Citations in Missouri
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Missouri.
Statistics for Missouri (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Missouri
A resident with dementia and anxiety, who was his/her own responsible party, was moved to a different room, including a locked memory care unit, without documented written notice or a signed agreement for the room change. The care plan indicated the room move had been discussed and agreed to, but the resident later reported not agreeing, becoming very upset and tearful, and feeling trapped in the locked unit. Staff, including CNAs and an agency LPN, stated that residents were supposed to receive written notice and that all parties should agree before a room change, but they were unsure if this occurred for this resident. EMR review showed no guardian or DPOA and no uploaded agreement related to the move, and the DON confirmed the resident had not been notified in writing and acknowledged unawareness of the regulatory requirement.
Two residents were affected when staff failed to follow and document physician orders for diagnostic testing. One resident with urinary retention, neuromuscular bladder dysfunction, and an indwelling catheter had multiple UAs ordered and marked as completed in the system, but the EMR contained no notes of urine collection attempts, refusals, or any UA results, despite care plan notes that the resident sometimes refused catheter care. Another resident with C. diff enterocolitis and morbid obesity fell while rising from a commode; after an X-ray could not be obtained, a CT of the back and right side was ordered, but the resident reported not being informed of the CT or a scheduled date, and the hospital scheduler stated the CT order was not received until days later and was initially invalid, preventing scheduling. Facility leadership and staff acknowledged that all MD orders should be followed and that attempts, refusals, and fax confirmations should be documented, but such documentation was absent in these cases.
The facility failed to maintain required inventories of personal belongings for two cognitively intact residents who reported missing clothing, despite a policy requiring completion and updating of inventory sheets and staff acknowledgment that such forms should be present and scanned into the medical record. A resident with anxiety, DM, and glaucoma did not receive an admission packet on the day of admission and lacked a baseline care plan, with the admission packet only signed later. The facility also used a new admission agreement that did not address prior $6,000 security deposits required under a previous management contract; one resident’s family provided documentation of having paid such a deposit, but subsequent invoices showed no record of a refund after discharge, while leadership reported unawareness of the prior deposit terms and that deposit funds were not turned over during the ownership change.
The facility failed to manage finances and operations in a way that ensured timely payment to key vendors and adequate supplies and staffing for resident care. After a change in ownership, staff reported chronic shortages of wipes, towels, plates, gloves, and incontinence products, with downgraded product quality and no clear departmental budgets. Housekeeping used substitute cleaning chemicals with uncertain dilution, and dietary staff reported the dish machine lacked soap and rinse chemicals for an extended period, leading to hand-washing dishes and serving meals on Styrofoam plates and foam cups despite resident council requests for regular dishware. Corporate-controlled ordering resulted in reduced quantities and substitutions of cheaper food items, while the RD reported not being paid and difficulty working with corporate. Multiple vendors, including primary food suppliers, a staffing agency, an oxygen supplier, pest control, and other service providers, confirmed large unpaid, past-due balances with no payments made under new management. CNAs and LPNs described bounced or incorrect paychecks, missing hours, and unresolved payroll issues, along with frequent short staffing, extended shifts, and nurse turnover, while maintenance and housekeeping staff were reduced and multiple vendors remained unpaid, affecting services throughout the facility.
Surveyors found that the facility failed to complete a thorough facility-wide assessment, leaving all sections documenting monthly average ADL assistance needs (bed mobility, transfers, bathing, eating, toileting, and mobility) blank, despite a census of 91 residents. The assessment contained only general statements about staffing assignments and infection prevention practices and did not quantify resident care needs. During the survey, additional issues were identified, including lack of required 12-hour CNA training in abuse/neglect and dementia care for sampled CNAs, insufficient nursing staff resulting in missed treatments and ADL care, absence of a restorative program and speech therapy, incomplete TB testing for sampled residents, missing EBP signage and PPE for residents on enhanced barrier precautions, and housekeeping staff not using an EPA-registered hospital disinfectant. The administrator acknowledged responsibility and stated the assessment was expected to be fully completed with total numbers of residents requiring assistance.
