Abode Health And Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Independence, Missouri.
- Location
- 17451 Medical Center Parkway, Independence, Missouri 64057
- CMS Provider Number
- 265456
- Inspections on file
- 23
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Abode Health And Wellness Center during CMS and state inspections, most recent first.
The facility failed to provide timely final accountings and proper disposition of trust funds for four deceased residents, including not reporting remaining trust balances to the state TPL unit for extended periods and continuing to receive and hold Social Security payments after death. For two residents, the facility continued to post Social Security deposits and withdraw room and board after they had expired, did not return Social Security funds, and made incorrect and duplicate surplus withdrawals that reduced the amounts left in their trust accounts. Two other deceased residents had smaller trust balances that were also not reported to the appropriate state agency within required timeframes, and facility management could not explain the additional room and board withdrawals or provide documentation of TPL submissions.
A facility failed to protect residents from misappropriation of controlled medications and to maintain accurate narcotic accountability. Multiple residents with chronic and acute pain had opioid orders, but pharmacy delivery and dispense logs, narcotic accountability sheets, and MARs showed large numbers of Percocet, oxycodone, and Norco tablets unaccounted for. An LPN/ADON was repeatedly the only person signing out PRN narcotics, often without corresponding MAR documentation, and residents reported not receiving doses that had been signed out. Entire narcotic cards and accountability sheets were missing, and a urine test for one resident was negative for opioids despite frequent sign-outs. Staff and the physician described ongoing concerns and suspicions of diversion, and the LPN admitted at least one instance of diverting narcotics between residents and having a non-working family member sign as a second nurse on an accountability log.
Surveyors found that the facility failed to accurately reconcile and document controlled narcotic medications for three residents with pain conditions. Pharmacy records showed repeated deliveries and dispensing of Percocet, oxycodone, and Norco, but several required narcotic accountability sheets were missing, and existing logs showed many more tablets signed out than were documented as administered on the MARs. An LPN documented dropped tablets without proper waste verification, removed tablets from one resident’s supply to give to another, and signed out early‑morning doses that a resident reported never receiving. Residents reported not receiving all of the narcotics recorded as removed for them. The ADON, responsible for narcotic logs, could not explain missing logs or unaccounted tablets and was unsure who audited narcotic records, while other staff and leadership confirmed that undocumented medications could not be proven given and that narcotic documentation on MARs and accountability logs should match.
A resident on hospice care with a history of heart failure and rheumatoid arthritis did not receive timely comfort medications due to facility staff failing to enter hospice physician orders for liquid morphine, lorazepam, and hyoscyamine. The DON requested tablet forms instead of liquid, causing further delay, despite the resident's difficulty swallowing. The resident experienced pain and restlessness until the medications were finally administered after several days of delay.
Staff failed to properly inspect a mechanical lift sling before transferring a resident with multiple health conditions, resulting in the sling strap breaking and the resident falling and hitting their head. The sling had signs of damage that were not identified, and inconsistent maintenance practices, including improper drying methods, contributed to the deficiency.
The facility failed to investigate injuries of unknown origin for two residents, one with a fractured arm and another with skin tears and bruises. The staff did not document or investigate the causes of these injuries, and the family of the resident with the fractured arm was not informed promptly. Interviews revealed a lack of awareness among staff about the need for incident reports and investigations, leading to a deficiency at the immediate jeopardy level.
The facility failed to ensure RN coverage for at least eight hours per day, seven days a week, as required by policy. On specific dates, no RN was scheduled or present, and the DON was unaware of the responsibility to cover these shifts. This affected the facility's ability to provide adequate care to its 55 residents.
The facility failed to implement Performance Improvement Plans (PIPs) to address areas needing improvement, affecting residents' quality of life. The QAPI committee, responsible for overseeing quality improvement projects, did not have any current PIPs, and the Assistant Director was unaware of what a PIP was until recently. The Executive Director expected areas of improvement to be identified in daily meetings and carried into a PIP, but this was not happening.
The facility failed to implement written procedures for its QAPI Program, affecting its ability to gather feedback for quality improvement. The QAPI committee lacked guidelines and did not track concerns for improvement, despite meetings attended by various staff members. The Executive Director was unaware of the absence of procedures, impacting all 55 residents.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices, and staff were not educated on EBP protocols. Additionally, the facility did not conduct required TB testing for new residents, and staff did not follow proper hand hygiene during wound care and eye drop administration. Observations showed a lack of PPE and signage, and interviews revealed staff were unaware of EBP and hand hygiene protocols.
The facility failed to appoint a qualified Infection Preventionist to manage its infection prevention and control program, as required by its policy. Interviews with the Administrator and DON revealed that the position had been vacant for years, leaving critical tasks such as monitoring infections and antibiotic usage unaddressed. This deficiency affects the facility's ability to effectively manage infections among its 55 residents.
The facility failed to maintain proper authorization forms for managing resident trust funds for three residents. The facility's policy requires written authorization for managing personal funds, but records showed no signed forms for these residents. The current BOM, new to the position, noted that the previous BOM did not track these forms, leading to the deficiency.
The facility failed to maintain accurate records for resident trust funds, including missing reconciled bank statements and timely posting of deposits, leading to account balances exceeding limits. Additionally, there were undocumented withdrawals from a resident's account.
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF/ABN) to three residents discharged from Medicare Part A, as required by policy. A misunderstanding among staff regarding when to issue SNF/ABNs contributed to this deficiency.
The facility failed to maintain a clean and safe environment, with issues such as dust buildup in vents, persistent urine odor in the 80 Hall, and insufficient hot water temperatures in resident rooms. Observations revealed dust and debris in various areas, and housekeeping practices were insufficient to address these issues. These deficiencies potentially affected at least 40 residents.
The facility failed to accurately complete MDS assessments for three residents, leading to discrepancies in care plans and treatment records. A resident's hospice status and pressure ulcer were not reflected, another resident's medication was misclassified, and a third resident's cognitive status and medical devices were omitted. The MDS Coordinator cited being overburdened with additional duties as a reason for these inaccuracies.
The facility failed to update care plans for several residents, leading to unaddressed needs such as hearing aid use, Hospice care, feeding assistance, and wound management. Staff were unaware of these needs due to outdated care plans, as confirmed by interviews with CNAs, LPNs, and the Executive Director.
The facility failed to provide necessary hygiene care for six dependent residents, leading to poor hygiene and discomfort. Residents missed scheduled baths or showers due to staffing issues and lack of adherence to policies. Interviews revealed staff were unaware of bath schedules and failed to document or follow up on missed showers.
The facility failed to ensure the activities program was directed by a qualified professional, as the Life Enrichment Coordinator did not complete the state-approved training course. The Coordinator admitted to not finishing the course due to administrative changes and lack of payment. Both the HR Director and Executive Director were unaware of the Coordinator's certification status, and the facility did not provide an Activities policy when requested.
A facility failed to document and assess wounds for a resident, leading to untreated facial and coccyx wounds, and did not schedule a follow-up appointment for another resident's surgical staple removal. Staff interviews revealed a lack of communication and oversight in wound care and follow-up processes.
The facility failed to maintain sanitary conditions for respiratory equipment for three residents. A resident on hospice had oxygen tubing on the floor without a storage bag. Another resident with COPD had a nebulizer pipe not bagged and tubing touching the floor. A third resident with cognitive impairment had equipment improperly stored. Staff interviews confirmed the expectation for proper storage, but no corrective actions were taken during observations.
During a winter storm, a LTC facility failed to provide adequate nursing staff, leading to overworked staff unable to safely administer medications to residents. The facility lacked an emergency staffing plan, and several residents did not receive their prescribed medications due to staff exhaustion. Despite attempts to communicate with staff, many were unable to reach the facility, and no management staff came in to assist.
The facility did not post nurse staffing information, including the facility census and staff hours, in a visible location for residents, visitors, and staff at each nursing station. Instead, the information was only available at the reception desk, requiring residents and visitors to ask staff for details.
The facility failed to maintain hot meal items at appropriate temperatures for residents receiving room trays. Despite kitchen items being at correct temperatures, meals were cold upon delivery due to delays and lack of monitoring. Residents consistently reported dissatisfaction, and staff interviews revealed inadequate oversight by the Dietary Manager and RD.
The facility failed to implement an Antibiotic Stewardship program due to the absence of an Infection Preventionist, resulting in no monitoring of antibiotic usage. Despite policies requiring oversight, the Executive Director and DON confirmed no one was performing these duties. Antibiotic orders from November 2024 to January 2025 showed several residents on antibiotics without a structured review process.
The facility failed to administer pneumococcal and influenza vaccines to several residents, despite policies requiring these vaccinations. A resident with COPD, diabetes, and heart disease had no documented vaccines, and another with COPD and heart failure also lacked records. Staff interviews revealed confusion over vaccine administration responsibilities, and missing consent documentation contributed to the oversight.
The facility failed to provide and document COVID-19 vaccinations for several residents, including those with significant health issues. A resident had no record of additional boosters, another had no vaccination status documented, and two others had no immunization records. Staff interviews revealed systemic issues, including misplaced consent forms and uncertainty about documentation responsibilities.
