Advanced Care Of St Joseph
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Joseph, Missouri.
- Location
- 3002 North 18th St, Saint Joseph, Missouri 64505
- CMS Provider Number
- 265754
- Inspections on file
- 30
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Advanced Care Of St Joseph during CMS and state inspections, most recent first.
Two residents were moved to different rooms multiple times without receiving written notification or the opportunity to participate in the decision, despite their care plans and diagnoses of anxiety and depression. Family members were also not informed in writing, and the facility lacked a consistent process for notifying residents or families about room changes.
Surveyors found that a resident did not receive appropriate care for continence or incontinence, including improper catheter care and insufficient measures to prevent UTIs. These lapses resulted in a deficiency related to the standard of care for residents with bowel and bladder needs.
A resident dependent on staff for hygiene, with cognitive and communication deficits, was repeatedly observed with significant facial hair and dried food on the face. The care plan did not address facial hair management, and the resident expressed a desire for hair removal. Staff were unaware of the issue, resulting in a failure to uphold the resident's dignity and personal preferences.
Residents were not given the opportunity or support to organize and participate in resident or family groups, as required. The facility did not facilitate or respect the formation and participation of these groups.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve complaints.
Three residents with cognitive and physical impairments did not consistently receive scheduled or preferred showers, as required by their care plans and facility policy. Staff interviews and documentation confirmed that showers were missed, leading to resident discomfort and dissatisfaction. The lack of a designated shower aide and reliance on available aides contributed to the inconsistency in providing necessary hygiene care.
Surveyors found that staff failed to discard expired leftovers, did not wear required beard nets, and did not maintain cleanliness in the walk-in refrigerator. Food carts delivered to residents had uncovered desserts and drinks, with some food items exposed to contamination and trays with spilled liquids. The cleaning schedule was incomplete, and management confirmed that these practices did not meet facility expectations.
A resident with a history of falls and on anticoagulant medication reported a fall to an RN, who failed to initiate neurological assessments. CNAs found the resident on the floor but did not notify a nurse before assisting the resident back to bed, contrary to protocol. The resident later showed increased confusion and a fractured collar bone, leading to hospitalization. The facility did not document the fall, and staff interviews confirmed protocol breaches.
The facility failed to administer medications and treatments timely and accurately for several residents, leaving blanks in the MAR and TAR. A resident with severe cognitive impairment and heart conditions experienced significant delays in medication administration. Another resident with multiple sclerosis and pressure ulcer risk had undocumented treatments, and a third resident with heart failure and diabetes had missed medication entries. Staff interviews confirmed these practices were not standard.
The facility failed to maintain a proper accounting system for residents' personal funds, with missing statements for six months and discrepancies in petty cash balance. The BOM, new to the position, noted the absence of records due to ownership changes. Additional receipts revealed a surplus attributed to a slush fund, contrary to proper practices.
The facility failed to store dry foods in sealed containers, risking pest contamination for 128 residents. Observations revealed unsealed breadcrumb bags and improperly closed cereal containers, confirmed by the DM, Registered Dietician, and Maintenance Supervisor. The facility's sanitation policy was not followed.
The facility failed to maintain an effective pest control program, with multiple sightings of mice and cockroaches in various areas, including the kitchen and nurses' stations. Observations revealed potential access points for pests, such as a hole in the storage room and gaps under doors. Despite documented sightings, the Administrator believed the issue had been resolved, indicating a lack of effective measures to address the pest control issues.
The facility failed to provide adequate respiratory care for four residents, with deficiencies in equipment maintenance and storage. A resident lacked a physician order for cipap use, and equipment was dusty and improperly stored. Another resident's oxygen rate was incorrect, and equipment was outdated and unclean. Two more residents had issues with nebulizer equipment maintenance. Staff interviews revealed confusion about responsibilities and a lack of clear procedures for maintaining respiratory equipment.