Surveyors found that staff repeatedly failed to follow infection prevention and control policies, including not implementing Enhanced Barrier Precautions for residents with catheters, wounds, and nephrostomy tubes, not posting EBP signage, and not using gowns during high-contact care. Perineal care was performed on multiple residents with improper glove use and without required hand hygiene, and catheter care was omitted after bowel movements. A shared Hoyer lift was used on two residents consecutively without disinfection between uses. Several newly admitted residents and newly hired employees lacked required two-step TB testing or TB screening documentation. Housekeeping staff used a non–EPA-registered all-purpose cleaner on floors instead of a hospital-grade disinfectant and were unsure of correct dilution, while supply limitations and lack of a housekeeping leader contributed to inconsistent cleaning practices.
The facility did not maintain an active antibiotic stewardship program as required by its own policy. The written policy, dated 7/1/25, called for an antibiotic stewardship program integrated with infection prevention and control, led by the Medical Director, DON, IPC nurse, and consultant pharmacist, with support from the Administrator and governing officials, and intended to optimize infection treatment and reduce adverse events from antibiotic use. However, the Administrator reported that the program had not been updated for many months, the IPC nurse had recently left, and the program had only just been restarted, leaving the facility without established antibiotic use protocols or a system to monitor antibiotic use for its resident population.
The facility did not follow its own policy requiring that COVID-19 vaccines be offered, education provided, and vaccination status documented for all residents. Record review for five residents with significant conditions such as heart failure, kidney disease, asthma, diabetes, osteomyelitis, stroke, and dysphagia showed no documentation that they were offered or received the COVID-19 vaccine, nor that any education or refusals were recorded. The Infection Preventionist stated that vaccines, refusals, and related education are expected to be offered on admission or upon request and documented in the medical record, but this was not done for these residents.
The facility failed to provide adequate nursing and therapy staffing and proper orientation for new and agency staff, resulting in multiple residents not receiving basic hygiene and therapy services. A resident was observed with oily hair and long, jagged fingernails and reported not getting a shower that week; another incontinent resident, dependent on staff for bathing, was seen in stained clothing and reported infrequent showers despite a twice-weekly schedule and missing shower documentation. A third resident had overgrown toenails and caked debris on the front teeth and reported that staff would not assist with nail care or oral hygiene, requiring family help, while a CNA attributed missed hygiene care to short staffing. Facility records showed no speech therapy services or restorative program over several months, and the rehab director and DON acknowledged the absence of these services. Multiple LPNs reported working without orientation or training, being left to work alone on their first day, and ongoing short staffing, while an LPN and the administrator described heavy reliance on agency staff, limited RN coverage, loss of key nursing roles, frequent leadership turnover, and lack of structured handoff of regulatory duties.
Surveyors found that multiple residents did not receive ordered medications because the facility failed to obtain and administer drugs as prescribed, despite policies requiring timely ordering, use of an E-kit or Pyxis, and prompt transcription of physician orders. One resident with multiple sclerosis and sleep apnea missed most doses of modafinil and Glatopa, with documentation of drugs not available and an incorrect order entry after an EMR change. Another resident with muscle weakness and diabetes missed numerous tramadol doses for pain, while a resident with kidney and respiratory failure missed repeated doses of tramadol and ordered eye drops, which staff documented as unavailable and the resident reported not receiving. A resident with chronic kidney disease and depression did not have a midodrine order or administration documented after the EMR switch, and bags of ordered IV saline labeled for this resident were found unused in the med room. Additional residents with chronic pain, HTN, UTI, CAD, HF, hypothyroidism, PVD, and clotting risks had extensive missed doses of atenolol, Augmentin, statins, thyroid hormone, beta-blockers, midodrine, diuretics, anticoagulants, antiplatelets, and antiarrhythmics, often marked as not available or simply not given. Staff reported problems with the new medication ordering system and inadequate training, while leadership acknowledged that blank MAR entries indicated missed doses and that staff were expected to reorder and escalate after a single missed dose.
