Resident Placed on Secured Unit Without Required Authorization or Consent
Summary
The facility failed to ensure that a resident placed on a secured behavioral unit met the established criteria for admission to that unit. Specifically, the resident had diagnoses including subdural hemorrhage, intracranial injury, hypotension, generalized anxiety disorder, and impaired cognition, and was identified as being at risk for elopement and wandering. The care plan indicated the resident resided on the secure unit for safety, with interventions to manage wandering behaviors. However, there was no physician order authorizing the resident's placement on the secured unit, and the resident had not signed a consent form for this placement. Further review revealed that the resident had not been declared incompetent, nor did they have a power of attorney or guardian. The facility's policy required that residents admitted to the secure behavioral unit must have a current mental health diagnosis, psychosocial or behavioral disturbance, be deemed incompetent by a physician, and have a current or active power of attorney or guardian. These requirements were not met in this case, as confirmed by staff interview and medical record review.
Penalty
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Surveyors found that the facility’s admission and valuables policies contained language stating the facility would not be responsible for resident money or personal items above a set dollar amount and would not be liable for lost or stolen items except in limited circumstances, effectively requiring residents or their representatives to waive facility liability for personal belongings. Review of records for two residents showed that, although admission agreements were properly signed, required Resident Inventory Listing forms were not completed, contrary to the facility’s own personal property policy. The administrator reported that the staff member responsible for inventories had left and not been replaced and stated that corporate legal guidance was that the facility was not required to replace stolen or missing items, with replacement handled only on a case-by-case basis.
Admission agreement signed without confirmed capacity. A resident with dementia, moderate cognitive impairment on BIMS, and pre-admission concerns for worsening cognition, poor self-care, and frequent falls signed his own admission paperwork. The record did not show attempts to contact his HC POA before the signature, and staff later acknowledged the resident was confused and that a psych note described cognitive deficits and memory gaps requiring POA support.
A resident admitted with diverticulosis and a cognitive communication deficit did not receive required admission documents at or before admission. The admissions packet was generated but later found unsigned and was only sent by certified mail after the resident had already discharged. The resident’s family confirmed the documents were received post-discharge. The Admissions Director acknowledged that some residents had not been given admission documents upon admission and that he mailed them later, citing frequent turnover in the admissions role. The DNS stated she expected admission documents to be provided timely.
Surveyors found that the facility’s admission agreement and related forms did not disclose the facility’s kosher diet practices and improperly required residents to waive certain rights and facility liability. The admission packet lacked written information about kosher dietary restrictions, and the Hospital Liaison reported that potential residents and families were not routinely informed in writing about the kosher diet, only possibly mentioned verbally without explanation. A Risk Acknowledgement form stated the facility was not responsible for stolen, lost, or damaged personal property and not responsible for the development of pressure sores, despite regulatory requirements against such waivers and requirements to provide care to prevent pressure sores. The NHA could not provide evidence that the admission agreement had been approved at the time of a change in ownership and confirmed that residents were not consistently informed in writing about the kosher diet.
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.
A resident with DM and HTN, who required supervision to maximal assistance with ADLs, was admitted without obtaining admission consent from the court-appointed conservator, despite facility policy requiring consent from the resident or responsible party and presentation of surrogate documentation at or before admission. The conservator later reported she had not been informed of the transfer and had not authorized the admission, and the Admission Coordinator acknowledged that the facility’s admission policy was not followed.
Noncompliant Admission Liability Language and Missing Resident Property Inventories
Penalty
Summary
Facility staff failed to ensure that admission policies and documents complied with requirements regarding resident property and financial protections. Review of the facility’s undated "Cash and Valuables Policy Update" showed language stating the facility would not be responsible for any money or personal items exceeding a $40.00 limit. The admission agreement dated 02/2018 further stated the facility would not be liable for any resident items that were lost or stolen, except for items noted for replacement under state guidelines. These provisions effectively required residents and/or responsible parties to waive facility liability for loss or damage to personal belongings as a condition of admission, contrary to regulatory requirements that residents not be required to give up Medicare or Medicaid benefits or pay privately as a condition of admission, and that they be informed of what care the facility does not provide. In addition, the facility did not follow its own "Personal Property" policy dated 12/2024, which required that residents’ personal belongings and clothing be inventoried and documented upon admission and as items were replenished. Record review for two residents showed that, although admission agreements were signed and dated by the residents/responsible parties and a facility representative in April 2026, there was no documentation that staff completed a Resident Inventory Listing form for either resident. During an interview, the administrator stated that the staff person responsible for completing inventory lists had quit and had not been replaced, and acknowledged that inventory sheets for these residents could not be located. The administrator also reported that the corporate legal department advised that in Missouri the facility was not required to replace stolen or missing items, and that the policy stated the facility was not responsible for replacing missing or stolen items except on a case-by-case basis.
