loss of 7.62% over a short period, but the medical record did not show that the family or representative was notified of this change. Interviews with staff, including an LPN, the administrator, and the DON, confirmed that the facility's protocol is to notify the physician and responsible party after a change in condition, but the facility was unable to provide a policy for this process. The facility census at the time was 80.
Failure to Update and Revise Care Plans After Significant Changes
Penalty
Summary
Facility staff failed to review and update care plans in response to changes in residents' care needs for multiple residents. Specifically, staff did not revise care plans after significant events such as falls or notable weight loss, nor did they consistently update care plans on a quarterly basis as required by facility policy. For example, one resident experienced a fall that resulted in an emergency room visit, but the care plan was not updated with new interventions following the incident. Another resident experienced a 5.7% weight loss in one month, but the care plan was not updated to address this change until over a month later, and there was no physician order to monitor or address the weight loss. Additionally, care plans for two residents were not updated quarterly as required. Interviews with the administrator and DON confirmed that care plans should be updated after significant changes, quarterly, and annually, and that new interventions should be added after events such as falls or significant weight changes. Both acknowledged that the MDS Coordinator and nurses are responsible for these updates, and that the DON is responsible for auditing care plans to ensure compliance. The DON admitted there was no excuse for the oversight in not verifying that care plans were updated after significant changes or on a quarterly and annual basis.
Employment of Staff with Disqualifying Criminal Conviction
Penalty
Summary
Facility staff failed to ensure compliance with hiring protocols by employing an individual with a disqualifying criminal conviction. Specifically, a certified nursing assistant (CNA) was hired despite having a Class A Felony conviction for First Degree Assault involving serious physical injury or a special victim, which is a disqualifying factor for employment in the facility. The facility's Abuse Prohibition Protocol Policy prohibits the employment of individuals found guilty of abuse or with abuse violations against their professional license, and the Hiring Process Policy requires checks of the Employee Disqualification List (EDL) and the Family Safe Care Registry (FSCR) for all potential hires. A review of the CNA's personnel file confirmed the hire date and revealed that the required criminal background check (CBC) conducted at the time of employment did not identify the disqualifying crime, as the facility relied on a private investigation firm rather than the mandated FSCR. It was only upon a subsequent CBC request that the disqualifying conviction was discovered. Interviews with facility staff indicated that the receptionist was responsible for conducting CBCs and that the oversight occurred prior to the current administrator's tenure, with the proper registry not being used during the initial hiring process.
Failure to Provide Bed Hold Policy Notification at Hospital Transfer
Penalty
Summary
Facility staff failed to provide written notification of the bed hold policy to residents or their representatives at the time of transfer to the hospital for three out of four sampled residents. According to the facility's own Bed Hold Policy Guidelines, notification is required upon admission, at the time of transfer to the hospital or leave, and at the time of non-covered therapeutic leave. Record review showed that for three residents, there was no documentation that a bed hold notice was issued during multiple hospital discharges and readmissions. Interviews with the residents confirmed that they did not receive a bed hold notice at the time of their transfers. Further interviews with facility staff, including the ADON, SSD, DON, and the administrator, revealed that the responsibility for issuing and filing the bed hold notice lies with the charge nurse, with follow-up by the SSD. However, staff were unaware that some notices had not been issued, and there was no clear process to double-check that the notices were consistently provided and documented. The facility census at the time was 88.