The facility failed to implement proper infection control measures, resulting in psychosocial harm to a resident with scabies due to lack of isolation. Additionally, several residents with MDROs were not placed on Enhanced Barrier Precautions, and staff did not follow hand hygiene protocols during meal service, leading to lapses in infection control.
A resident with severe cognitive impairment was transferred to the ER without a written transfer notice being provided to them or their representative. The facility's SSD later admitted to printing new notices and obtaining signatures days after the transfer, indicating a lapse in protocol.
A resident was transferred to the ER without receiving written notification of the bed hold policy, as required. The facility's Administrator and Social Services Director could not provide evidence that the policy was communicated at the time of transfer, leading to a deficiency in procedure.
A facility failed to accurately code the MDS for a resident in hospice care, as revealed by a review of records and interviews. The resident, who was severely cognitively impaired, was not coded for hospice in the MDS Section O. The MDS Coordinator acknowledged the oversight, and the DON confirmed that MDS responsibilities are managed by the MDS Coordinator. The facility's policy requires a Significant Change in Status Assessment for hospice enrollment, which was not followed.
The facility failed to complete a Level 1 PASARR for two residents with mental health diagnoses, as confirmed by the Business Office Manager and Administrator. The residents' electronic medical records lacked the required documentation, indicating non-compliance with PASARR requirements.
A resident with a skin condition and self-isolation was not provided with a comprehensive care plan addressing her scabies treatment, sores, self-perception, or mental health. Despite being cognitively intact and receiving treatment for itching, her care plan only noted blisters related to fluid retention. Interviews with the ICP and DON confirmed that a care plan should have been generated.
A facility failed to document behavior monitoring for a resident on psychotropic medications, contrary to its policy requiring such documentation to demonstrate medication benefits. Interviews revealed that while side effects were monitored, behavior monitoring was not documented. The administrator acknowledged the oversight, noting that behavior monitoring should have been identified in meetings.
A facility failed to secure medications properly, with two vials of albuterol sulfate found at a resident's bedside without a self-administration order, and 17 insulin pens left unattended on a medication cart. Both the DON and Administrator confirmed that medications should be stored securely, highlighting a breach in the facility's medication storage policy.
The facility did not update the daily nurse staffing information, leaving outdated postings visible for several days. The responsibility for updating the staffing sheet was shared between the Staff Schedule Coordinator during weekdays and the weekend manager or charge nurse on weekends. However, the absence of a company policy on posting the daily staffing sheet contributed to this oversight.
A facility failed to enforce its drug-free policy, leading to repeated drug use incidents in a shared room. One resident, with a history of substance abuse, was found unresponsive multiple times, requiring Narcan. The roommate, with severe cognitive impairment, alerted staff but was not protected from potential exposure. Despite staff concerns, the facility did not implement effective safety measures, citing residents' rights.
Failure to Provide Written Notification and Choice for Room Changes
Penalty
Summary
The facility failed to protect the rights of two residents by not providing written notification of room changes to them or their family members, as required by facility policy. Both residents had care plans indicating the right to be fully informed in advance of any room or roommate changes and to participate in decision-making, especially given their diagnoses of anxiety, depression, and other medical conditions. Despite this, one resident experienced six room changes in six weeks without written notice or the opportunity to decline, resulting in emotional distress. The resident's family member, who was the responsible party, also reported not being notified or consulted about at least five of these moves. Another resident was moved to a different room without consent, despite expressing a desire not to move and not wanting a new roommate. The move was executed while the resident was at lunch, and belongings were relocated without the resident's participation. The Social Services Director confirmed that written notifications were not provided, and there was no established policy or process for room change notifications. Notification practices were inconsistent, sometimes occurring only a few hours before the move, and records of written notices were not maintained.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These deficiencies were observed through direct surveyor findings, indicating lapses in the standard of care required for residents with these needs.