Failure to Provide Written Notice and Obtain Agreement for Resident Room Change
Penalty
Summary
The facility failed to honor a resident’s right to be informed and to exercise self-determination regarding a room change. A resident with unspecified dementia of unspecified severity without behavioral disturbance and an anxiety diagnosis was admitted as his/her own responsible party, with no guardian or DPOA documented. The resident’s care plan noted dementia and documented that on 1/6/26 a room move was discussed and the resident agreed, and that on 1/7/26 staff were assisting with the move when the resident became upset and stated a desire to leave the facility. A quarterly MDS dated 1/8/26 showed the resident had severely impaired cognition and no wandering behavior. During a later interview, the resident reported not agreeing to the room move, becoming very upset and tearful, not understanding why he/she had been moved to a locked unit, and feeling trapped there, and was unable to state whether written notice of the room change had been received. Record review of the EMR showed the resident had no guardian or DPOA, was his/her own responsible party, and there was no signed agreement uploaded related to the room move. Multiple staff interviews (two CNAs and an agency LPN) confirmed that all residents were supposed to receive written notice of room moves and that all parties needed to agree before a room change, but they were unsure whether this resident had received written notice; the agency LPN reported the resident was upset and refused to move while being escorted down the hall. The DON confirmed the resident had not been notified in writing about the room move, was unsure why written notification had not been provided, and stated unawareness of the regulation, while acknowledging the resident should have been notified in writing. The facility’s own Resident Rights policy stated that information about resident rights and responsibilities would be given orally and in writing, but there was no documentation that written notice of the room change had been provided to this resident.
Failure to Follow and Document Physician Orders for UA and CT Imaging
Penalty
Summary
The deficiency involves the facility’s failure to ensure physician orders were followed and appropriately documented for two residents. One resident with urinary retention, neuromuscular bladder dysfunction, severely impaired cognition, and an indwelling catheter had physician orders for urinalyses in December 2025, with the electronic order status showing both tests as completed. However, review of the electronic medical record revealed no nursing notes related to collection of the ordered urine specimens and no laboratory results for any urinalysis in December. The resident’s care plan included monitoring and reporting signs and symptoms of UTI and noted that the resident had a fixation with the genital area and sometimes refused catheter care, but there was still no documentation that staff attempted to obtain the ordered UAs, that the resident refused, or that collection was otherwise unsuccessful. For the second resident, who had diagnoses including enterocolitis due to C. difficile and morbid obesity, an unwitnessed fall occurred while the resident was attempting to stand from a commode. An X-ray was ordered but could not be obtained due to the resident’s abdominal size, and the physician then ordered a CT scan of the back and right side. The facility’s order summary showed the CT scan order, and staff interviews indicated that the order was to be faxed to a local hospital. The resident later reported being unaware that a CT scan had been ordered and not being given a scheduled date for the procedure. A hospital scheduling manager reported not seeing a CT order for the resident until several days after the order date and stated that the CT had not been scheduled because the facility sent an invalid order that required correction before scheduling. The administrator, CNAs, LPNs, and the DON all stated that physician orders were expected to be followed as written and that failed attempts to collect UAs or send out imaging orders should be documented in the EMR, MAR, or TAR, including confirmation of fax receipt when applicable. The DON confirmed there was no documentation that the UAs for the first resident could not be collected and no documentation confirming that the CT order for the second resident had been sent or received before the date identified by the hospital scheduler.