Admission Agreement Signed Without Confirmed Capacity
Penalty
Summary
The facility failed to ensure that one resident had the capacity to understand the terms of the admission agreement before signing it. Resident R64 was admitted with diagnoses including hypertension, hyperlipidemia, and dementia, and the admission MDS showed a BIMS score of 11, indicating moderate cognitive impairment. Pre-admission hospital documentation described the resident as a poor historian with cognitive impairment/dementia that was likely worsening, along with concerns about inability to care for self, frequent falls, balance problems, and not taking medications for months. The record showed that Resident R64's admission agreement was completed and signed by the resident, even though the clinical record did not include documentation that attempts were made to contact the resident's health care POA. The resident's POA was listed in the pre-admission paperwork and on the Durable Health Care POA document, but the facility did not document efforts to involve that representative before the resident signed the paperwork. A nursing note also described the resident as very confused and slightly agitated, and the social worker documented family concerns about the current POA's intentions and finances. During interview, the NHA stated the resident signed his own paperwork because no one was answering the phone and the family thought the POA was stealing his money. The NHA also stated that it took until December to get someone to evaluate the resident for capacity, and referenced a psychology note that said the resident had cognitive deficits and memory gaps and needed a POA to help with medical, financial, and other needs. Despite this, the facility allowed the resident to sign the admission agreement, and the NHA confirmed the facility failed to ensure the resident had the capacity to understand the terms of the admission agreement.
Failure to Provide Admission Documents at or Before Admission
Penalty
Summary
The facility failed to ensure that a resident received required admission documents at or before admission, as required for resident rights and understanding of services. One resident admitted in October 2025 with diagnoses including diverticulosis and a cognitive communication deficit did not receive the admission packet at the time of admission. A certified mail receipt dated February 6, 2026, with a handwritten note showed that the admissions packet had originally been generated on October 30, 2025, but it was later discovered that it was not signed. The packet was subsequently sent to the resident by certified mail, and the resident’s family member confirmed that the admission documents were not received until after the resident had discharged from the facility. The Admissions Director stated he noticed that some residents had not received their admission documents upon admission and that he mailed the documents to those residents, also noting that many staff had been in the admissions position and some had been terminated or had quit. The DNS stated she expected staff to provide residents their admission documents in a timely manner.
Noncompliant Admission Agreement and Failure to Disclose Kosher Diet Requirements
Penalty
Summary
The deficiency involves the facility’s admission agreement and related documents failing to disclose special service limitations related to the facility’s kosher diet and improperly requiring residents to waive certain rights and facility liability. Record review of the admission packet showed that the Admission Agreement did not contain information about the facility’s kosher dietary practices, despite the facility following a kosher diet. A separate welcome packet included an “Always Available Menu” listing items such as tuna salad, egg salad, turkey, bologna, and pastrami sandwiches, with a note that any alternate chosen must reflect a kosher-appropriate option (dairy for dairy meal, meat for meat meal), but there was no other mention of special dietary considerations. The Hospital Liaison, who speaks with potential residents in the hospital, stated that residents and families are not informed in writing prior to admission that the facility follows a kosher diet, and that she may only casually mention it without explaining what it means unless specifically asked. Further review of the admission documents revealed that the Admission Agreement required the resident and sponsor to agree not to hold the facility responsible for injury or harm that could have been avoided if they had hired a private duty nurse. A separate Risk Acknowledgement form stated that the facility was not responsible for stolen, lost, or damaged personal property and was not responsible for the development of pressure sores, despite regulatory requirements prohibiting waiver of potential facility liability for personal property losses and requiring the facility to provide quality care, including treatment and services to prevent pressure sores. When requested, the NHA was unable to provide proof that the admission agreement had been approved at the time of the change in ownership in 2017 and confirmed that residents were not informed in writing prior to admission that the facility followed a kosher diet. The NHA could not verify that any brochure describing the kosher diet was consistently provided to residents and offered no rationale for the noncompliant admission agreement and risk acknowledgement language.
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 Obtain Required Admission Consent From Resident’s Conservator
Penalty
Summary
The deficiency involves the facility’s failure to obtain admission consent in accordance with its policy and procedure titled “admission to the Facility.” One resident was admitted on a specified date with diagnoses including diabetes mellitus and hypertension. The resident’s History and Physical dated 12/12/2025 documented that the resident did not have the capacity to understand and make decisions, while the MDS dated 12/14/2025 indicated the resident was able to understand and be understood by others and required varying levels of assistance with ADLs, including supervision, moderate assistance, and maximal assistance for mobility and self-care tasks. Despite the resident’s documented need for assistance and questions about decision-making capacity, the facility proceeded with admission without obtaining consent from the resident or the responsible party. During an interview, the resident’s family member stated she was the court-appointed conservator and reported that the prior facility did not inform her that the resident was being transferred and that she did not give the admitting facility permission to take the resident. In a concurrent interview and record review, the Admission Coordinator acknowledged that the facility’s policy was not followed when the conservator’s consent was not obtained prior to admission and stated that the conservator’s admission consent should have been obtained to ensure the resident’s and conservator’s wishes were respected. Review of the facility’s admission policy dated 1/2023 showed that residents are to be admitted only upon written order of the attending physician and with the consent of the resident or responsible party, and that identifying paperwork for any appointed surrogate or representative must be presented prior to or upon admission. These requirements were not met in this case.
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