The facility failed to maintain its AEDs in working condition, as observed during a survey. The AED on hallway A lacked a battery and pads, while the AED on hallway B had used pads and no replacements. The crash cart checklists did not include AED checks and had not been updated since mid-December. Interviews revealed that the night shift charge nurse was responsible for checking the AEDs, but this was not done, and there were no extra pads or batteries available. The DON confirmed that AEDs should be evaluated monthly, but this was not happening.
The facility failed to maintain consistent code status documentation for two residents, leading to discrepancies in their medical records. One resident's DNR order was incomplete, and another's EHR lacked advanced directives. Staff interviews revealed uncertainty about residents' code statuses, highlighting a lack of consistent documentation and communication.
A resident with severe cognitive impairment suffered a spiral fracture of the left forearm, but the facility failed to notify the family or physician for five days. The delay in communication and action resulted in a deficiency, as the facility did not adhere to its policy of timely notification and appropriate medical response.
A resident with severe cognitive impairment and dementia suffered an acute spiral fracture of the left forearm, which was not reported to the physician or state agency in a timely manner. The facility's staff, including the DON and Assistant Director, were unaware of the requirement to report such injuries, leading to a delay in informing the resident's family and authorities. The facility's policies mandated immediate reporting of injuries of unknown origin, which was not followed in this case.
A facility failed to create a baseline care plan within 48 hours for a resident with heart failure and chronic kidney disease. The resident was unsure about the care plan, and staff interviews revealed a lack of awareness about baseline care plans. The MDS Coordinator, responsible for initiating care plans, admitted to not completing them due to time constraints. The facility's policy required a baseline care plan within 48 hours, but this was not followed, leading to a deficiency.
A resident admitted with multiple health issues did not have a comprehensive care plan developed within the required timeframe. The MDS Coordinator, new to the position, had not completed all care plans, and the previous coordinator had not done them correctly. The resident's care plan was delayed, and staff were unaware of its status, highlighting a lapse in the facility's care planning process.
The facility failed to correctly transcribe physician orders for two residents after a pharmacist's review. One resident's Fluticasone inhaler order was incorrectly documented, and another resident's Digoxin level labs were not drawn as recommended. The MRRs were not communicated to the LPN, and the DON did not verify order transcription.
A resident with muscle weakness and obesity was unable to participate in activities due to the facility's failure to provide necessary assistance. Despite expressing interest, the resident was not helped out of bed due to staffing issues with the mechanical lift. Staff interviews revealed a lack of communication and coordination, leading to the resident's exclusion from activities.
The facility failed to provide adequate pressure ulcer care for two residents, resulting in missed wound care opportunities and lack of proper documentation. Both residents were at high risk for pressure ulcers and did not receive necessary interventions, such as pressure-reducing devices. Staff interviews revealed a lack of training and resources, and the facility did not have a designated Wound Nurse to oversee wound care assessments and documentation.
A resident, who was severely cognitively impaired, fell and sustained a head injury. The facility failed to investigate the fall, assess the resident post-fall, or implement new interventions. The resident's care plan lacked fall-related interventions, and no incident reports were completed. Interviews revealed staff were unaware of investigation requirements, and vital signs were not documented.
A resident with a gastrostomy tube was not properly monitored for tube placement or residuals before administering medications and feedings. Documentation was incomplete, and staff lacked training on proper procedures. The facility's policy was not followed, leading to a deficiency in care.
The facility failed to assist two residents in obtaining Medicaid, impacting their financial support. One resident's Medicaid status was pending due to a lack of awareness and follow-up by the Social Service Designee and previous Business Office Managers. The other resident's Medicaid status was inactive, and the relative received no assistance until the current BOM intervened. The Executive Director acknowledged these issues predated the current BOM.
The facility failed to properly manage and document narcotic medications, with discrepancies in narcotic counts and documentation for two residents. Narcotic counts were not consistently performed by two nurses at shift changes, and discrepancies were not communicated to the DON, who did not audit the counts.
The facility failed to ensure MRR recommendations were followed and physicians responded for two residents. The MRRs were not completed as required, and there was a lack of accountability among staff, with the DON unaware of their responsibility to ensure MRR completion and correct transcription of medication orders.
The facility failed to properly store and handle medications, with refrigerated medications found in the cart, loose pills in drawers, and incomplete temperature logs. The medication room lacked soap and had a stained sink, indicating poor maintenance. Interviews revealed unclear responsibilities for cleanliness and storage, contributing to these deficiencies.
A resident with severe cognitive impairment and dysphagia was not provided with the correct diet texture as per physician's orders. Despite assessments indicating the need for a pureed diet, the resident continued to receive regular texture meals, leading to coughing during meals. Conflicting dietary orders and poor communication among staff contributed to this deficiency.
A resident's personal funds were not returned to their family within the required 30 days after death. Instead, the Business Office Manager discussed donating the funds or keeping them personally, ultimately writing the check to themselves without proper authorization. Facility leadership confirmed that the refund process was not followed, and the family was not contacted or provided with the funds, as required by policy.
A Business Office Manager misappropriated $7,279.74 from a deceased resident's trust account by altering a refund check intended for the family, forging a signature, and cashing it for personal use. The facility's required procedures for handling resident funds after death were not followed, and the family did not authorize the transfer or receive the refund. The misappropriation was discovered through internal auditing, and the BOM admitted to the actions.
A CNA forcefully pushed a resident with severe cognitive impairment into a recliner, causing the resident to land hard and appear confused. The incident was observed by the resident's family via a video camera. The resident did not recall the incident due to Alzheimer's dementia. The local police were notified, and the facility administration was informed.
A facility failed to maintain an effective infection control program, lacking infection data analysis and proper hand hygiene practices. A resident with COPD and cognitive impairment received inadequate perineal care from a CNA, who used improper techniques and placed soiled linen on the floor. The DON was unaware of the infection monitoring deficiencies and the increase in urinary tract infections.
The facility failed to implement an antibiotic stewardship program (ASP) as required by their policy, with no documentation of ASP utilization from February 2023 to February 2024. The newly hired DON was unaware of the need for an ASP, and the Administrator could not locate ASP documentation. The former MDS Coordinator, who was responsible for the ASP, had left the facility, and a Corporate Nurse was scheduled to take over these responsibilities.
Failure to Timely Settle and Report Deceased Residents’ Trust Funds and Social Security Payments
Penalty
Summary
The deficiency involves the facility’s failure to provide timely final accountings of resident trust fund balances and to properly handle resident funds after death for four expired residents. For one resident who expired, the ledger showed a balance of $133.40 in the resident trust account that was not reported to the Department of Social Services Third Party Liability Unit (TPL) 143 days after death. The facility continued to receive and hold Social Security deposits and withdraw room and board after this resident expired, including multiple $960.00 Social Security deposits and $910.00 room and board withdrawals, even though room and board for prior months had already been withdrawn. These Social Security deposits were not returned to Social Security more than 100 days after deposit. Another expired resident had $2,731.79 in the resident trust account that was not reported to TPL 91 days after death. The facility continued to receive and hold Social Security funds and withdraw room and board after this resident expired, including a $1,529.00 Social Security deposit labeled as room and board that was not refunded or returned to Social Security 50 days after deposit. For this same resident, review of the trust ledger showed incorrect and duplicated surplus (room and board) withdrawals for several months, with amounts of $1,190.00 and $1,479.00 taken when email correspondence from the Department of Social Services indicated the correct monthly surplus should have been $1,152.00 or $1,151.00, resulting in an additional $2,212.49 that should have remained in the resident trust account but was not reported to TPL. Two other expired residents had smaller trust balances of $55.14 and $50.21, respectively, that were not reported to TPL 146 days and 106 days after death. Email correspondence from the Regional Business Office Manager stated that TPL submissions were made for all four residents but did not provide submission dates or documentation, did not explain why additional room and board was withdrawn after two residents expired, and indicated the facility was waiting for Social Security to request or recoup funds for one resident.