Failure to Administer Pain Medications and Reassess Smoking Privileges
Penalty
Summary
Facility staff failed to ensure that a resident received pain medications as ordered following the postponement of a scheduled surgery. The resident, who was cognitively intact and diagnosed with Parkinson's Disease and osteoporosis, had a care plan that included scheduled and PRN pain medications. After the surgery was canceled, staff did not obtain a physician's order to resume medications that had been placed on hold, nor did they document an order for the medication holds or their resumption. The electronic Medication Administration Record (eMAR) showed that pain medications such as Tizanidine and Hydrocodone/Acetaminophen were not administered on several occasions, with reasons documented as either "not available" or "on hold." The resident and family were told by charge nurses that no medications were on hold, but the resident later learned from a Certified Medication Technician that Tizanidine was on hold, resulting in unmanaged pain and confusion about medication administration. Interviews with staff revealed a lack of clarity and communication regarding medication holds and resumption after surgery cancellation. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged that medication holds were not properly managed and that staff did not obtain the necessary physician orders. The DON stated that medication holds and resumptions were typically communicated during shift reports or through notes, but this process failed when the nurse responsible for the holds left the facility. Additionally, staff did not utilize the STAT box to obtain unavailable pain medication, further contributing to the resident not receiving prescribed pain management. The facility also failed to complete and document smoking risk assessments to re-assess smoking privileges for two residents who smoke. Despite incidents where one resident was observed smoking inside the building and another was involved in a dispute over cigarettes, there was no documentation of re-assessment of their smoking privileges in the electronic medical record. Interviews with staff and administration indicated confusion over who was responsible for completing smoking assessments, with inconsistent practices and lack of follow-through when incidents occurred.
Failure to Enforce Smoking Material Policies Creates Accident Hazard
Penalty
Summary
Facility staff failed to ensure the environment was free from accident hazards by not enforcing policies regarding the retention of smoking materials among residents. The facility's admission packet and smoking policy clearly state that residents may not retain matches or lighters, and that staff are to confiscate such items if found. However, two residents were allowed to keep cigarettes and lighters in their possession, contrary to facility policy and their care plans. One resident, assessed as cognitively intact and a safe smoker, was observed lighting a cigarette in the dining room, an area where smoking is prohibited, and was found with lighters in his possession. Staff interviews revealed uncertainty about whether the resident still had access to smoking materials, and the resident himself confirmed keeping cigarettes and a lighter in his room. The care plan for this resident did not include any interventions or restrictions related to smoking, despite incidents of unsafe smoking behavior in the facility. Another resident, whose cognition was not assessed but was also documented as a safe smoker, was observed in the dining room with cigarettes and a lighter visible in a waist pouch, despite a care plan stating that these items should be kept at the nursing station and that smoking should be supervised. Staff interviews indicated a lack of clarity and consistency regarding which residents were permitted to retain smoking materials and where these items should be stored, leading to lapses in supervision and enforcement of safety protocols.
Failure to Complete Quarterly MDS Assessments
Penalty
Summary
The facility staff failed to conduct quarterly assessments using the Minimum Data Set (MDS) for 19 residents out of a sample of 20, as required by federal regulations. The assessments were not completed within the mandated 92-day interval, as outlined in the Resident Assessment Instrument (RAI) manual. This deficiency was identified through interviews and record reviews, revealing that the MDS assessments for these residents were not documented in the months of July and August 2024. The facility census at the time was 83 residents. Interviews with facility staff, including the MDS Coordinator, Assistant Director of Nursing (ADON), and the administrator, highlighted that the previous MDS Coordinator had been frequently absent, leading to a backlog in MDS assessments. The current MDS Coordinator is attempting to catch up on the overdue assessments. The ADON indicated that the Director of Nursing (DON) is responsible for oversight of the MDS process, but the DON has been occupied with covering RN hours on the floor, limiting their availability. The administrator was unaware of the extent of the backlog and noted that corporate oversight had not reported the issue.
Inadequate Water Management Program Leads to Legionella Risk
Penalty
Summary
The facility failed to develop and implement comprehensive policies and procedures for the inspection, testing, and maintenance of its water systems to prevent the growth of waterborne pathogens, specifically Legionella. The facility's water management program lacked essential components such as control measures, corrective actions, and specific testing protocols. The program did not include policies related to water management, and the facility only planned to test the water if a positive case of Legionnaire's disease occurred. The water system description identified areas where Legionella could grow, such as temperature permissive water heaters and areas of possible stagnation, but did not address system dead legs or include necessary control measures. Interviews with facility staff revealed a lack of awareness and understanding of the water management program and its requirements. The maintenance director admitted to not testing the water for Legionella and was unaware of specific water management policies. The maintenance director also lacked knowledge about terms like temperature permissive and special considerations for healthcare facilities. The Infection Preventionist was not familiar with the water management program, and the administrator acknowledged not having reviewed the program in depth. The facility's control measures were limited to monitoring water temperatures and visual inspections, with no documentation of corrective actions. A resident was sent to the hospital with respiratory distress and tested positive for Legionella, highlighting the facility's failure to adequately manage its water systems. The facility's water management plan did not include facility-specific policies, control measures, or corrective actions, and there was no documentation of water flushing or other preventive measures. The lack of a comprehensive water management program and the staff's limited understanding of the requirements contributed to the deficiency, putting residents at risk of exposure to Legionella and other waterborne pathogens.