Failure to Maintain Personal Property Inventories and Provide Accurate Admission and Deposit Information
Penalty
Summary
The deficiency involves the facility’s failure to maintain and update residents’ personal belongings inventories and to follow its grievance and missing property policy, as well as failures related to admission information and financial agreements. The facility’s policy dated 7/1/25 stated that residents and representatives have the right to report missing items, that staff may resolve grievances immediately or follow the grievance procedure if unable to do so, and that supervisory personnel are responsible for notifying residents and representatives of the outcome of missing property investigations. For one cognitively intact resident admitted on 6/3/25 with diagnoses including arthritis and spinal stenosis, there was no inventory of personal belongings sheet in the medical record despite observation of multiple personal items in the room. This resident reported missing specific clothing items, stated they had informed multiple staff members, and reported that no one followed up and that they had never been provided an inventory sheet at admission or afterward. Another cognitively intact resident admitted on 4/27/25 with diagnoses including heart failure, hip fracture, diabetes, and kidney disease also had no inventory sheet in the record, despite having numerous clothing items in the room, and reported multiple tops missing after being sent to laundry, stating they had never completed an inventory of personal belongings. Staff interviews confirmed that the facility’s process required inventory sheets to be completed on admission and updated when new items were brought in, with forms to be scanned into the medical record. A CMT stated that paper inventory sheets were available on each hall and should be completed and updated, and the Laundry Supervisor stated that an inventory sheet should exist for every resident and be located either in the medical record or in the resident’s room. The Laundry Supervisor reported not having seen inventory sheets for the two residents with missing clothing and being unable to locate their missing items. The Administrator and DON stated they expected staff to complete inventory sheets on admission and update them when new items arrived, and that staff should attempt to locate missing clothing and initiate an investigation if items were not found. Additional deficiencies involved admission information and financial agreements. One resident admitted on 1/5/26 with diagnoses including anxiety, diabetes, and open angle glaucoma did not have a baseline care plan in the record and reported not receiving a welcome/admission packet on admission; the admission packet on file was signed by the resident on 1/23/26, indicating it was not provided on the day of admission as expected by the Administrator. The facility’s prior admission agreement under the previous management company required a $6,000 interest-free security deposit, refundable within 45 days after discharge, and described how it would be treated for Medicaid and room-and-board charges. The current admission agreement under new management did not address the prior contract or deposits made under it. For a resident with severe cognitive impairment and multiple diagnoses including hypertension, non-Alzheimer’s dementia, and asthma, documentation from the family showed a $6,000 deposit paid at application along with room and board charges, and progress notes documented the resident’s transfer and discharge; however, invoices reviewed later showed no documentation of a refund of the $6,000 deposit. Interviews with the Regional Nurse Consultant and Administrator revealed unawareness of the prior deposit requirement, lack of documentation addressing previous deposits in the new agreement, and that funds related to deposits were not turned over during the ownership change, while the facility was still operating under the previous management company and honoring the original contract.
Failure to Pay Vendors and Maintain Adequate Supplies and Staffing for Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a way that ensured timely payment to key vendors and adequate procurement of supplies and services necessary for resident care. Staff interviews revealed that after a change in ownership, the facility experienced significant budget and payment issues, resulting in limited supplies such as wipes, towels, plates, gloves, and incontinence products. Central Supply staff reported that prior to the ownership change there were no supply problems, but afterward corporate imposed strict limits on quantities, downgraded product quality, and removed departmental budgets. Staff described gloves that ripped when donned and a switch from higher-quality briefs to lower-quality ones that did not contain urine effectively, with residents complaining about the briefs and staff reporting increased odors and residents being soiled. Housekeeping staff reported that the facility stopped purchasing the usual floor-cleaning chemicals and that they were using an all-purpose cleaner instead, with uncertainty about correct dilution and the last bottle nearly gone. The facility also failed to ensure timely payment to multiple critical vendors, including food suppliers, a dietician, staffing agencies, oxygen suppliers, pest control, and other service providers, placing residents at risk for interruption of services and inadequate care as stated in the report. The dietary department reported that the dish machine had been without soap and rinse chemicals for over a month, leading staff to wash dishes by hand and serve meals on