Failure to Address Resident's Facial Hair and Hygiene Needs
Penalty
Summary
A resident with a history of stroke, diabetes, impaired cognition with communication deficit, and dementia was dependent on nursing staff for all hygiene care and unable to perform these tasks independently. The resident's care plan acknowledged the right to dignity but did not address the management of facial hair by nursing staff. Multiple observations over several days documented the resident sitting in the dining room with facial hair greater than one inch on the upper lip, around the mouth, chin, and extending down the neck. On one occasion, dried food from a previous meal was noted on the outside of the resident's mouth and facial hair. During interviews, the resident expressed a desire to have the facial hair removed, stating that it was bothersome. A CNA reported being unaware of the unwanted facial hair and indicated that shaving should occur during showers or as needed. The DON confirmed that residents who do not wish to have unwanted facial hair can be shaved by nursing staff on shower days and as needed. The lack of attention to the resident's facial hair and hygiene needs, as well as the omission in the care plan, resulted in a failure to honor the resident's right to dignity and self-determination.
Failure to Honor Resident Rights to Organize and Participate in Groups
Penalty
Summary
The facility failed to honor the right of residents to organize and participate in resident and family groups. This deficiency was identified when it was observed that residents were not provided the opportunity or support to form or participate in such groups within the facility. The report notes that the facility did not facilitate or respect the organization and participation of these groups as required.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address and resolve resident complaints in a timely and non-retaliatory manner.
Failure to Provide Timely Showers and Maintain Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for three residents who required assistance with activities of daily living, specifically bathing and showering. Observations, interviews, and record reviews revealed that these residents did not consistently receive showers as scheduled or preferred, despite facility policies requiring showers to be provided per resident request or facility schedule. For example, one resident received only one shower in June despite being eligible for five, and another received only four out of eight required showers in June. Documentation and interviews with staff and residents confirmed that showers were missed, and residents expressed discomfort and dissatisfaction with the infrequency of bathing. The affected residents had varying degrees of cognitive and physical impairment, with diagnoses including cancer, heart failure, diabetes, depression, and anxiety disorder. Care plans indicated the need for staff assistance with bathing and specified the frequency and method of bathing, such as sponge baths when showers could not be tolerated. Staff interviews revealed a lack of a designated shower aide and reliance on available aides to provide showers, which contributed to the inconsistency. Residents reported feeling unclean and uncomfortable due to missed showers, and staff acknowledged complaints and the expectation that residents should receive showers according to their preferences and care plans.
Deficiencies in Food Storage, Preparation, and Service Standards
Penalty
Summary
Surveyors identified multiple failures in food storage, preparation, and service within the facility's dietary department. Staff did not discard expired leftovers in the refrigerator, with items such as sauerkraut, sliced onions, and cheese found past their expiration dates, and some containers were not properly sealed. The walk-in refrigerator was observed to have moldy fruit and butter containers on the floor, significant dirt and grime in a corner, black grime along the base of the wall, and heavy rust on shelving support rods. The weekly cleaning schedule was incomplete, with only two assignments documented for the first week of the month and no cleaning assignments posted for the following month. Additionally, a dietary aide was observed working at the dishwashing station on multiple occasions without a required beard net, despite having a full beard. During meal service, food carts delivered to resident halls had uncovered desserts and drinks, with the plastic covering the cart touching exposed food items. Several trays had spilled liquids from uncovered drink cups, resulting in dampened napkins and utensils. Interviews with dietary management and the administrator confirmed that staff were expected to wear beard nets, maintain a posted and completed cleaning schedule, discard leftovers after seven days, and cover drinks and desserts during tray delivery. However, these practices were not consistently followed, as evidenced by the observations and staff interviews.