Failure to Conduct Background Checks and Investigate Resident Injury
Penalty
Summary
The facility failed to conduct proper background checks on five employees, including a Dietary Aide, Nurse Aide, Housekeeping staff, another Dietary staff, and a Registered Nurse, out of a sample of ten employees. The facility's Screening Abuse and Neglect Manual mandates that all applicants must be checked against the Certified Nurse Assistant (CNA) Registry before hire to ensure they do not have a Federal Indicator for abuse or neglect. However, the assistant business office manager (ABOM) was unaware of the requirement to run CNA registry checks on all staff, not just CNAs, leading to the oversight. Interviews with the ABOM, Assistant Director of Nursing (ADON), and the Administrator revealed a lack of awareness and communication regarding the necessity of these checks. Additionally, the facility failed to investigate an injury of unknown origin for a resident. The resident, who had intact cognition, required substantial assistance with lower body dressing, had an upper extremity impairment, and used a wheelchair, was observed with a red left cheek, swelling under the left eye, a laceration on the forehead, and a swollen left wrist and hand. Despite these injuries, there was no documentation of an investigation into their cause. The ADON acknowledged being informed of the injuries but did not conduct a formal investigation or fill out a report, failing to follow the facility's protocol for investigating injuries of unknown origin. The Administrator expected the charge nurse to initiate an investigation, notify relevant parties, and document the findings, but this process was not followed. The lack of investigation and documentation left the cause of the resident's injuries unexplored, and the Administrator was not informed of the incident. This oversight highlights a breakdown in communication and adherence to established procedures for handling injuries of unknown origin within the facility.
Inconsistent Treatment and Code Status Documentation
Penalty
Summary
The facility staff failed to meet professional standards of care for Resident #31 by not providing the prescribed treatment as ordered. The resident, who has moderate cognitive impairment, lower extremity impairment, and diagnoses of Parkinson's and Diabetes, had a physician's order for Tubi grip to be applied to both lower extremities every shift and removed at bedtime for generalized edema. However, observations on multiple occasions showed the resident without the Tubi grips. Interviews with staff revealed that the resident often refused to wear the Tubi grips, but there was a lack of documentation regarding these refusals and no notification to the physician, as required by the facility's policy. Additionally, the facility staff failed to provide consistent documentation regarding the code status for two residents. Resident #3 was assessed as having moderate cognitive impairment, with conflicting documentation showing both full code status and do not resuscitate (DNR) status. Similarly, Resident #30, who was cognitively intact, had discrepancies in documentation, with records showing both full code and DNR status. Observations noted the use of colored stickers on residents' doors to indicate code status, but there was confusion among staff about their meaning, and the documentation did not consistently match the residents' wishes. Interviews with various staff members, including the social services director and the assistant director of nursing, highlighted a lack of awareness regarding the inconsistencies in code status documentation. The social services director, responsible for maintaining and updating advance directives, admitted to not being aware of the discrepancies and acknowledged that audits were not conducted frequently enough to ensure accuracy. The administrator also expressed concern that inconsistent records could lead to residents' wishes not being upheld in an emergency.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. The facility's RN staff schedule for July, August, September, and early October 2024 showed multiple days without RN coverage for the required hours. Specifically, there were numerous days in July and August where no RN was present, and in September, the facility did not have an RN for eight consecutive hours per day. The issue persisted into October, with no RN coverage from October 1st to October 8th. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the administrator revealed that the facility only had one full-time RN, who was the DON. The DON worked 12-hour night shifts to cover gaps in nursing coverage and was on call when not scheduled. The ADON, responsible for scheduling, acknowledged the requirement for RN coverage but cited cost issues with using agency staff. The administrator confirmed the staffing situation and the facility's awareness of the requirement for RN coverage.