Styrofoam plates and foam cups instead of regular dishware, despite resident council requests for regular plates and bowls. The Dietary Manager stated that corporate controlled ordering, frequently pushed back on quantities, and substituted cheaper or different food items than those ordered, including lower-quality ground beef and reduced quantities of produce such as bananas and grapes. The Registered Dietician reported difficulty communicating with corporate, uncertainty about the food-ordering staff’s food service experience, and that he or she had not been paid for services since the new ownership took over. Vendor records and interviews confirmed large unpaid balances to primary food vendors and other suppliers over several months with no payments made under the new management. In addition, the facility’s financial and administrative failures extended to payroll and contracted services, affecting staffing and resident care. CNAs and LPNs reported bounced paychecks, incorrect pay rates, missing hours, and unresolved payroll discrepancies, with explanations referencing time clock issues and processing from an out-of-state corporate office. A staffing agency representative reported that after ownership changed, the facility used agency staff without making any payments on multiple invoices totaling approximately $179,000, leading the agency to stop providing staff. The Plant Operations Manager and other staff reported cuts to housekeeping and maintenance staff, unpaid pest control and snow removal vendors, and multiple vendors not being paid. A beautician reported not being fully paid and receiving no assistance from the facility in contacting private-pay residents’ families for payment. An oxygen vendor, an additional food vendor, and a pest control company each confirmed that no payments had been made since before the new management took over, with balances significantly past due. The report notes that the Department of Health and Senior Services attempted to contact the corporate business office manager without returned calls, while the facility census was 91 and the deficient practice was described as having the potential to affect all residents by placing them at risk for interruption of services and inadequate care. Staff also described how these financial and operational issues contributed to staffing instability and workload problems. CNAs and LPNs reported frequent short staffing, difficulty obtaining agency staff, and situations where nurses were unsure when they would be relieved, with some working extended hours such as 23 hours on a shift. The DON was reported to be working the floor extensively, contributing to burnout, and multiple nurses reportedly left due to uncertainty about relief and staffing. The Plant Operations Manager stated that staffing and supplies were an issue and that he was pulled in different directions, including filling in for housekeeping, while the transition in ownership had been hard on residents and families. The Administrator acknowledged that there had been multiple Administrators and DONs since the ownership change, that regulatory duties were not handed off between Administrators, and that agency staffing was used to meet minimum staffing requirements, while also indicating that a system for continuity of care was still being developed. These combined actions and inactions in financial management, vendor payment, supply procurement, and staffing administration led to the cited deficiency for failure to administer the facility in a manner that enabled effective and efficient use of resources to meet residents’ needs.
Incomplete Facility-Wide Assessment and Related Care Resource Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a complete and thorough facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. The written Facility Assessment, last updated on 12/18/25, included basic operational data such as licensed bed count, average daily census, and average admissions and discharges by shift, but left all sections for monthly average assistance with activities of daily living (ADLs) blank. Specifically, no data were recorded for residents’ needs in bed mobility (sit to lying), mobility (sit to stand), bathing, transfers, eating, toileting, or other care, and there were no entries for levels of assistance such as set up, supervision/partial/moderate assistance, or dependent/max assistance. The assessment also contained only general narrative descriptions of how staff assignments are determined and how the infection prevention and control program is evaluated, without tying these to quantified resident care needs. During the survey, additional problems were identified that related to staffing, training, and infection control, which were not reflected in or supported by the incomplete facility assessment. These included the absence of required 12-hour CNA competencies in abuse/neglect and/or dementia care for all sampled CNAs employed more than one year, insufficient nursing staff to meet resident needs as evidenced by staff interviews and reports of missed treatments and missed ADL care, and the lack of a restorative program or speech therapy. Infection control issues were also found, including missing tuberculosis testing for all sampled residents, residents on enhanced barrier precautions without appropriate signage or PPE supplies, and housekeeping staff not using an EPA-registered hospital disinfectant for floor cleaning. In an interview, the Administrator stated an expectation that the facility assessment be fully completed with total numbers of residents requiring assistance and acknowledged responsibility for ensuring the assessment’s completion.