Misappropriation and Poor Accountability of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of controlled medications and to maintain required accountability documentation for narcotics. Multiple facility policies related to theft and misappropriation of resident property, controlled substances, discarding and destroying medication, and medication administration and documentation were requested by surveyors but not provided. The facility’s own records showed extensive discrepancies between narcotic accountability sheets, pharmacy delivery and dispense logs, and medication administration records (MARs) for several residents receiving opioid analgesics for chronic pain and other pain conditions. For Resident #1, who had chronic pain and a moderately impaired BIMS score, the POS included multiple PRN and scheduled orders for Percocet and later Norco. Pharmacy records showed repeated deliveries of 30-count packs of Percocet and Norco, each requiring its own accountability sheet. However, the facility could not produce several of these accountability sheets, leaving entire 30-count packs of narcotics unaccounted for. On the available accountability sheet dated 8/26/25, LPN A signed out 22 Percocet tablets between 9/1/25 and 9/5/25, while the MAR documented administration of only 4 tablets during that period, leaving 18 tablets unaccounted for. There was also an incident where LPN A documented that 2 tablets were dropped on the floor without a second staff signature to verify wasting. Subsequent pharmacy dispense logs and MARs for Norco showed additional discrepancies, with 12 to 14 tablets at a time unaccounted for, and a urine test for opioids on Resident #1 returning negative despite consistent sign-outs of opioids by LPN A. For Resident #6, who was cognitively intact and had pain in the right knee, the POS included PRN and scheduled Percocet orders. Review of the MAR and pharmacy logs showed unaccounted Percocet tablets in multiple time frames, including 1 missing tablet in early October, 1 missing tablet in late November, and 5 missing tablets in December. The resident reported only receiving pain medication at night, never requesting PRN doses during the day, and specifically denied receiving early-morning doses that LPN A had signed out. For Resident #9, who was cognitively intact with chronic pain, the POS included PRN oxycodone and later scheduled Norco. An accountability sheet dated 9/10/25 showed that LPN A removed 30 oxycodone tablets and was the only staff member signing the log, while the MAR documented administration of only 5 tablets, leaving 24 unaccounted for. Additional discrepancies occurred with Norco obtained from both the medication cart and the automatic dispenser, with multiple tablets unaccounted for in October, November, and December. Interviews with staff and the physician further described patterns leading to the deficiency. The DON in training explained that PRN narcotics were administered from bubble packs on the cart and scheduled narcotics from a Pyxis-style machine, and that narcotic administration required documentation both on the MAR and the narcotic accountability sheet. The physician stated that he changed residents’ PRN oxycodone orders to scheduled hydrocodone because he knew oxycodone was not being administered as it was being signed out and suspected narcotic diversion, noting that undocumented medications could not be proven given. Multiple staff, including a CMT and an LPN, reported missing narcotics, patterns of LPN A being the only person signing out PRN narcotics, residents denying receipt of those medications, and entire cards of narcotics disappearing after shifts worked by LPN A. LPN A, who was the ADON and responsible for monitoring narcotic logs, acknowledged prior investigation for diversion, admitted diverting narcotics from one resident to another on a specific date and having a family member falsely sign as a second nurse on an accountability log, and admitted making mistakes with narcotic accountability while being unable to explain why narcotic administrations were not documented on MARs. The Administrator and regional nurse consultant confirmed that LPN A had been under investigation for diversion under both previous and current ownership, that previous owners did not share investigation results, and that LPN A was later allowed access to narcotics again, during which time narcotics continued to go missing.
Unaccounted Narcotics and Incomplete Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for and document controlled narcotic medications for multiple residents, resulting in numerous unaccounted tablets and inconsistent records between narcotic accountability sheets, Medication Administration Records (MARs), and pharmacy delivery/dispense logs. For one resident with chronic pain and moderate cognitive impairment, multiple Percocet and Norco orders were in place over several months. Pharmacy packing slips showed repeated deliveries of 30‑count packs of Percocet and Norco, but several corresponding narcotic accountability sheets were missing and could not be provided. Where accountability sheets were available, the number of tablets signed out did not match the number documented as administered on the MAR, leaving significant quantities of Percocet and Norco unaccounted for. In one instance, an LPN documented that two Percocet tablets were dropped on the floor but there was no second‑staff waste documentation. For a second resident with right knee pain and intact cognition, Percocet was ordered first as PRN and later as a scheduled bedtime dose. Pharmacy records showed delivery of multiple 30‑count Percocet packs, but at least one accountability sheet was missing. On the available accountability sheet, tablets were signed out on several dates, including entries by the ADON/LPN indicating a tablet was dropped without a destruction log, and documentation that tablets were removed from this resident’s supply to administer to another resident. MAR review showed far fewer administrations than tablets removed on the accountability sheet, resulting in multiple unaccounted Percocet tablets. The resident reported only receiving pain medication at night, never requesting PRN doses during the day, and specifically stated they did not receive early‑morning doses that had been signed out by the LPN. For a third resident with congestive heart failure and chronic pain, oxycodone and later Norco were ordered, initially as PRN and then as scheduled twice daily. Pharmacy packing slips documented delivery of oxycodone blister packs, but one entire accountability sheet for a 28‑count pack was missing. On another oxycodone accountability sheet, many more tablets were signed out than were documented as administered on the MAR, leaving numerous oxycodone tablets unaccounted for. After the switch to Norco and use of a medication dispensing machine, pharmacy dispense logs showed more Norco tablets removed than were documented as administered on the MAR or reflected on the available accountability sheets, again resulting in unaccounted tablets. This resident stated they did not ask for PRN pain medication very often and did not receive all of the oxycodone that had been signed out on the narcotic logs. Interviews with staff and leadership confirmed that nurses were responsible for PRN narcotics from the cart and bubble packs, CMTs for scheduled narcotics from the dispensing machine, and that all narcotic administrations were expected to be documented both on the MAR and on narcotic accountability sheets. The ADON/LPN, who was responsible for monitoring narcotic logs and as‑needed narcotics, acknowledged being unsure why logs were missing and narcotics unaccounted for, and was also unsure who was responsible for auditing narcotic logs and administration. The DON in training, CMT, physician, and administrator/regional nurse consultant all stated that if a medication was not documented on the MAR, it could not be proven that it was given, and that narcotic documentation on MARs and accountability logs should match. Despite these expectations, the facility was unable to produce all required accountability sheets and could not reconcile multiple discrepancies between narcotic removals, MAR entries, and pharmacy records for the three residents. No facility policy for Medication Administration and Documentation was provided when requested, and the pharmacy’s operational manager confirmed that each 30‑count narcotic pack should have its own accountability sheet and that if an accountability sheet cannot be accounted for, neither can the narcotic pills associated with it. Across the three residents, there were repeated patterns of missing accountability sheets, unexplained discrepancies between tablets removed and tablets documented as administered, undocumented wastage, and resident reports that they did not receive some of the narcotics that had been signed out for them. These actions and omissions led to the identified deficiency in ensuring residents were free from significant medication errors related to controlled substance reconciliation and documentation.
Failure to Provide Timely Hospice Comfort Medications
Penalty
Summary
A deficiency occurred when the facility failed to provide timely and appropriate care and services to a resident receiving hospice care. The resident, who had a history of hypertensive heart disease with heart failure, chronic diastolic heart failure, and rheumatoid arthritis, was admitted to hospice and required comfort medications for pain, anxiety, and secretions. The hospice physician gave verbal orders for liquid morphine, lorazepam, and hyoscyamine sulfate, which were to be documented and administered by facility staff. However, these orders were not entered into the resident's Medication Administration Record (MAR) or Treatment Administration Record (TAR), and the medications were not provided to the resident as ordered. The delay in medication administration was due to facility staff not entering the hospice physician's orders into the computer system, as well as a request from the DON to have the medications provided in tablet form instead of liquid, citing concerns about drug diversion. The hospice physician and family members reported that the resident had difficulty swallowing, and the liquid form was preferred for faster and easier administration. Despite repeated communication from hospice and family members, the comfort medications were not started promptly, and the resident experienced pain and restlessness during this period. Interviews with facility staff, hospice staff, and family members confirmed that the hospice medication orders were misplaced or not acted upon, and that there was confusion and delay in implementing the hospice plan of care. The resident did not receive the prescribed comfort medications until several days after the initial hospice orders, and only after the orders were rewritten and entered into the system. Observations showed the resident was unresponsive and in distress prior to receiving the medications. The facility failed to coordinate with hospice and follow the resident's plan of care, resulting in unmet needs for pain and symptom management.
Failure to Inspect Mechanical Lift Sling Results in Resident Fall
Penalty
Summary
Facility staff failed to follow established policies and procedures for the safe use of mechanical lifts, resulting in an incident where a resident fell during a transfer. The staff did not properly inspect the lift sling for signs of wear or damage prior to use, as required by both facility policy and manufacturer instructions. During the transfer, the strap on the sling broke, causing the resident to fall from the sling and hit their head on a recliner, resulting in two bumps on the back of the head. The incident occurred while the resident was being assisted by a CNA and an RN using a Hoyer lift. The resident involved had multiple medical conditions, including osteoporosis, osteoarthritis, muscle weakness, and was on anticoagulant therapy for atrial fibrillation, increasing the risk of injury from falls. The care plan specified the use of a mechanical lift for transfers when the resident was fatigued or in pain, and interventions were in place to address fall risk. Despite these precautions, the failure to inspect the sling prior to use directly contributed to the accident. Interviews and record reviews revealed that the facility's practice for sling maintenance and inspection was inconsistent. The Maintenance Director reported monthly checks of slings, but also noted that slings had been dried in a dryer against manufacturer recommendations, which could compromise sling integrity. Staff statements indicated that while some were trained to inspect slings before use, there was no documented in-service training on sling inspection prior to the incident. The sling involved in the incident had no service date, and the broken strap showed evidence of a cut or fraying that should have led to its removal from service.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to follow its policy and procedure in investigating an injury of unknown origin for a resident who sustained a fractured arm. The resident, who was severely cognitively impaired and required maximum assistance with daily activities, complained of pain in the left forearm. An X-ray revealed a spiral fracture, but there was no documentation of an incident report or investigation into the cause of the injury. The family was not informed of the fracture until six days later, and the facility staff did not conduct a thorough investigation or notify the family promptly. Another resident, who was also severely cognitively impaired and dependent on staff for care, had skin tears and bruises that were not investigated. The resident's care plan did not include information about skin injuries, and there was no documentation of how the skin tear occurred. The facility staff, including the DON, were unaware that an investigation was required to determine the root cause or contributing factors of the injuries. Interviews with facility staff revealed a lack of awareness and understanding of the need to document and investigate injuries of unknown origin. The DON and Assistant Director did not initiate incident reports or investigations, and there was no documentation of staff interviews regarding the injuries. The facility's failure to follow its policies and procedures resulted in a deficiency at the immediate jeopardy level, indicating a serious risk to resident safety.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight hours per day, seven days a week, as required by their policy. This deficiency was identified through interviews and record reviews, which revealed that on specific dates, there was no RN scheduled or present to cover the required shifts. The facility's staffing policy, revised in August 2022, mandates that RNs provide services for at least eight consecutive hours every 24 hours, seven days a week. However, on January 5th and 6th, 2025, there was no RN coverage, and the Director of Nursing (DON), who was expected to fill in, was unaware of this responsibility and did not work on those days. Interviews with the DON, Assistant Director, and Executive Director confirmed that there should have been RN coverage for at least eight hours in a 24-hour period. The Assistant Director, responsible for staffing, acknowledged that if full-time staff did not pick up a shift, they would contact a staffing agency or offer incentives to staff. Despite these measures, the facility failed to ensure RN coverage on the specified dates, and the DON was not informed of the expectation to cover shifts lacking RN presence. This oversight had the potential to affect all 55 residents of the facility.