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility staff failed to adhere to their policies and procedures for immunizing residents against Pneumococcal disease, as evidenced by the lack of documentation and administration of vaccines to two residents. The facility's policy required consultation with the resident's physician to determine the need for vaccinations and a physician's order to administer them. However, the records for two residents, one admitted with a signed pneumococcal vaccination consent, showed no documentation of the vaccine being offered, received, or refused. Another resident, who had previously received a PCV13 vaccine, also had a signed consent but lacked documentation of being offered or receiving the recommended PCV20, PCV21, or PCV23 vaccines. Interviews with the Assistant Director of Nursing/Infection Preventionist and the administrator revealed a lack of oversight and follow-through in the immunization program. The Infection Preventionist admitted to not keeping up with offering pneumococcal boosters since taking on the role and was unaware of why some residents were not vaccinated. The administrator confirmed that the Infection Preventionist was responsible for the vaccination program and acknowledged that the immunization policy was not followed, agreeing that eligible residents should have been offered the vaccines.
Failure to Complete Discharge Summary and Plan
Penalty
Summary
Facility staff failed to complete a comprehensive discharge summary or post-discharge plan of care for a resident who was discharged. The facility's policy requires staff to provide a discharge summary and post-discharge plan to ensure a safe departure and sufficient aftercare information. However, the medical record of the discharged resident did not contain these documents. Interviews revealed that the Social Services Director (SSD) was responsible for completing the discharge summary and other discharge information but admitted to not doing so. The Assistant Director of Nursing (ADON) confirmed that the SSD is responsible for setting up home health or therapy if needed and for discharge education. The facility administrator also expected the SSD to ensure discharge information was documented in the resident's medical record.
Deficiency in Dialysis Care and Documentation
Penalty
Summary
Facility staff failed to provide appropriate care and services for a resident requiring hemodialysis, as they did not adhere to professional standards of practice. The facility's policy for dialysis care included daily checks for thrill, inspection of the access site for signs of infection, and maintaining communication with the dialysis unit. However, the resident's medical records lacked documentation of these assessments, including monitoring vital signs, shunt condition, and daily weights. Additionally, there were no physician orders for dialysis or care of the shunt, and communication forms were not completed. Interviews with facility staff revealed a lack of awareness and adherence to the dialysis care policy. Charge Nurse L only documented issues if reported by the dialysis clinic, while LPN A was unaware of the policy and the need for pre- and post-dialysis assessments. The ADON acknowledged the absence of orders and assessments, attributing it to a lack of staff education and oversight. The administrator was also unaware of the deficiencies in documentation and communication, despite expectations for proper orders and assessments.
Medication Administration Errors Result in 6.45% Error Rate
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than 5%, resulting in a 6.45% error rate during the observation of 31 medication administration opportunities. Two errors were identified, affecting one resident diagnosed with Dementia/Alzheimer's, hypertension, and a hip fracture. The first error involved a Certified Medical Technician (CMT) crushing Metoprolol Succinate ER tablets, which should not be crushed as per the medication guidelines. The CMT acknowledged the mistake, realizing that the extended-release nature of the medication was compromised, potentially leading to the full dose being administered at once. The second error occurred when the same CMT administered Latanoprost eye drops to both eyes of the resident, despite the physician's order specifying administration to the left eye only. The CMT admitted to not reviewing the updated medication administration record closely enough, which led to the error. Interviews with the Assistant Director of Nurses (ADON) and the administrator confirmed that extended-release medications should not be crushed and that medication errors should be reported to the Charge Nurse and discussed in QAPI meetings. The Charge Nurse emphasized the importance of following medication orders as written.