Failure to Conduct Neurological Assessments After Unwitnessed Fall
Penalty
Summary
The facility failed to complete necessary neurological assessments for a resident after an unwitnessed fall was reported. The resident, who had a history of falls and was on anticoagulant medication, reported to an RN that they had fallen the previous night and had been picked up off the floor by someone. Despite the resident showing signs of increased confusion and having visible bruises, the RN did not initiate the required neurological assessments as per the facility's head injury policy. Additionally, the facility's CNAs did not follow protocol when they found the resident on the floor. Instead of notifying the nurse immediately, they assisted the resident back to bed without a nurse's assessment. This action was contrary to the facility's fall policy, which requires a nurse to assess the resident before repositioning them after a fall. The CNAs later informed the charge nurse of the incident, but the delay in reporting and the lack of immediate assessment contributed to the deficiency. The resident's condition worsened, with increased confusion and a fractured collar bone discovered later. The facility staff failed to document the fall on the night it occurred, and the resident was eventually sent to the hospital. Interviews with the facility's staff, including the DON and the Administrator, confirmed that the expected protocols for handling unwitnessed falls and conducting neurological assessments were not followed, leading to the deficiency.
Medication and Treatment Administration Deficiencies
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice, as evidenced by the failure of licensed nursing staff to ensure that physician's orders were carried out for three of five sampled residents. Medications were not administered timely for these residents, and there were blanks left in the medication administration record (MAR) and treatment administration record (TAR) for two residents. The facility's policies required that medications and treatments be administered as ordered by the physician and documented appropriately, but these standards were not met. Resident #1, who was severely cognitively impaired and had multiple diagnoses including coronary artery disease and heart failure, experienced significant delays in medication administration. For instance, medications scheduled for 7:00 A.M. were often administered hours later, sometimes as late as 2:18 P.M. This resident's care plan required medications to be given as ordered to manage conditions such as depression and hypertension, but the facility failed to adhere to these orders consistently. Resident #4, who was cognitively intact but had multiple sclerosis and was at risk for pressure ulcers, also experienced issues with medication and treatment administration. There were multiple instances where medications and wound care treatments were not documented as administered, leaving blanks in the MAR and TAR. Similarly, Resident #5, who had heart failure and diabetes, had several instances of missed or undocumented medication and treatment administrations. Interviews with facility staff, including LPNs and RNs, confirmed that leaving blanks in the MAR and TAR was not standard practice, indicating a systemic issue with documentation and adherence to physician orders.
Deficiency in Resident Personal Funds Management
Penalty
Summary
The facility failed to maintain a proper accounting system for residents' personal funds, as evidenced by the lack of available personal funds statements for six out of twelve months reviewed from June 2023 to November 2023. The business office manager (BOM) was unable to provide a policy or explanation for the discrepancies in the petty cash balance, which was off by $59.09 during an observation. The BOM, who started employment in December 2023, noted that the position had been vacant for two months prior and that the facility had undergone two ownership changes, which contributed to the lack of records. Further observations revealed additional receipts, leading to a surplus of $204.06 in petty cash, which the BOM attributed to a facility slush fund. The administrator confirmed that the facility was taken over by a new company on June 1, 2023, and that previous records were maintained on paper by the prior owner. The administrator also stated that there should not be a slush fund and that petty cash should balance with cash on hand and receipts, indicating a failure in maintaining proper accounting practices.