Failure to Implement Performance Improvement Plans
Penalty
Summary
The facility failed to develop and implement Performance Improvement Plans (PIPs) to address areas of needed improvement, which could affect all facility areas, including residents' quality of life. The facility's Quality Assurance and Performance Improvement (QAPI) Program, as outlined in their Governance and Leadership Policy dated March 2020, was supposed to be overseen by the QAPI committee, with the Administrator ultimately responsible for interpreting results and findings to the governing body. However, during an interview, the Assistant Director admitted that there were no current PIPs in place and was unaware of what a PIP was until two weeks prior. The survey process identified several areas needing improvement, including showers for residents, wound care, general documentation, and investigations in all areas. The Executive Director expressed an expectation that PIPs would be in place and that areas of improvement would be identified during daily stand-up meetings with department heads. These areas of improvement were expected to be carried over into a PIP. The lack of PIPs indicates a failure in the facility's QAPI process, as the QAPI committee was responsible for coordinating, developing, implementing, monitoring, and evaluating performance improvement projects to achieve specific goals. This deficiency highlights a gap in the facility's proactive approach to quality improvement, as outlined in their QAPI program.
Lack of QAPI Procedures Leads to Quality Deficiency
Penalty
Summary
The facility failed to develop and implement written procedures for its Quality Assurance and Performance Improvement (QAPI) Program, which hindered the ability to gather feedback for quality improvement. The QAPI program, as outlined in the facility's policy dated March 2020, was supposed to be based on data, resident and staff input, and other performance measures. However, the facility's QAPI committee lacked procedures or guidelines to follow, and there were no current improvement projects. The committee met monthly, depending on the physician's schedule, but concerns brought to the meetings were not tracked for improvement. Interviews revealed that the QAPI committee meetings were attended by various staff members, including the Medical Director, MDS Coordinator, and others, but there were no detailed notes available from these meetings. The Executive Director was unaware that the QAPI committee did not have procedures or guidelines to follow and had only received a policy from the corporate office. The lack of structured procedures and guidelines for the QAPI committee led to the inability to effectively address and improve quality deficiencies, potentially affecting all 55 residents in the facility.
Inadequate Infection Control and Lack of EBP Implementation
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. Five residents who should have been on EBP were not provided with the necessary personal protective equipment (PPE), and staff were not educated on EBP protocols. Observations revealed that there were no signs or isolation carts with PPE outside the residents' rooms, and staff were seen performing care without wearing the required PPE. Interviews with staff, including Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs), indicated a lack of awareness and training regarding EBP. Additionally, the facility failed to conduct Tuberculosis (TB) testing for three residents upon admission, as required by their policy. The Director of Nursing (DON) and other staff members were unaware of the protocol for TB testing and screening, and there was no documentation of TB tests being administered to the residents. Interviews with the DON and Executive Director revealed that there was no tracking system in place to ensure TB tests were completed and documented in the residents' medical files. The facility also failed to ensure proper hand hygiene during wound care and the administration of eye drops. Observations showed that staff did not wash their hands after removing gloves or between different care activities, such as cleaning wounds and applying ointments. Interviews with staff confirmed that they were not following hand hygiene protocols, and the DON admitted that there was no designated person responsible for ensuring compliance with hand hygiene practices. The lack of adherence to infection control measures and hand hygiene protocols contributed to the deficiencies identified in the facility's infection prevention and control program.
Failure to Designate an Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist to oversee the infection prevention and control program, as required by their policy dated September 2022. The policy outlined that the Infection Preventionist should coordinate the implementation and updating of the infection prevention and control program, collect and analyze infection and antibiotic usage data, and provide this information to nursing staff and healthcare practitioners. Additionally, the Infection Preventionist was expected to have specialized training, including antibiotic stewardship, and be employed on-site at least part-time. During interviews, both the Administrator and the Director of Nursing confirmed that there was no one currently in the role of Infection Preventionist, and the facility had not had someone in this position for years. Consequently, no one was performing the necessary tasks and responsibilities, such as monitoring and tracking infections, antibiotic usage, and ensuring proper use of Transmission-Based Precautions and Enhanced Barrier Protection. This lack of oversight and coordination in infection control measures could potentially impact the facility's ability to manage infections effectively among its 55 residents.
Failure to Maintain Authorization Forms for Resident Trust Funds
Penalty
Summary
The facility failed to maintain proper authorization forms for managing resident trust funds for three residents out of four sampled in a review. The facility's policy, dated March 2023, requires that personal funds of residents be used exclusively for the resident, with written authorization from the resident, their legal guardian, or a legal representative. However, the review of the Resident Fund records revealed that there were no signed authorization forms for Residents #5, #2, and #39, which would allow the facility to manage their funds. During an interview, the Business Office Manager (BOM) acknowledged that the previous BOM did not keep track of the authorization forms signed by the residents. The current BOM had only been in the position since December 17, 2024, indicating a possible lapse in the transition of responsibilities. This oversight led to the deficiency in maintaining the necessary documentation to manage the residents' financial affairs as per the facility's policy.
Deficiencies in Resident Trust Fund Management
Penalty
Summary
The facility failed to maintain accurate and reconciled bank statements for resident trust funds from January 2024 to September 2024. The absence of these reconciled statements was confirmed during interviews with the Assistant Director and the Business Office Manager (BOM), who acknowledged that the previous BOM did not perform the necessary reconciliations. Additionally, the facility did not maintain records of monthly ending petty cash amounts from January 2024 to December 2024, and there was a discrepancy of $19.00 in the petty cash count sheet for December 2024. The facility also failed to post deposits into resident trust fund accounts in a timely manner. For two residents, deposits made in October 2024 were not posted until December 31, 2024, causing their account balances to exceed the Missouri Health Net limit. The BOM confirmed that these deposits were not posted by the previous BOM and were only recorded by the current BOM at the end of December 2024. Furthermore, the facility did not maintain signatures or receipts for withdrawals from one resident's account. Withdrawals of $100.00 and $50.00 made in September and October 2024, respectively, lacked proper documentation. The BOM, who started in December 2024, confirmed the absence of receipts or signatures for these transactions.
Failure to Provide SNF/ABN to Discharged Residents
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF/ABN) to three residents who were discharged from Medicare Part A. The facility's policy, revised in September 2022, mandates that an SNF/ABN should be issued when Medicare A coverage for extended care items or services is terminated. However, upon review, it was found that Residents #41, #43, and #56 did not receive the required SNF/ABN upon their discharge from Medicare Part A. This oversight was identified through a review of the facility's Beneficiary Notice worksheet and the residents' records. Interviews conducted during the investigation revealed a misunderstanding or miscommunication regarding the issuance of SNF/ABNs. The Social Services Director indicated that they were instructed not to issue SNF/ABNs for residents discharged from Medicare A, but only when Medicare B benefits were ending. This was contradicted by the Contract Administrator, who confirmed that SNF/ABNs should have been completed for the affected residents. This discrepancy in understanding and execution of policy led to the deficiency identified in the report.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by several observations and interviews. A heavy buildup of dust was found in the ceiling vent of the dining room, and the 80 Hall was noted to have a persistent strong urine odor. Housekeeper A indicated that the cleaning agents used were not strong enough to eliminate the odor, and the urine may have soaked into the floor. The Executive Director acknowledged the issue and discussed potential solutions with the Maintenance Supervisor. Additionally, the hot water in several resident rooms was found to be below the required temperature of 105°F, with temperatures recorded as low as 81.3°F. Further observations revealed a buildup of dust and debris in various areas, including resident rooms and shower rooms. Cobwebs were found in corners and behind beds, and dust was present in ceiling vents. The Maintenance Director, who was new to the facility, was unsure about the hot water heater servicing the 80 Hall. Housekeeper B mentioned that deep cleaning was expected to be done in a couple of rooms per day, but regular cleaning only involved spot cleaning and dusting visible areas. These deficiencies potentially affected at least 40 residents in the facility.