Failure to Implement EBP, Maintain Aseptic Care Practices, Disinfect Equipment, and Complete TB Screening
Penalty
Summary
Surveyors identified multiple infection prevention and control deficiencies involving failure to implement Enhanced Barrier Precautions (EBP), improper perineal care technique, inadequate disinfection of shared equipment, and lack of required tuberculosis (TB) screening for residents and staff. Several residents with indwelling devices or open wounds did not have EBP signage or personal protective equipment (PPE) available, and staff did not use gowns during high-contact care activities as required by facility policy and CDC/CMS guidance. For example, a resident with a urinary catheter had no EBP order, no EBP signage, and no PPE available; CNAs performed incontinence and catheter care wearing only gloves, then used the same contaminated gloves to apply a clean brief, adjust bedding, and touch privacy curtains. Another resident with left leg wounds requiring dressing changes had saturated dressings and ongoing wound care performed by an LPN and the ADON without gowns, and without EBP signage or PPE supplies in or outside the room, despite the ADON acknowledging the resident was on EBP and that gowns were not available in the facility. Additional residents with indwelling urinary catheters and nephrostomy tubes also lacked EBP implementation. One cognitively intact resident with an indwelling catheter had no EBP orders and no EBP signage; a CNA entered the room, donned only gloves, and performed perineal care and catheter manipulation while leaning against the resident, without wearing a gown. Another resident with nephrostomy tubes and daily dressing changes had an EBP order, but repeated observations showed no EBP signage and no PPE at or near the room. A staff member entered, donned gloves, and changed the nephrostomy dressings without an isolation gown. A resident with pressure ulcers and a wound care order also had no EBP signage or PPE available over several days. Staff interviews revealed inconsistent understanding of EBP, with one LPN stating they were not exactly sure which residents required EBP and a CNA reporting that isolation gowns had not been seen for weeks. Surveyors also observed improper perineal care and hand hygiene practices. For one severely cognitively impaired resident, an LPN removed a soiled brief, cleaned the perineal area, then with the same gloved hands applied a clean brief, assisted the resident to dress, transferred the resident to a wheelchair, and propelled the resident to the dining room, without changing gloves or performing hand hygiene. Another resident with a catheter had perineal care performed without PPE, and catheter care was not completed after stool was cleaned from the rectal area; the CNA later stated they "guessed" they should clean the catheter and genitals. The facility’s own incontinent care policy required hand hygiene, glove changes, and use of clean surfaces of cloths for each wipe, which were not followed in these observations. The survey further documented failure to disinfect shared equipment and to complete required TB screening. A Hoyer lift was used to transfer one resident from bed to wheelchair and then immediately used to transfer another resident for weighing and back to bed, without any cleaning or sanitizing between residents. Staff, including an LPN, CNA, and the DON, acknowledged that the lift should have been wiped down between residents. Review of medical records for multiple newly admitted residents showed no documentation of two-step TB testing or TB screening, despite facility policy requiring TB screening at or before admission. Similarly, review of employee files for numerous newly hired staff showed no documentation of TB tests or chest x-rays, contrary to the facility’s Employee Tuberculosis Test policy. Environmental cleaning practices also failed to meet facility policy requiring use of an EPA-registered hospital disinfectant. Housekeeping staff reported that the facility had stopped purchasing the previous disinfectant product and were instead using Medorra Limpreza All Purpose Cleaner Lavender scent for floors, measuring it by eye into mop buckets without clear dilution instructions. The product container lacked an EPA registration number, and checks of EPA resources and the manufacturer’s website did not verify it as an EPA-registered or hospital-grade disinfectant. Housekeepers and other staff described supply limitations and lack of a Housekeeping Director, and the Regional Nurse Consultant confirmed there was no training on how much floor chemical to use, while the Administrator stated he expected housekeeping to use appropriate supplies and know correct chemical amounts.
Failure to Maintain an Active Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and maintain an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The written Antibiotic Stewardship policy, dated 7/1/25, stated that the facility would implement an antibiotic stewardship program as part of its overall infection prevention and control program, with the purpose of optimizing treatment of infections and reducing adverse events associated with antibiotic use. The policy identified the Medical Director, DON, IPC Nurse, and Consultant Pharmacist as leaders of the program, with support from the Administrator and governing officials. However, during an interview, the Administrator reported that the antibiotic stewardship program had not been updated since March 2025, that the IPC Nurse had recently quit, and that the facility had only just restarted the program on 1/22/26, despite the Administrator’s expectation that the program should have been in place for the facility’s census of 91 residents. No specific residents, their medical histories, or clinical conditions at the time of the deficiency were described in the report, and no resident-specific antibiotic use data or monitoring activities were documented. The deficiency is based on the lack of an active, updated antibiotic stewardship program and the absence of established antibiotic use protocols and a monitoring system as required by the facility’s own policy.