Deficiency in Food Storage Practices
Penalty
Summary
The facility failed to ensure that dry foods were stored in sealed containers, compromising food freshness and protection from pests for all 128 residents who received food prepared in the kitchen. During an initial tour of the kitchen, two 25-pound bags of breadcrumbs were found in a small storage room, with one bag open to air, undated, and unsealed, and the other unopened. Both bags were made of paper and not stored in sealed containers, making them susceptible to insects, pests, or rodents. Additionally, three 18-gallon plastic containers with dry cereal were observed with lids that could not be closed properly, allowing potential access for pests. The observations were confirmed by the Dietary Manager (DM) during the initial tour and again during a second tour, where the same issues with the cereal containers were noted. The DM, along with the Registered Dietician and the Maintenance Supervisor, confirmed the observations during the second tour. The DM acknowledged understanding the concerns during an interview. The facility's policy on sanitation inspection, dated 09/01/21, emphasizes the need for food service areas to be clean, sanitary, and compliant with state and federal regulations, which was not adhered to in this instance.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program across multiple areas, including five of six halls, two nurses' stations, shower rooms, the therapy room, and the kitchen, which includes the dish room area. The facility's policy, dated 09/01/21, outlined the need for an effective pest control program to eradicate and contain common household pests and rodents. However, during an initial tour of the kitchen, a hole was observed behind the cove base in the small storage room, creating potential access for pests. Additionally, a mouse dropping was found on a container of powdered sugar, which was stored above unsealed containers of dry cereal. Gaps were also noted at the bottom of doors leading from the dry storage room and the hallway across from the kitchen, providing further access points for pests. The facility's pest control contract included routine pest control and spot service for specific concerns, as noted on the Pest Sighting/Evidence Log. This log revealed multiple sightings of mice and cockroaches in various areas, including the nurses' stations, kitchen, dish room, and several halls, from January to June 2024. Despite these documented sightings, the Administrator acknowledged awareness of the issue but believed it had been resolved. The observations were confirmed by the Dietary Manager, Registered Dietician, and Maintenance Director, indicating a lack of effective measures to address the pest control issues as per the facility's policy.
Inadequate Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide adequate respiratory care for four residents, as observed through various deficiencies in the handling and maintenance of respiratory equipment. For Resident 62, there was no physician order for the use of a cipap machine, and the equipment was found to be dusty and improperly stored. The Director of Nursing confirmed the lack of a physician order, and the resident's cipap mask was observed uncovered and unbagged, contributing to potential infection control issues. Interviews with staff revealed a lack of awareness and procedures for cleaning and maintaining cipap and bipap equipment. Resident 24's oxygen rate was not set according to the physician's order, and the equipment was similarly found to be dusty and improperly maintained. The resident's oxygen tubing was outdated, and the nebulizer mask was left uncovered. Interviews with staff indicated confusion about responsibilities for cleaning and maintaining respiratory equipment, with some staff unaware of who was responsible for these tasks. The Director of Nursing acknowledged the lack of a specific policy for cleaning and maintaining respiratory equipment, relying instead on manufacturer guidelines. Residents 45 and 53 also experienced deficiencies in respiratory care. Resident 45's nebulizer chamber contained liquid, and the oxygen concentrator filter was clogged with dust, indicating a lack of proper maintenance. Resident 53's nebulizer equipment was left unbagged with liquid residue, and staff interviews confirmed that the equipment was not cleaned and stored as required. The facility's policies and staff interviews highlighted inconsistencies and a lack of clarity in the procedures for maintaining respiratory equipment, contributing to the observed deficiencies.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an appropriate infection control program for several residents, leading to psychosocial harm for one resident. Specifically, the facility did not follow its policy for isolation during treatment for scabies for a resident, who was not placed on contact isolation during multiple treatments in March, April, and May. The resident, who was cognitively intact, experienced severe itching and distress, and the facility's staff, including the Infection Control Preventionist (ICP) and Maintenance Supervisor, were not adequately informed or involved in the isolation and cleaning procedures. The resident's room and belongings were not properly cleaned or isolated, and the resident continued to suffer from symptoms without proper isolation measures being implemented. Additionally, the facility did not adhere to its Enhanced Barrier Precautions (EBP) policy for residents with multidrug-resistant organisms (MDROs). Several residents with chronic wounds and positive cultures for MRSA and other organisms were not placed on EBP, and staff were observed not wearing personal protective equipment (PPE) during high-contact care activities. The ICP provided a list of residents needing EBP, but the facility failed to implement these precautions, and the Administrator was unaware of the residents with positive cultures. Furthermore, the facility did not follow appropriate hand hygiene practices during meal service. Staff, including the Medical Records Supervisor and Certified Nurse Aides, were observed not performing hand hygiene between delivering meal trays to residents' rooms. Despite training and expectations set by the facility, there was no specific policy addressing hand hygiene during meal service for nursing staff, leading to lapses in infection control practices.
