Aspire Senior Living Platte City
Inspection history, citations, penalties and survey trends for this long-term care facility in Platte City, Missouri.
- Location
- 220 O'rourke Drive, Platte City, Missouri 64079
- CMS Provider Number
- 265696
- Inspections on file
- 26
- Latest survey
- June 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Aspire Senior Living Platte City during CMS and state inspections, most recent first.
Staff were observed being unnecessarily rough while providing care to two residents, failing to honor their rights to dignity and respect. This deficiency was identified through observation, interview, and record review.
A resident sustained an open fracture to the right femur, and the DON assessed the injury but did not report it to DHSS or immediately notify the Administrator. This failure to report an injury of unknown origin was identified through interviews and record review.
A resident sustained an open fracture to the right femur, and the DON assessed the injury but did not initiate an investigation to determine its cause. This failure to respond appropriately to an alleged violation was identified through interview and record review.
A CMT verbally abused a resident with multiple health conditions by yelling derogatory terms related to the resident's body type and abilities, and physically pushed the resident's wheelchair aggressively after the resident did not move as instructed. The incident was witnessed by a staff member and later admitted by the CMT, despite recent training on abuse prevention.
Staff did not report an injury of unknown origin after becoming aware that a resident had a right leg femur fracture. The incident was not reported as required, and continued non-compliance was identified during a revisit.
A resident sustained a femur fracture of unknown origin, and the facility did not complete a thorough investigation or maintain documentation to show that the alleged violation was fully investigated.
Two residents were subjected to rough and undignified care during personal hygiene assistance, including being handled forcefully and without proper communication. Staff interviews and direct observation confirmed that care was provided in a hurried and rough manner, with one CNA scrubbing a resident's perineal area vigorously and failing to explain the procedure. These actions did not align with facility policies requiring gentle, respectful, and person-centered care.
A resident with dementia and a history of physical aggression was observed by staff with their hand down the front of another resident's pants, constituting non-consensual sexual contact. The incident was witnessed by another resident and reported to staff, who intervened. Both residents involved had severely impaired cognitive skills and complex medical histories, and neither recalled the incident during interviews.
A resident with severe cognitive impairment and quadriplegia was found to have a right femur fracture of unknown origin. Despite facility policy requiring immediate reporting of such injuries, the DON and Administrator did not notify authorities within the required timeframe, instead waiting for additional information from the hospital and corporate office. Staff interviews confirmed no known cause for the injury, and the event was not reported as mandated.
A resident with severe cognitive and physical impairments sustained a femur fracture of unknown origin. The facility did not conduct a thorough investigation or maintain adequate documentation as required by policy, relying only on brief verbal staff interviews without written statements or detailed records. The incident followed a prior mechanical lift event, but the investigation failed to identify all involved staff or fully explore the cause of the injury.
The facility failed to update and follow the code status of two residents as directed by their guardians. One resident's guardian requested a DNR status, but the facility did not update the records, leading to unwanted CPR. Another resident's guardian also requested a DNR status, but the facility failed to document the change. Staff interviews revealed communication lapses and unclear responsibilities in handling code status updates.
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Multiple residents reported receiving cold, unappetizing food, and staff interviews confirmed ongoing issues with maintaining food temperatures, particularly for room trays.
The facility failed to adhere to professional standards of food service safety, including improper use of beard coverings, inadequate hand hygiene, failure to label and date food items, and poor kitchen cleanliness. Staff did not consistently follow protocols, and the facility lacked systematic approaches to ensure food safety and sanitation.
The facility failed to treat residents with respect and dignity by not knocking on doors before entering, leaving doors open during peri-care, and not responding to call lights in a timely manner. These actions affected four residents, leading to exposure and incontinence issues.
The facility failed to respect and facilitate the rights of two residents to go outside unsupervised, despite their cognitive ability and expressed preferences. Staff confirmed that residents were required to be supervised while outside due to safety concerns and staff availability.
The facility failed to maintain a sufficient surety bond to protect resident funds. The average monthly balance of resident funds was $27,000.00, but the facility only had a $1,000.00 bond, making it insufficient by $22,000.00. The Business Office Manager admitted that the bond had not been reassessed since a recent change in ownership.
The facility failed to protect resident rights by not providing accessible information regarding the State Long Term Care Ombudsman program and the State Survey Agency. Residents were unaware of what an ombudsman was, where the information was posted, or how to reach the ombudsman. The Administrator confirmed the information was posted but did not know how residents had been educated on accessing it.
The facility failed to clarify the code status of two residents and did not ensure the DPOA for another resident was properly invoked. Discrepancies were found between signed DNR sheets and physician's orders, and only one physician declared a resident incapacitated when two were required. Staff inconsistencies in recording and communicating code status were also noted.
The facility failed to maintain a safe, clean, and comfortable environment, with significant cleanliness issues, damaged furniture, and inadequate temperature control. Additionally, the facility did not provide a sufficient amount of bed linens, towels, and washcloths, causing discomfort and inconvenience to residents and staff. Interviews with staff and residents confirmed these deficiencies, and the facility's administration acknowledged the ongoing problems.