Inaccurate MDS Assessments Lead to Care Plan Discrepancies
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their care plans and treatment records. Resident #9's MDS did not reflect their hospice status and failed to assess their skin condition, despite having a Stage IV pressure ulcer on the right cheek and being on hospice care. The MDS Coordinator acknowledged the oversight, citing being overburdened with additional duties as a reason for not updating the MDS accurately. Resident #40's MDS inaccurately indicated the use of an anticoagulant medication, while the resident was actually on an antiplatelet medication, aspirin. This error was attributed to a mistake by the MDS Coordinator, who marked the wrong medication classification. The Executive Director confirmed that the charge nurse and the Director of Nursing (DON) were responsible for ensuring the medication section of the MDS was accurate. Resident #3's MDS was incomplete, missing information on the resident's cognitive status, pressure ulcer, peg tube, and urinary catheter. The MDS Coordinator admitted to not completing the updates due to being frequently called to work on the floor, which hindered the completion of care plans. The DON expected the MDS to reflect current and accurate resident information, including the presence of medical devices and conditions.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to provide continuity of care by not reviewing and revising comprehensive care plans for four residents. Resident #15, who was admitted with otalgia, unspecified hearing loss, and anxiety, received a new hearing aid for the left ear. However, the care plan did not reflect the use of hearing aids, and staff were unaware of the resident's need for hearing aid batteries. Interviews with CNAs and LPNs revealed a lack of awareness about the resident's hearing aid, indicating a failure to update the care plan with current information. Resident #28, diagnosed with Alzheimer's Disease, age-related physical debility, and anxiety, entered Hospice care, but the care plan did not document this change. Despite receiving Hospice services, the care plan remained outdated, as confirmed by interviews with LPNs and the Executive Director. This oversight highlights a failure to incorporate significant changes in the resident's condition into the care plan. Resident #39, who was cognitively intact and dependent on staff for feeding assistance, had no goals or interventions regarding feeding assistance in the care plan. The resident's family reported that staff were not providing the necessary feeding assistance. Additionally, Resident #9's care plan did not include a facial wound, despite physician orders and observations confirming its presence. The MDS Coordinator admitted to being overwhelmed with additional duties, leading to incomplete and outdated care plans. These deficiencies demonstrate a systemic issue in updating and maintaining accurate care plans for residents.
Failure to Provide Adequate Hygiene Care
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for six dependent residents, leading to poor hygiene and physical discomfort. The facility did not assist these residents in completing Activities of Daily Living (ADL), specifically bathing and showering. The facility's policy on ADLs was requested but not provided, and the existing Bath, Shower/Tub policy was undated and not effectively implemented. Residents were not receiving their scheduled baths or showers, with some going weeks without proper hygiene care. Resident #12, who was cognitively intact and dependent on staff for showering, did not receive a bath or shower for most of December 2024 and January 2025. The resident expressed discomfort and dissatisfaction with the lack of hygiene care. Similarly, Resident #44, who was severely cognitively impaired and required substantial assistance, also missed most of their scheduled showers during the same period. The resident's family had to provide supplemental baths, as the facility failed to meet the resident's hygiene needs. Other residents, including Resident #109, Resident #3, Resident #39, and Resident #50, experienced similar neglect in receiving scheduled baths or showers. Interviews with staff revealed a lack of awareness of residents' bath schedules and preferences, and a failure to document or follow up on missed showers. The facility's staffing issues, such as the absence of bath aides and inadequate CNA support, contributed to the deficiency. Despite the facility's policy requiring two showers per week, residents were often left without proper hygiene care, leading to complaints from residents and their families.
Unqualified Life Enrichment Coordinator Directs Activities Program
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional. The Life Enrichment Coordinator, responsible for the activities program, did not complete the state-approved training course. This was confirmed during an interview where the Coordinator admitted to starting the course but not completing it due to changes in facility administration and lack of payment for the course. The Human Resources Director was unaware of the Coordinator's certification status and assumed they were certified. The Executive Director also did not know the Coordinator's educational background and was unaware of the lack of certification. Additionally, the facility did not provide an Activities policy when requested.
Deficiencies in Wound Care and Follow-Up Appointments
Penalty
Summary
The facility failed to complete and document weekly wound assessments for a resident with a coccyx wound and a facial wound on the cheek. The facility did not have a system in place to review the progress of these wounds, and the resident's cheek, neck, and chest were not kept free of dried drainage from the facial wound. The resident's treatment orders were not consistently followed, with multiple instances of missed wound treatments documented in the Treatment Administration Record (TAR). Interviews with staff revealed a lack of clarity regarding responsibility for wound assessments and documentation, as well as an absence of a process to monitor wound progress. Another resident was affected by the facility's failure to ensure a follow-up surgical appointment was made per discharge orders to remove surgical staples. The resident had been discharged from the hospital with instructions for a follow-up appointment for staple removal, but no such appointment was scheduled. The facility's staff, including the receptionist and nurses, were unaware of the need for this follow-up, and the resident's staples were not removed until much later than recommended. Interviews with facility staff, including the Director of Nursing (DON), Licensed Practical Nurses (LPNs), and the Assistant Director, highlighted a lack of communication and oversight regarding wound care and follow-up appointments. The facility did not have a system in place to track and monitor residents' wounds, and there was no discussion of wounds in their meetings. The administrative and nursing staff were unaware of the resident's staples and the need for a follow-up appointment, indicating a breakdown in communication and responsibility within the facility.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to maintain sanitary conditions for oxygen and nebulizer equipment for three residents. Resident #40, who was on hospice care with a history of pneumonia, had an oxygen concentrator in their room with tubing and a nasal cannula on the floor without a storage bag. Despite the oxygen being prescribed as needed, observations over several days showed the equipment was not stored properly, and staff interviews revealed a lack of adherence to the facility's policy on oxygen equipment storage and maintenance. Resident #3, diagnosed with COPD, had oxygen equipment improperly stored on a tray at the foot of their bed, with the nebulizer pipe not in a bag and the oxygen tubing touching the floor. Staff interviews indicated that the tubing and nebulizer pipe should have been bagged, but neither the CNA nor the LPN took corrective action during observations. Supplemental Resident #51, who was severely cognitively impaired and had COPD and respiratory failure, also had oxygen and nebulizer equipment improperly stored, with tubing wound around the concentrator and the nebulizer pipe in a drawer, both not in bags. The Executive Director confirmed the expectation for staff to maintain equipment in sanitary conditions.
Inadequate Staffing During Winter Storm
Penalty
Summary
The facility failed to provide sufficient nursing staff over a 48-hour period during a winter storm, resulting in overworked staff who were unable to safely administer routine medications to residents. The facility's staffing policy required licensed nurses and certified nursing assistants to be available 24/7 to ensure resident safety and well-being, but this was not adhered to during the storm. The Director of Nursing (DON) and Assistant Director were responsible for ensuring adequate staffing, but no emergency plan was documented, and the facility did not have a plan to get staff to the facility during inclement weather. During the storm, several residents did not receive their prescribed medications, including those for high cholesterol, diabetes, heart failure, dementia, and other conditions. For instance, one resident did not receive nine out of eleven medications, while another did not receive any of their four prescribed medications. The lack of medication administration was due to the exhaustion of the nursing staff, who worked extended hours without relief. The staff were instructed to rest in shifts, but they did not feel comfortable doing so, leading to further fatigue and inability to perform their duties effectively. Interviews with staff revealed that the Assistant Director attempted to communicate with staff via text messages and the facility's communication board, urging them to make every effort to come to work despite the weather. However, many staff were unable to reach the facility, and no management staff came in to assist. The DON, who was new to the position, was not aware of the staffing issues and did not receive any calls to come in. The facility's failure to plan for and manage staffing during the storm resulted in significant deficiencies in resident care.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information, including the facility census and the total number of each staff and actual hours worked by both licensed and unlicensed staff directly responsible for resident care, per shift on a daily basis. This information was not visible for residents, visitors, and staff to view at each nursing station. The facility census was 55 residents at the time of the survey. Observations revealed that the staffing sheet was posted at the far right of the reception desk, which was not visible to residents or visitors who did not stop at the desk. Interviews with various staff members, including a receptionist, LPNs, and a CNA, confirmed that the staffing information was only posted at the front reception desk. Staff indicated that residents or visitors needed to ask staff members to know the number of staff or which staff were working. The Director of Nursing, Assistant Director, and Executive Director stated that the staffing information was posted daily and should be accessible to all residents, visitors, and staff, but it was not posted at each nursing station as required.