Failure to Provide Timely Transfer Notice
Penalty
Summary
The facility failed to provide a written transfer notice to a resident and their resident representative during an emergent hospital transfer. The resident, who was severely cognitively impaired with a BIMS score of four out of 15, was transferred to the emergency room on the order of the hospice medical director due to concerns of a bowel obstruction. The transfer occurred without the required written notice being documented in the electronic medical record. Interviews with the facility's Administrator and Social Services Director (SSD) revealed that the written transfer notices were not initially available. The SSD admitted to printing new notices and obtaining the resident representative's signature only on the day of the interview, which was several days after the transfer. There was no evidence to show that the resident or their representative received the written notice at the time of the transfer, indicating a lapse in the facility's protocol for notifying residents and their representatives about transfers.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a resident or their representative with written notification of the bed hold policy prior to the resident's transfer to the hospital. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who was severely cognitively impaired, was transferred to the emergency room for evaluation due to a suspected bowel obstruction. However, there was no documentation in the electronic medical record indicating that the bed hold policy was communicated to the resident or their representative at the time of transfer. During an interview, the facility's Administrator acknowledged the absence of the bed hold documentation, which was typically kept in a designated folder. The Social Services Director later provided a document with the resident's name and a date, but it was revealed that the signatures were obtained only after the incident, and no original documentation could be found. This lack of documentation and timely communication of the bed hold policy constituted a deficiency in the facility's procedures.
Failure to Accurately Code MDS for Hospice Care
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, identified as Resident 37, who was reviewed for MDS accuracy. The deficiency was identified through a review of records, interviews, and policy review, which revealed that the MDS for Resident 37 did not indicate hospice care, despite the resident being in a hospice program. The resident's annual MDS assessment showed a Brief Interview for Mental Status (BIMS) score of four out of 15, indicating severe cognitive impairment. However, the MDS Section O, which covers Special Treatments, Procedures, and Programs, did not reflect the resident's hospice status. Interviews conducted during the investigation revealed that the MDS Coordinator acknowledged the oversight, stating that the MDS did not indicate hospice care and that there were issues when they assumed their role in November. The Director of Nursing (DON) confirmed that they do not handle MDS responsibilities, which are managed by the MDS Coordinator. The facility's policy on MDS 3.0 Completion requires a Significant Change in Status Assessment (SCSA) when a resident enrolls in a hospice program or changes hospice providers, which was not adhered to in this case.
Failure to Complete Level 1 PASARR for Two Residents
Penalty
Summary
The facility failed to ensure that a Level 1 Pre-Admission Screening and Resident Review (PASARR) was completed for two residents, identified as R22 and R60, who were reviewed for PASARR compliance. R22 was admitted with diagnoses of major depressive disorder, schizoaffective disorder, and anxiety, while R60 was admitted with bipolar disorder and schizoaffective disorder. Upon review of their electronic medical records, it was found that there was no documentation of a Level 1 PASARR having been completed for either resident. During interviews, the Business Office Manager confirmed that the Level 1 PASARR documentation could not be found in the records of R22 and R60, acknowledging that it should have been present. The Administrator also stated that a Level 1 PASARR was expected to be in the residents' records, indicating a lapse in the facility's compliance with PASARR requirements.
Failure to Develop Comprehensive Care Plan for Resident with Scabies
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R61, who was at risk for unmet psychosocial needs due to a skin condition and subsequent self-isolation. The facility's policy requires a comprehensive person-centered care plan for each resident, including measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. However, R61's care plan did not address her scabies treatment, sores on her chest, back, arms, and trunk, self-isolation, self-perception, or mental health. This oversight was identified through observation, interviews, and record reviews. R61, who was cognitively intact with a BIMS score of 14 out of 15, reported having scabies for two to three months and expressed severe discomfort due to itching. Despite receiving treatment with permethrin cream and Hydroxyzine HCL for itching, her care plan only noted blisters related to fluid retention on her left lower extremity, with interventions to avoid scratching and keep fingernails short. Interviews with the Infection Control Preventionist and the Director of Nursing confirmed that a care plan should have been generated to address these issues.