Lack of Hospice Care Documentation for Residents
Penalty
Summary
The facility staff failed to document collaboration of care with hospice providers for the development and implementation of a coordinated plan of care and communication between the facility and local hospice provider for two residents receiving hospice services. The facility's Nursing Facility Services Agreement mandates regular communication and documentation between the hospice and the facility to ensure the needs of hospice patients are met continuously. However, for Resident #49, who had a diagnosis of cancer and a life expectancy of less than six months, and Resident #82, who had a diagnosis of kidney disease, there was no documentation of a plan of care or communication between the facility and the hospice provider in the hospice binder or the residents' medical records. Interviews with facility staff, including an LPN, the Assistant Director of Nursing (ADON), and the administrator, revealed an expectation for hospice communication and care plans to be documented in the hospice binder at the nurses' station. Despite these expectations, the documentation was missing, and the ADON acknowledged previous discussions with hospice about this issue, though it remained unresolved. The administrator also confirmed the expectation for documentation of hospice visits, changes in condition, and care plans, which were not present in the records reviewed.
Medication and Treatment Carts Left Unlocked and Unattended
Penalty
Summary
Facility staff failed to store medications and biologics safely, as observed when medication and treatment carts were left unlocked in public areas accessible to residents. The facility's policy mandates that all medications be stored in locked cabinets, medication rooms, or carts, and that hazardous substances be kept in separate locked containers. However, observations on multiple occasions showed the 200 hall medication cart and the 300 hall treatment cart left unlocked and unattended in the hallways. Interviews with facility staff, including a Certified Medication Technician, a Charge Nurse, the Assistant Director of Nurses, and the administrator, confirmed that medication and treatment carts should always be locked unless staff are directly in front of them. The staff acknowledged the potential for residents to access the carts or for drugs to be misplaced, indicating a clear understanding of the policy and the associated risks. Despite this, the carts were repeatedly found unsecured, highlighting a failure to adhere to the facility's medication storage policy.
Failure to Document Physician-Ordered Wound Care
Penalty
Summary
Facility staff failed to maintain professional standards of practice by not documenting the provision of wound treatment for one resident, as ordered by the physician. The facility's policy on physician orders lacked specific guidance on ensuring accuracy when transcribing these orders into the resident's medical records. A review of the resident's medical records revealed that a physician's order for wound care, dated 07/17/24, was not documented in the Physician Order Sheet (POS) for the period of 07/02/24 through 08/01/24. This oversight occurred despite the resident being assessed as cognitively intact and having a specific wound care regimen prescribed by the physician. Interviews with facility staff, including an LPN and the administrator, highlighted that both nurses and the Director of Nursing (DON) were responsible for inputting and verifying orders in the resident's medical records. However, the LPN was unaware of any order to cover the resident's wounds with a dressing after surgery on 07/14/24. The administrator confirmed that the charge nurse or DON was expected to accurately enter orders into the medical records, and acknowledged the potential risk of the wound not healing or becoming infected if wound care orders were not followed.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility staff failed to revise the care plans for three residents following falls, as required by their policy. The policy mandates that the Minimum Data Set (MDS) Coordinator is responsible for updating care plans with new interventions after a fall. However, the care plans for the residents did not reflect any new interventions after their falls. Resident #1, with moderate cognitive impairment, had an unwitnessed fall documented in their medical records, but their care plan lacked any new intervention. Similarly, Resident #2, with severe cognitive impairment, experienced an unwitnessed fall, yet their care plan was not updated with new interventions. Resident #3, who is cognitively intact, had both a non-injury fall and a fall with injury, but their care plan also did not include any new interventions. Interviews with facility staff revealed a lack of clarity and accountability regarding the updating of care plans. The MDS Coordinator acknowledged the responsibility to update care plans but admitted to possibly missing updates due to personal health issues. The Director of Nursing (DON) and the administrator both confirmed that the MDS Coordinator was responsible for updating care plans and that daily meetings were held to discuss falls and interventions. However, there was confusion about who was responsible for auditing the care plans for accuracy, with the DON believing it might be the corporate nurse's responsibility. This lack of oversight and communication led to the deficiency in updating the care plans after falls.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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