Failure to Maintain Appropriate Meal Temperatures
Penalty
Summary
The facility failed to maintain hot meal items on room trays at or close to 120°F for five sampled residents out of ten who received room trays. The deficiency was identified through observation, interviews, and record reviews. The facility's policy required the Dietary Services Manager or designee to ensure meals were palatable and served at appropriate temperatures, but this was not adhered to. Residents consistently reported receiving cold food, and the resident council minutes reflected ongoing concerns about food temperature and quality. Observations revealed that while hot items in the kitchen were at appropriate temperatures, the food delivered to residents' rooms was significantly cooler. For instance, an omelet and sausage link delivered to a resident were recorded at 104°F and 92.8°F, respectively. Interviews with residents confirmed that meals were often cold upon delivery, affecting their consumption and satisfaction. The delivery process was observed to be lengthy, with delays caused by additional tasks such as assisting residents or retrieving items, contributing to the temperature drop. Interviews with staff, including the Dietary Manager and Registered Dietitian, indicated a lack of monitoring of meal temperatures on room trays. The Dietary Manager acknowledged hearing complaints about cold food but had not implemented measures to check tray temperatures. The Registered Dietitian, who visited the facility monthly, also did not routinely check room tray temperatures. This lack of oversight and response to resident complaints contributed to the ongoing issue of cold meals being served to residents.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an Antibiotic Stewardship program and a system to monitor antibiotic usage, as required by their policies. The facility's policy, dated September 2022, outlined that the Infection Preventionist was responsible for coordinating the infection prevention and control program, including antibiotic stewardship. However, during the survey, it was found that there was no one currently in the role of Infection Preventionist, and therefore, no one was performing the tasks or taking responsibility for maintaining the Antibiotic Stewardship program. This lack of oversight was confirmed by both the Executive Director and the Director of Nursing (DON), who stated that they were not involved in antibiotic stewardship activities. The facility's policy on Antibiotic Stewardship, dated December 2016, required that antibiotics be prescribed and administered under the guidance of the stewardship program, with specific elements such as drug name, dose, frequency, and duration of treatment clearly documented. Despite this, the review of the facility's antibiotic order list from November 2024 to January 2025 showed that several residents were on antibiotics, but there was no evidence of a structured program to monitor or review these prescriptions. The absence of an Infection Preventionist and the lack of a functioning Antibiotic Stewardship program led to a deficiency in the facility's ability to manage and monitor antibiotic use effectively.
Failure to Administer Vaccines in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in administering pneumococcal and influenza vaccines to residents. Four residents, out of a sample of five, did not receive the necessary vaccinations, despite the facility's policies requiring that all residents be offered these vaccines unless medically contraindicated. The facility's records showed a lack of documentation for the administration of these vaccines, and interviews with residents and family members revealed uncertainty about whether the vaccines had been administered. Resident #44, who had chronic obstructive pulmonary disease, diabetes, and heart disease, had no documented orders or records of receiving flu or pneumonia vaccines. Similarly, Resident #109, who depended on supplemental oxygen and had COPD and heart failure, had no records of receiving these vaccines, despite the physician's order allowing for the influenza vaccine. Resident #2 had no documentation of pneumonia vaccine status and lacked records for the influenza vaccine for 2024, while Resident #9's refusal of the flu vaccine was not properly documented, including the absence of education on the risks and benefits. Interviews with facility staff, including the Director of Nursing and a Licensed Practical Nurse, revealed confusion and lack of clarity regarding the responsibility for administering vaccines. The Director of Nursing admitted to being unsure about where vaccine documentation should be recorded, and the Executive Director confirmed that consent documentation was missing. This lack of organization and accountability contributed to the failure to provide necessary vaccinations to the residents, as required by the facility's policies.
Failure to Provide and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not providing COVID-19 vaccines to three sampled residents. Resident #2 had received initial COVID-19 vaccinations and a booster but had no record of additional boosters being offered. Resident #9's records lacked any documentation of COVID-19 vaccination status. Resident #44, who was severely cognitively impaired and had multiple health conditions, had no immunization records or physician orders for the COVID-19 vaccine. Resident #109, with significant health issues, also had no immunization records, and the resident could not recall receiving any vaccines upon admission. Interviews with staff revealed systemic issues in the vaccination process. LPN A stated that new residents were supposed to be offered the COVID-19 vaccine, but this was not happening. The DON confirmed that new residents should be offered vaccines upon admission, but consent forms were misplaced, and there was uncertainty about where vaccine documentation should be recorded. The Executive Director acknowledged that the Social Services Designee was responsible for offering vaccines, but the consent documentation was missing, leading to a lack of proper documentation and administration of COVID-19 vaccines.
Failure to Maintain AEDs in Working Condition
Penalty
Summary
The facility failed to ensure that the Automated External Defibrillators (AEDs) were in working condition, as observed during a survey. The AED on hallway A was found in a bag on the crash cart without a battery or pads, and the crash cart checklist did not include checking the AED machine. Similarly, the AED on hallway B had used pads stuck together and no new pads available. The crash cart checklist for hallway B also did not include checking the AED machine and had not been updated since mid-December. Interviews with the Assistant Director and Executive Director revealed that the night shift charge nurse was responsible for checking the AEDs, but this was not being done, and there were no extra pads or batteries available. The Director of Nursing (DON) confirmed that the AED machines should have been evaluated monthly to ensure they were in working order, but this was not happening. The facility had two AED machines, and approximately 25% to 30% of the residents were a full code, meaning lifesaving measures were to be taken if their heart stopped. The lack of maintenance and availability of essential components for the AEDs, such as pads and batteries, led to the deficiency, as the facility did not have the necessary supplies to ensure the AEDs were operational in case of an emergency.
Inconsistent Code Status Documentation for Residents
Penalty
Summary
The facility failed to maintain consistent documentation of code status for two residents, leading to discrepancies in their medical records. Resident #54 had a diagnosis of Cognitive Communication Deficit and was initially documented as full code in the physician's progress notes. However, the resident's Outside the Hospital DNR Order was incomplete, lacking the physician's printed name and license number. The resident's care plan was later revised to indicate a DNR status, but this change was not consistently reflected across all documentation, including the face sheet and the DNR sheet. Resident #209 was admitted with diagnoses of heart failure and chronic kidney disease, among others. The resident's electronic health record (EHR) lacked documentation of advanced directives, and there was no code status listed on the resident's profile page. Interviews with staff revealed uncertainty about the resident's code status, and the care plan indicated a full code status, but this was not consistently documented across the EHR, including the POS and MAR. Interviews with facility staff, including LPNs, CNAs, and the Director of Nursing, highlighted a lack of consistent documentation and communication regarding residents' code statuses. The Social Service Designee was identified as responsible for ensuring residents' wishes were documented, but discrepancies persisted in the records. The facility's policy required a physician's order to support code status, but this was not consistently followed, leading to confusion and potential risk in emergency situations.
Failure to Notify Family of Resident's Fracture
Penalty
Summary
The facility failed to notify the family of a resident about a significant change in the resident's condition, specifically a spiral fracture of the left forearm. The resident, who had severe cognitive impairment due to dementia, complained of arm pain, and an X-ray was ordered on the same day. The X-ray results, which confirmed the fracture, were available but not communicated to the resident's family or physician until five days later. The delay in communication was due to a lack of documentation and follow-up by the nursing staff. The Director of Nursing (DON) was informed of the resident's pain and the X-ray order but did not see the X-ray report until several days later. The facility's policy required timely notification of the physician and family, which was not adhered to in this case. The failure to notify the family and physician promptly resulted in a delay in the resident receiving appropriate medical attention for the fracture. Interviews with facility staff, including the DON, Assistant Director, and Executive Director, revealed that the delay in notification was not acceptable and contrary to the facility's procedures. The staff acknowledged that the physician and family should have been informed immediately upon receiving the X-ray results, and the resident should have been sent to the hospital for evaluation and treatment. The lack of timely communication and action led to the deficiency identified in the report.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in a timely manner for a resident who was severely cognitively impaired and diagnosed with dementia. The resident required maximum assistance with all activities of daily living. On a particular day, the resident complained of pain in the left forearm, and a deformity was noted. An X-ray was ordered, revealing an acute spiral fracture of the distal diaphysis of the ulnar bone. However, there was no documentation of the X-ray being done, the results, or the physician being notified in the resident's electronic health record (EHR). Interviews with facility staff, including the Director of Nursing (DON), Assistant Director, and Executive Director, revealed a lack of awareness that an injury of unknown origin needed to be reported to the state agency. The resident's family was informed of the X-ray and fracture several days after the incident. The facility's policy required immediate reporting of such injuries to various authorities, including the state licensing/certification agency, the local/state Ombudsman, the resident's representative, the attending physician, and the facility's medical director. The facility's failure to follow its policies and procedures resulted in the injury not being reported to the appropriate authorities. The DON admitted that the X-ray results were not reported to the physician in a timely manner, and the injury was not reported to the state agency. The interim administrator acknowledged that the physician should have been notified by the charge nurse when the X-ray results were received, and the state agency should have been informed by the facility administrator at the time of the injury.