The facility failed to ensure residents knew how to file a grievance, as evidenced by interviews and observations. Thirteen residents stated they did not know how to file a grievance or who the grievance officer was. Staff members were also unaware of the grievance process, and the grievance forms were inaccessible to wheelchair-bound residents. The Administrator confirmed these issues and was unsure if residents were educated about the grievance process.
The facility failed to check the CNA Registry and complete necessary background checks for three staff members before hiring, as required by policy. Interviews with management confirmed that these checks should have been done prior to employment.
The facility failed to provide written notices of transfer or discharge to residents or their responsible parties, including necessary details and appeal rights, and did not notify the State LTC Ombudsman. This affected two residents with significant health issues. Staff were unaware of these requirements, and the facility lacked a policy for transfers and discharges.
The facility failed to inform two residents and their families of the bed hold policy during hospital transfers. One resident with cognitive impairments and multiple diagnoses was sent to the hospital after a fall, and another resident with severe medical conditions was hospitalized for sepsis and pneumonia. Both cases lacked documentation of bed hold notices, and staff were unaware of the policy.
The facility failed to complete the Minimum Data Set (MDS) assessments within the required time frames for three residents upon their admission. The delays were attributed to staffing changes and errors by the previous Regional MDS Coordinator, resulting in the facility receiving errors for these late submissions.
The facility failed to ensure complete, accurate, and individualized care plans for residents, leading to unaddressed needs such as assistance with ADLs, use of side rails, hospice services, and management of medical conditions like pressure ulcers and cellulitis. The lack of formal training and oversight in the care plan process contributed to these deficiencies.
The facility failed to ensure dependent residents received necessary services for personal hygiene and ADLs. Multiple residents missed scheduled showers, did not receive complete perineal care, and were not repositioned or toileted as needed. Staff cited insufficient staffing and lack of supplies as reasons for these deficiencies.
Facility staff failed to use proper techniques during transfers for three residents, leading to discomfort and potential harm. One resident experienced pain due to improper gait belt use, another was repositioned without a gait belt causing discomfort, and a third was transferred with a gait belt incorrectly placed, indicating a lack of understanding of proper techniques.
The facility failed to maintain the hydration status for three residents and all residents who attended a group meeting, as staff did not consistently pass fresh ice water. Interviews with residents and staff revealed that fresh ice water was not provided every shift due to insufficient staffing, contrary to the facility's policy for assisted nutrition and hydration.
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in the management of oxygen concentrators and tubing. Observations revealed empty humidified water bottles, undated and improperly stored oxygen tubing, and uncleaned filters. Staff interviews indicated a lack of knowledge regarding proper respiratory care protocols.
The facility failed to assess residents for risk of entrapment from bed rails prior to installation and did not ensure the bed's dimensions were appropriate for the residents' size and weight. Additionally, the staff did not complete side rail assessments or obtain a physician's order prior to installation for five residents. The maintenance supervisor installed bed rails without conducting any assessments or measurements, and the administrator acknowledged that side rail assessments should be completed upon admission but were not being done properly.
The facility failed to provide sufficient nursing staff, resulting in delayed responses to call lights, lack of assistance with toileting, failure to reposition residents, inadequate feeding assistance, and missed showers. Residents reported long wait times and inconsistent care due to staff shortages, with observations confirming these issues. The facility's Director of Nursing and staff acknowledged the staffing problems, which compromised the quality of care provided to residents.
The facility failed to ensure staff administered medications with a medication error rate of less than 5%, resulting in a 24% error rate. Errors included improper administration of eye drops, nasal sprays, and insulin injections, as well as mishandling of oral medications. Staff were observed not following manufacturer guidelines and facility policies, leading to potential harm to residents.
The facility failed to ensure residents were free from significant medication errors when an LPN did not prime insulin pens before administering insulin to two residents, resulting in three significant medication errors. The facility's policy and manufacturer guidelines require priming, but this step was not followed.
The facility failed to ensure sufficient staffing to serve meals in a timely manner, affecting three residents. One resident with neurocognitive disorder was not assisted with meals, leading to cold, untouched food. Another resident with impaired cognition waited over 23 minutes for assistance and did not receive supper the previous night. A third resident also missed supper and had to be given a sandwich by the charge nurse. Staff and management acknowledged issues with staffing, training, and meal service.
The facility failed to have a comprehensive QAPI plan, affecting all 66 residents. The new Administrator could not locate any QAPI policies and procedures and reported that only one QAPI meeting had been held, attended by department heads, the staffing coordinator, and the dietary/housekeeping supervisor. Monthly discussions with the Medical Director were also mentioned.
The facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies as part of their QAA committee, affecting all 66 residents. The facility lacked a policy for their QAA process and was unable to provide records of the QAA and QAPI plan. The Administrator, who started recently, mentioned they had only conducted one QAPI meeting with department heads and other key staff.