Lack of Behavior Monitoring for Psychotropic Medication Use
Penalty
Summary
The facility failed to provide documentation of behavior monitoring for the continued use of an antipsychotic medication for a resident reviewed for unnecessary medications. The facility's policy on the use of psychotropic drugs requires that residents are not given such medications unless necessary to treat a specific condition, and the medication's benefits must be demonstrated through monitoring and documentation of the resident's response. However, for the resident in question, there was no order to monitor or document behaviors related to the use of psychotropic medications, which included Aripiprazole, Buspirone, Fluoxetine, and Hydroxyzine. Interviews with facility staff revealed that while side effects of psychotropic medications were monitored, there was no documentation of behavior monitoring. A registered nurse indicated that unusual behaviors would be charted in progress notes, but no such documentation was found. The facility administrator acknowledged that behavior monitoring should have been identified during morning meetings, and there should have been an order for behavior monitoring related to the use of psychotropic medications.
Medication Storage Deficiency
Penalty
Summary
The facility failed to adhere to its medication storage policy, which mandates that all drugs and biologicals be stored in locked compartments. During an observation, two full vials of albuterol sulfate were found next to a nebulizer machine in a resident's room. The resident, identified as R26, did not have a physician's order to self-administer the medication, nor was there any documentation of a self-administration assessment in the electronic medical record (EMR). This oversight was confirmed by a registered nurse, who acknowledged that medications should not be at the bedside. Additionally, during an inspection of the medication cart, 17 insulin pens were found on top of the cart, unattended, while the responsible nurse was away from the area. The Director of Nursing confirmed this observation and stated that medications should be stored in the cart and not left on top or at the resident's bedside. The facility's administrator also expressed that medications should not be left at the bedside or on top of the medication cart, indicating a clear deviation from the facility's established medication storage protocols.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted and available for residents, families, and visitors. Observations on three separate occasions revealed that the staffing information posted was outdated, displaying the staffing details from 06/17/24, despite being observed on 06/18/24, 06/19/24, and 06/20/24. Interviews with the Staff Schedule Coordinator and the Administrator confirmed that the responsibility for updating and posting the staffing sheet was divided between the coordinator during weekdays and the weekend manager or charge nurse during weekends. However, the Human Resource Specialist noted that there was no company policy regarding the posting of the daily staffing sheet, contributing to the oversight.
Failure to Prevent Drug Use in Shared Room
Penalty
Summary
The facility failed to operationalize its Illegal Drug Use policy, resulting in a hazardous environment for two residents sharing a room. Staff repeatedly found illegal drugs and drug paraphernalia in the room, yet no effective measures were implemented to prevent these occurrences. Despite being aware of the situation, the facility leadership did not provide adequate direction or supervision to ensure the safety of the residents. The facility's policy stated that it was a drug-free environment, but the lack of enforcement and supervision led to repeated incidents of drug use by one of the residents. One resident, who had a history of substance abuse, was found unresponsive multiple times due to drug overdoses, requiring the administration of Narcan. The resident's roommate, who had severe cognitive impairment and a history of drug abuse, was the one who alerted staff to these emergencies. Despite the roommate's distress and the potential risk of accidental exposure to drugs, the facility did not implement additional safety measures or notify the roommate's guardian about the presence of drugs in the room. Interviews with staff revealed that they were aware of the drug use and had reported their concerns to the facility's administration, but no significant changes were made to address the issue. The facility's leadership acknowledged the problem but cited residents' rights as a reason for not conducting searches or implementing stricter supervision. The lack of a comprehensive plan to prevent drug use and ensure resident safety contributed to the ongoing risk and repeated incidents.
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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