Failure to Offer and Document COVID-19 Vaccination for Multiple Residents
Penalty
Summary
The facility failed to follow its COVID-19 vaccination policy by not offering, educating about, or documenting COVID-19 vaccination for five reviewed residents. The written policy dated 7/1/25 required that COVID-19 vaccinations be offered to all residents unless medically contraindicated, that residents be educated in an understandable manner using CDC or FDA information about risks and benefits, that they be given an opportunity to ask questions, and that the facility maintain documentation of vaccination status, education, and refusals in the medical record. Record review for the sampled residents showed no documentation that any of them had been offered or received the COVID-19 vaccine, nor that any education or refusals had been recorded. The affected residents had multiple significant medical diagnoses. One resident had heart failure and kidney disease, another had asthma and kidney disease, another had diabetes and osteomyelitis of the foot, another had heart failure and a history of stroke, and another had stroke, dysphagia, and kidney disease. Despite these conditions, there was no documentation in any of their medical records regarding COVID-19 vaccination offers, administration, or refusals. In an interview, the Regional Nurse Consultant, who also serves as the facility’s Infection Preventionist, stated that he expected COVID-19 vaccinations to be offered on admission or upon resident request, and that all vaccinations, refusals, and related education should be documented in the medical record, which was not reflected in the reviewed records.
Insufficient Nursing, Therapy Staffing, and Orientation Leading to Unmet Basic Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on a 24-hour basis to meet residents’ basic care needs, as well as insufficient therapy staffing and inadequate orientation for new and agency staff. The facility’s own Facility Assessment, updated in December 2025, lacked completed data fields for residents’ assistance needs with activities of daily living such as bed mobility, transfers, bathing, eating, and toileting, despite stating that staffing assignments were based on census, acuity, and resident preferences. Observations showed residents with unmet hygiene needs: one resident was seen in the dining room with oily, stringy hair and long, jagged fingernails and reported not having received a shower that week, attributing this to not enough staff and requesting nail care. Another resident, incontinent of urine and dependent on staff for showers, was observed in stained clothing with frizzy, messy hair and reported being scheduled for showers twice weekly but wanting more frequent showers due to odor and visitors; documentation showed only three showers in January and no shower records for December. Further observations showed another resident in bed on two separate days with toenails approximately 1/8 inch long and jagged and a whitish-yellow substance caked on the front teeth. This resident reported asking staff for nail trimming without assistance and stated that children had to come in to help with toothbrushing because staff were too busy. A CNA confirmed that nail care should be provided after showers and attributed the lack of oral hygiene assistance to staffing shortages, noting the resident required staff help with showers and personal hygiene. In addition to nursing care issues, review of therapy minutes from early September through late January showed no speech therapy evaluations, minutes, or services offered, and the Director of Rehab reported there was no speech therapy in place, only a recently hired PRN speech therapist, and that there had been no restorative program since their start at the facility. The DON acknowledged awareness of the lack of therapy and the absence of a restorative therapy program. Interviews with nursing staff and administration revealed systemic staffing and orientation problems. One LPN, initially an agency nurse who became a direct hire, stated being a brand-new nurse who received no orientation and was unaware of how poor staffing levels were. Another LPN reported it was their first day in the building, had never worked there as agency staff, and was working solo since early morning without training, relying on resident charts and other LPNs for questions. A third LPN described ongoing short staffing since new management took over, with only one night nurse until very recently, heavy reliance on agency staff, and critical care needs on the units such as IV medications and wound vacs. This LPN also reported that the admissions nurse did not help on the floor when short-staffed, the wound nurse had quit, the DON was working the floor extensively, and staff turnover was high. The Administrator confirmed frequent leadership changes, heavy use of agency staff, issues with RN coverage, and that regulatory duties were not handed off between administrators, while stating that agency staffing was used to meet minimum staffing requirements and that the DON was working on a system to ensure continuity of care amid frequent staff turnover.