Failure to Create Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to create a baseline care plan within 48 hours of admission for a resident diagnosed with heart failure and chronic kidney disease. The resident was unsure if a care plan was in place and mentioned signing something upon admission but did not receive a copy. A review of the resident's electronic health record showed no baseline care plan data available, and interviews with staff revealed a lack of awareness and understanding regarding baseline care plans. Certified Nurses Aides were unaware of baseline care plans, and the MDS Coordinator admitted to not completing or updating all care plans due to being frequently called to work on the floor. The Director of Nursing, Assistant Director, and Executive Director acknowledged that a baseline care plan should be completed within 72 hours of admission, with the MDS Coordinator responsible for initiating it. However, the MDS Coordinator, who had been in the position for two weeks, stated that the previous coordinator did not handle care plans correctly, and they did not have time to complete baseline care plans. The facility's policy required a baseline care plan to be developed within 48 hours of admission, but this was not adhered to, resulting in a deficiency.
Failure to Develop Timely Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, identified as Resident #109, who was admitted with diagnoses including dependence on supplemental oxygen, muscle weakness, and heart failure. The facility's policy required a comprehensive care plan to be developed within seven days of the completion of the resident's Minimum Data Set (MDS) and no more than 21 days after admission. However, the resident's care plan was not completed within this timeframe. Interviews revealed that the resident did not recall participating in a care plan meeting and was unfamiliar with the care process. The MDS Coordinator, who had been in the position for two weeks, admitted to not completing all care plans and noted that the previous coordinator had not been doing them correctly. Further investigation into the resident's Electronic Health Record (EHR) showed no baseline or comprehensive care plan had been developed until nearly a month after the resident's admission. Staff interviews indicated a lack of awareness regarding the completion of the care plan for the resident. The MDS Coordinator was identified as responsible for creating and updating care plans, but the process was not followed, resulting in a delay in the development of the resident's care plan. The facility's Director of Nursing and Executive Director confirmed the MDS Coordinator's responsibility for maintaining accurate and current care plans.
Failure to Transcribe Physician Orders Correctly
Penalty
Summary
The facility failed to ensure physician orders were accurately changed and transcribed following a pharmacist's review for two residents. For one resident, the pharmacist recommended changing the Fluticasone inhaler order from as needed to twice a day, which the physician agreed to. However, the physician's order sheet incorrectly documented the order as two puffs every six hours as needed, contrary to the agreed recommendation. This discrepancy indicates a failure in the transcription process of medication orders. For another resident, the pharmacist noted that the resident, who was on Digoxin for congestive heart failure, had not had a Digoxin level lab drawn since February 2023. Despite the physician agreeing to order these labs, the lab results did not include Digoxin levels in April and May 2024. The order for annual Digoxin level checks was documented five months after the pharmacist's recommendation, and the results from October 2024 were not found. Interviews revealed that the MRRs were not properly communicated to the LPN responsible for entering medication order changes, and the DON did not verify the transcription of orders.
Failure to Facilitate Resident Participation in Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests and well-being of a resident who was admitted with diagnoses including muscle weakness, morbid obesity, and heart failure. Despite the resident expressing a desire to participate in activities and requiring assistance to attend them, the facility did not ensure the resident's participation. The activity logs for October, November, and December 2024 showed that the resident did not attend any activities. The resident's care plan indicated the need for assistance and encouragement to attend activities, but this was not effectively implemented. Interviews with staff revealed a lack of communication and coordination in facilitating the resident's participation in activities. The resident reported that staff did not assist with getting out of bed due to the need for a mechanical lift, which required two CNAs to operate. The CNAs and LPNs interviewed were either unaware of the resident's interest in activities or did not inquire about it. The Activities Director acknowledged that residents needing mechanical lifts did not attend activities and had not communicated staffing issues to the DON. The DON expected CNAs to comply with resident requests for assistance, but this expectation was not met, resulting in the resident's exclusion from activities.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper skin and wound assessments and treatments for residents at high risk for pressure ulcers. Two residents, identified as Resident #3 and Resident #39, did not receive the necessary care and interventions to prevent and treat pressure ulcers. The facility's Wound Care Policy required weekly assessments and documentation of wounds, which were not completed for these residents. Additionally, the facility did not provide pressure-reducing devices for these residents, who were often left in bed without being repositioned or transferred to a chair. Resident #3 had a history of muscle weakness and hemiplegia and was at risk for pressure ulcers. The resident's treatment records showed multiple instances where prescribed wound care was not documented as completed. Observations revealed that the resident was frequently left in bed without pressure-reducing devices, and there was no documentation of skin or wound assessments for December 2024 and January 2025. Interviews with staff indicated a lack of training and resources to properly assess and document wounds, and the facility did not have a designated Wound Nurse. Resident #39, who was cognitively intact and dependent on staff for bathing, developed pressure ulcers on the coccyx area. The resident's treatment records also showed missed wound care opportunities, and there was a lack of documentation for skin assessments. Family members expressed concerns about the resident not being moved from bed frequently enough, contributing to the development of pressure ulcers. Staff interviews confirmed that there were no pressure-reducing devices in place for the resident, and the facility lacked a process to monitor and document wound care effectively.
Failure to Investigate and Address Resident Fall
Penalty
Summary
The facility failed to investigate a fall, assess a resident after a fall, and implement new interventions following the incident involving a resident. The resident, who was severely cognitively impaired and dependent on staff for most care, was found on the floor with a bump and bruising on the right temple. The resident's wheelchair was nearby with brakes not engaged, and EMS was called to transport the resident to the hospital. However, there was no documentation of an assessment or investigation into the cause of the fall. The resident's care plan, which was last updated before the fall, did not include any interventions related to falls or skin injuries. After the fall, no new interventions were added to the care plan to prevent further incidents. The resident's fall risk evaluation noted that the resident was chairbound, incontinent, and had adequate vision, but did not reflect the recent fall. Interviews with staff revealed that the DON was unaware of the need for an investigation into the fall and that vital signs should have been documented. The LPN who found the resident on the floor did not perform neurochecks, citing a reluctance to move the resident. The facility's policies on accident investigation and reporting were not followed, as no incident reports or investigations were completed for the fall.
Deficiency in Feeding Tube Care and Documentation
Penalty
Summary
The facility failed to properly assess and document the care of a resident with a feeding tube, leading to a deficiency. The resident, who had a gastrostomy tube due to dysphagia and other medical conditions, was not properly monitored for tube placement or residuals before administering medications and liquid feedings. The facility's policy required confirmation of tube placement and checks for gastric residual volume, but these were not consistently documented or performed. The resident's medical records, including the Medication Administration Record (MAR) and Treatment Administration Record (TAR), showed numerous instances where documentation was incomplete or missing. There were multiple occasions where the amount of tube feeding administered was not recorded, and residual amounts were not documented, including zero residuals. Additionally, the facility's Skills Fair did not include education on gastrostomy tubes, and staff interviews revealed a lack of training and knowledge on proper procedures for tube feeding care. Interviews with staff, including LPNs and the Director of Nursing (DON), highlighted a lack of education and oversight in the administration of tube feedings. Staff admitted to not checking tube placement or residuals and not receiving adequate training from the facility. The DON acknowledged the absence of audits to ensure proper charting and care, and admitted to not knowing how to check tube placement or residuals, indicating a systemic issue in the facility's training and monitoring processes.
Failure to Assist Residents with Medicaid Applications
Penalty
Summary
The facility failed to provide timely assistance to two residents who were Medicaid pending, impacting their ability to procure Medicaid to assist with their expenses. Resident #35 was listed as Medicaid pending, and the Social Service Designee (SSD) was unaware of the residents' Medicaid status or the reasons for discontinuation. The resident's relative was informed by the previous Business Office Manager (BOM) about a letter that led to the Medicaid pending status, but the relative never saw the letter. The application process for Medicaid only began in November 2024, and the facility's processes were described as inadequate by the relative. Resident #29 was also listed as Medicaid pending, with Medicaid status inactive since February 2024. The resident's relative reported that the previous BOMs did not assist in filling out the Medicaid paperwork correctly. The relative began the renewal application in November 2023 without assistance until the current BOM started helping. The relative had sent a letter to MO Health Net and received a reply that the resident's case was closed, requiring reapplication. The Executive Director acknowledged the existence of these issues before the current BOM's tenure.
Narcotic Medication Management Deficiency
Penalty
Summary
The facility failed to ensure proper management and documentation of narcotic medications, as evidenced by discrepancies in the narcotic count and documentation processes. The Controlled Substance Key Exchange Record showed multiple instances where two nurses did not sign off on the narcotic count at the beginning and end of each shift, with nine out of 28 opportunities left blank over a specified period. Additionally, there were inconsistencies in the number of narcotic cards counted, with several opportunities left uncounted. These lapses in procedure were not communicated to the Director of Nursing (DON), who was ultimately responsible for ensuring the accuracy of narcotic counts. Specific issues were identified with two residents' medication records. For one resident, there was a discrepancy between the number of times Hydrocodone-Acetaminophen was signed out on the Controlled Drug Receipt/Record/Disposition Form and the Nurses' Medication Administration Record (MAR), with the medication being signed out more times on the form than documented on the MAR. Another resident's Oxycodone count was incorrect, with fewer pills remaining than documented. Interviews with nursing staff revealed that narcotic counts were not consistently performed, and the DON was not informed of these discrepancies, nor did the DON audit the narcotic counts to ensure their accuracy.