Widespread Failure to Obtain and Administer Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician-ordered medications were obtained from the pharmacy and administered as ordered, resulting in numerous missed doses and “drug not available” occurrences for multiple residents. Facility policies required timely faxing and reordering of medications, use of the emergency kit or automatic dispensing unit for first doses, and prompt transcription and implementation of physician orders, including ensuring prompt delivery from the pharmacy. Despite these policies, staff frequently documented medications as unavailable, left blanks or holes on the MARs where doses should have been recorded, and did not consistently ensure that orders were correctly entered when the facility changed electronic medical record (EMR) systems. One resident with multiple sclerosis, repeated falls, and obstructive sleep apnea had an order for modafinil 100 mg, three tablets once daily, and Glatopa 40 mg SQ every other day. Modafinil was documented as drug not available for 20 of 22 opportunities, and Glatopa was documented as drug not available for 5 of 10 opportunities in one EMR system. After the facility switched to a second EMR, Glatopa was documented as not administered 8 of 9 opportunities, and the modafinil order was incorrectly entered as 100 mg, one tablet, instead of three tablets. A nurse’s note indicated the resident had not received modafinil since admission, and the DON later confirmed the EMR 2 order was incorrect. The pharmacist stated that only two doses of Glatopa (a one-week supply) had been dispensed and that failure to dispense or give modafinil correctly could potentially increase fall risk. Another resident with muscle weakness and diabetes had an order for tramadol 50 mg twice daily for pain, but the eMAR showed multiple missed doses over nearly two weeks, with staff documenting that tramadol was not administered because it was unavailable. The resident reported not receiving pain medication routinely. A different resident with acute kidney failure, acute respiratory failure, and muscle weakness had orders for tramadol, Bion Tears eye drops, and olopatadine eye drops; the eMAR showed repeated missed doses of all three medications over several days to weeks, with progress notes consistently stating the medications were unavailable. This resident reported not receiving eye drops and stated nurses told them the drops were not available. A resident with chronic kidney disease, major depressive disorder, and anxiety had an order for midodrine 2.5 mg twice daily and for sodium chloride 0.9% IV infusions twice weekly. After the facility switched EMR systems, there was no physician order or administration documentation for midodrine in the new EMR, and two bags of sodium chloride labeled for the resident were observed sitting on top of the medication room refrigerator, with blank documentation for certain infusion dates. A hospital nurse reported that when this resident arrived at the hospital, their blood pressure was very low and remained low overnight. The DON later stated the midodrine order had not been transferred correctly into the new EMR and that the resident should have received the sodium chloride infusions. Another resident with chronic pain, diabetes, anxiety, high blood pressure, and a history of healed physical injury had an order for atenolol 50 mg daily, which was documented as not administered for all available opportunities. The same resident had an order for Augmentin three times daily for a urinary tract infection, with multiple doses over several days documented as not administered. The resident stated they had never received atenolol since it was ordered and had not received the antibiotic, and staff told them the antibiotic was on order. A further resident with coronary artery disease, heart failure, diabetes, high cholesterol, anemia, peripheral vascular disease, hypothyroidism, major depressive disorder, and chronic kidney disease had multiple cardiac, anticoagulant, thyroid, and blood pressure medications ordered, including atorvastatin, levothyroxine, metoprolol, midodrine, spironolactone, Eliquis, clopidogrel, and amiodarone. The eMAR showed extensive missed doses for each of these medications, with some documented as medication not available and others simply not given, and only one progress note indicating a call to the pharmacy about spironolactone. Staff interviews revealed systemic issues contributing to the missed medications. A certified medication technician stated that the facility had recently changed to a new medication ordering system, that the system was “messed up,” and that medications were frequently not given because they had not been ordered properly; the technician also reported not receiving proper training on the new system. An LPN stated that medications should be administered per physician order and that if a medication was unavailable, the nurse should document this and call the physician or pharmacy. The DON stated that holes and blank spots on the MAR meant medications were not given, that staff should check the Pyxis and request STAT delivery if medications were out, and that if a medication was on backorder, the physician should be contacted for a substitute order. The DON also stated that staff were expected to reorder medications timely and notify pharmacy and the physician after one missed dose, rather than after multiple missed doses, which contrasted with the repeated documentation of unavailable medications and numerous missed administrations found in the records.
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