Failure to Follow Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that Medication Regimen Review (MRR) Pharmacy recommendations were followed and that physicians responded to these recommendations for two residents. The facility's policy required that a consultant pharmacist perform a monthly MRR for each resident receiving medications, with a written report provided to attending physicians within 24 hours for any non-life-threatening medication irregularities. However, for Resident #209, the MRR recommended updating the diagnosis for Tamsulosin to Benign Prostatic Hypertrophy, but there was no physician response or update in the resident's medical record. Similarly, for Resident #2, there were no responses to MRRs over several months, and the facility failed to provide these reports upon request. Interviews with facility staff revealed a lack of clarity and accountability regarding the completion and follow-up of MRRs. The Licensed Practical Nurse (LPN) indicated that MRRs were directed to the Director of Nursing (DON), who was responsible for ensuring their completion. However, the DON was unaware of this responsibility and had not verified the completion of MRRs or the transcription of medication orders. The Executive Director confirmed that the DON was responsible for ensuring MRRs were completed and orders were transcribed correctly, but this process was not followed, leading to the deficiency.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and handling of medications, as observed during a survey. Medications that required refrigeration, such as Gabapentin, were found in the medication cart instead of being refrigerated. Additionally, there were loose pills in the medication cart drawer, indicating a lack of proper organization and cleanliness. The medication refrigerator temperature logs showed significant gaps in documentation, with 11 days in December and 15 days in January where temperatures were not recorded, potentially compromising medication efficacy. The medication room was also found to be inadequately maintained, with no soap in the dispenser and a stained sink. Interviews with LPNs and the DON revealed that there was a lack of clarity and enforcement regarding responsibilities for maintaining cleanliness and ensuring proper storage conditions. The night nurse was supposed to check and document the refrigerator temperature, while housekeeping, under nursing supervision, was responsible for cleaning the medication room and ensuring it was stocked. However, these tasks were not consistently performed, leading to the observed deficiencies.
Failure to Follow Correct Diet Texture Orders for Resident
Penalty
Summary
The facility failed to ensure that the physician's orders regarding diet texture for a resident were correct and consistently followed. A resident with severe cognitive impairment and a diagnosis of oropharyngeal dysphagia was initially placed on a regular diet with a regular texture. However, subsequent assessments indicated the need for a mechanically altered diet, specifically a pureed texture. Despite this, the resident continued to receive meals with a regular texture, leading to episodes of coughing during meals, which were observed by staff and family members. The resident's dietary orders were not properly updated or communicated among the facility's staff. There were conflicting orders in the resident's medical records, with both regular and pureed diet orders being active simultaneously. The Speech Therapist's evaluation in July 2024 recommended a diet upgrade, but the specific texture was not clearly communicated or documented, resulting in continued confusion about the appropriate diet for the resident. Interviews with facility staff, including the MDS Coordinator, LPN, and RD, revealed a lack of clarity and communication regarding the resident's dietary needs. The RD confirmed that the resident should have been on a pureed diet, but the orders were not correctly updated. The facility's failure to discontinue the regular diet order and ensure the resident received the appropriate diet texture contributed to the deficiency in providing adequate nutritional care for the resident.
Failure to Return Deceased Resident's Funds Within Required Timeframe
Penalty
Summary
The facility failed to properly account for and return a deceased resident's personal funds within 30 days, as required by both facility policy and state regulations. After the resident's death, a refund of $7,279.74 was due to the resident's family. The Business Office Manager (BOM) was responsible for managing resident funds and was aware of the overpayment. Instead of processing the refund according to policy, the BOM discussed with the resident's Durable Power of Attorney (DPOA) the possibility of donating the funds to the facility or giving the money to the BOM personally. The DPOA did not explicitly authorize either action and was uncertain about the proper procedure. The BOM ultimately wrote the check to themselves, rather than returning the funds to the family or following the required process. Interviews and record reviews revealed that the facility's policy required a complete accounting of the resident's remaining personal funds to be submitted within 30 days of death, and that funds should not be distributed until this process was completed. The Administrator and the Administrator-in-Training (AIT) both confirmed that the refund should have been processed and sent to the family within the required timeframe. However, the BOM failed to initiate the refund request, and the family was not contacted or provided with the funds. The resident's account statement continued to show the money as owed to the family. Further investigation by facility leadership and the corporate office indicated ongoing difficulties in obtaining financial records and deposit details from the BOM. The President of Health Care Administration and the CFO were unable to reconcile the accounts due to lack of cooperation from the BOM, who delayed or avoided providing necessary information. The deficiency was identified through interviews with staff, the DPOA, and review of facility records, all of which confirmed that the required procedures for handling resident funds after death were not followed.
Misappropriation of Resident Funds by Business Office Manager
Penalty
Summary
A deficiency occurred when the facility failed to prevent the misappropriation of a resident's funds following the resident's death. The Business Office Manager (BOM) wrote a check for $7,279.74 from the resident's trust account, originally intended as a refund to the resident's family, and altered the payee name to themselves using white out. The check was then endorsed and cashed by the BOM, despite facility policy prohibiting such actions and requiring two authorized signatures for checks over $5,000, with neither signature allowed to be that of the payee. The BOM also forged the signature of the retired vice president on the check, who confirmed they had not signed it and would not have approved a check made out to an employee. The facility's policies required that, upon a resident's death, a complete accounting of the resident's remaining personal funds be submitted within 30 days, and that no funds be distributed until this process was complete, except for funeral expenses if necessary. In this case, the BOM did not follow these procedures and failed to process the refund to the family as required. The BOM claimed the family wanted the money donated to the facility or given to them personally, but the designated power of attorney (DPOA) for the resident denied authorizing the BOM to keep or donate the funds. The DPOA reported that BOM suggested these options but did not receive explicit consent. The misappropriation was discovered when the corporate office noticed an out-of-sequence check and initiated an investigation. The BOM admitted to writing and cashing the check, and a note was found in their office further admitting to taking the funds. The family had not received the refund and had not been contacted by the facility, as the police advised against further communication during their investigation. The BOM was terminated for violating the facility's policies regarding resident funds and gratuities.
CNA Roughly Handles Resident
Penalty
Summary
The facility failed to provide care in a respectful and dignified manner when a Certified Nursing Assistant (CNA) forcefully pushed a resident into their recliner. The incident was observed by the resident's family via a video camera in the resident's room. The video showed the CNA guiding the resident roughly, pushing them forward, and then shoving them into the recliner, causing the resident to land hard and appear confused. The resident, who has severe cognitive impairment due to Alzheimer's dementia, did not recall the incident when interviewed later. The resident involved has multiple diagnoses, including congestive heart failure, Meniere's disease, Alzheimer's dementia, pain, anxiety, age-related physical debility, depression, and mood disturbance. The resident requires assistance for all activities of daily living and is at high risk for falls. The facility's policy on dignity emphasizes treating residents with respect and supporting their individual needs and preferences, which was not adhered to in this incident. The local police department was notified, and the facility administration was informed of the incident. The CNA involved claimed not to remember the incident and stated they would never intentionally hurt anyone. The resident's Durable Power of Attorney (DPOA) expressed that the resident would have been very upset if they could remember the incident. The family decided not to press charges against the CNA.
Infection Control Deficiency Due to Improper Practices
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the lack of tracking and trending of resident infections and improper hand hygiene practices. The facility's infection surveillance records showed no analysis of infection data, including trends or patterns, and no comparison with previous months or years. Additionally, the facility's policies on perineal care and linen disposal were not followed, contributing to the deficiency. A Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) were involved in the incidents, with the CNA failing to use proper perineal care techniques and hand hygiene, and placing soiled linen directly on the floor. A resident involved in the deficiency was admitted with diagnoses including a need for assistance with personal care, chronic obstructive pulmonary disease (COPD), and a communication deficit. The resident was cognitively impaired and frequently incontinent of bladder, occasionally incontinent of bowel, requiring assistance with toileting. During an observation, the CNA used a single perineal cleansing wipe for multiple swipes without changing the surface, did not wash hands after removing gloves, and placed soiled linen on the floor. Interviews with the CNA and the Director of Nursing (DON) revealed a lack of recent perineal care training and awareness of infection monitoring deficiencies.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program (ASP) that included protocols for antibiotic use and a system to monitor antibiotic use, as required by their policy. The policy, revised in December 2016, stated that antibiotic usage and outcome data should be collected and documented using a facility-approved tracking form, and that all clinical infections treated with antibiotics should be reviewed by the Infection Preventionist (IP) or designee. However, a review of the facility's ASP from February 1, 2023, to February 1, 2024, showed no documentation that the facility was utilizing an ASP. Interviews with facility staff revealed a lack of awareness and responsibility regarding the ASP. The Director of Nursing (DON), who was newly hired in December 2023, was unaware of the need for an ASP and assumed that the pharmacy was tracking antibiotics related to infections. The DON also mentioned plans to obtain IP certification but was unsure who was currently performing IP tasks. The Administrator was unable to locate any ASP documentation and stated that the former Minimum Data Set (MDS) Coordinator, who left the facility on February 12, 2024, was responsible for the ASP. A Corporate Nurse was scheduled to start as the facility IP and MDS Coordinator on February 14, 2024, to take over these responsibilities.
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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