The facility failed to have an Infection Prevention program and staff did not follow proper infection control practices. A CMT administered medications that had fallen on the floor to a resident, and CNAs did not wash hands between glove changes or clean up urine before placing a fall mat over it. Another CMT used bare hands to handle medication capsules.
The facility failed to establish an IPCP that included an antibiotic stewardship program to address antibiotic use protocols and monitor antibiotic use. A resident with multiple diagnoses, including a UTI, was prescribed antibiotics, but the facility lacked a system to map or track infections. The Administrator confirmed the absence of an active Antibiotic Stewardship Program.
The facility failed to maintain documentation showing that staff received training on abuse, neglect, exploitation, misappropriation of resident property, dementia management, and resident abuse prevention. Interviews with staff revealed inconsistencies in training, and the Administrator and Business Office Manager could not locate any inservice sheets.
The facility failed to ensure nurse aides received the required 12 hours of in-service education, including training on abuse, neglect, and dementia care. Interviews and record reviews revealed a lack of documentation and confirmed that the training had not been provided since the current administrator took over.
The facility staff failed to complete a comprehensive discharge summary for a resident with multiple diagnoses, including dementia and diabetes, who was discharged home with a Home Health agency. The Administrator admitted that no one was responsible for discharge summaries after the last MDS Coordinator left, and the facility lacked a discharge process policy.
The facility failed to ensure a resident with dementia had a personalized care plan, leading to inadequate management of the resident's aggressive behaviors. Staff lacked training in dementia care, and the facility did not complete a comprehensive MDS assessment or develop specific interventions for the resident's needs.
Failure to Ensure Dignified and Respectful Care
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect during care. Based on observation, interview, and record review, staff members were unnecessarily rough while providing care to these residents. This deficiency was identified among two of six sampled residents, with the facility census at 73 at the time of the survey. The report specifically notes that the actions of staff did not honor the residents' rights to a dignified existence, self-determination, and communication, as required by regulation.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the Department of Health and Senior Services (DHSS) when a resident sustained an open fracture to the right femur. The Director of Nursing (DON) assessed the resident but did not report the injury to DHSS and did not immediately inform the Administrator. This deficiency was identified through interview and record review, and it affected one resident out of a facility census of 73. The report notes that this deficiency remains uncorrected and references previous similar findings.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to initiate an investigation into an injury of unknown origin when a resident sustained an open fracture to the right femur. The Director of Nursing assessed the resident but did not begin an investigation to determine the cause of the injury. This deficiency was identified through interview and record review and affected one resident out of a facility census of 73. The deficiency remains uncorrected, and previous similar examples are referenced in a prior Statement of Deficiencies.
Verbal and Physical Abuse of Resident by CMT
Penalty
Summary
Certified Medication Technician (CMT) A verbally and physically abused a resident with multiple medical conditions, including extreme binge eating disorder, obesity, anxiety, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and oxygen dependence. The resident required moderate assistance with activities of daily living and used a wheelchair for mobility. On the morning of the incident, CMT A yelled derogatory and disparaging terms at the resident, specifically referencing the resident's body type, and forcefully pushed the resident's wheelchair forward after the resident did not move as instructed. This behavior was witnessed by a housekeeping aide, who reported hearing CMT A repeatedly yell at the resident and then observed the aggressive physical action. The resident, when interviewed, denied being aware of any derogatory language or mistreatment and stated that staff were good to them. However, CMT A admitted to losing their temper, using inappropriate language, and pushing the resident's wheelchair with excessive force. Facility records confirmed that CMT A had received recent training on abuse and neglect. The facility's abuse prevention policy defines such actions as abuse, including both verbal and physical abuse, and requires the protection of residents from such treatment.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin after staff became aware that one resident had sustained a right leg femur fracture. Despite being informed of the injury on 2/27/25, the incident was not reported as required. This deficiency was identified during a revisit, where continued non-compliance was noted. The facility census at the time was 67 residents.
Failure to Investigate and Document Alleged Violation
Penalty
Summary
The facility failed to complete a thorough investigation after one resident sustained a femur fracture of unknown origin. There was no documentation maintained to show that the alleged violation was thoroughly investigated. This deficiency was identified through interview and record review, with a facility census of 67 residents. The lack of a comprehensive investigation and proper documentation regarding the incident involving the resident's femur fracture constituted a failure to respond appropriately to the alleged violation.
Failure to Provide Dignified and Respectful Care During Personal Care Activities
Penalty
Summary
Staff failed to treat two residents with dignity and respect during the provision of personal care. One resident, who was cognitively intact and dependent on staff for activities of daily living, reported that a CNA was unnecessarily rough while providing care, rolling the resident hard and fast, and using excessive force during perineal care. The resident also described discomfort due to staff yelling at each other over the resident during care. Multiple staff interviews confirmed that the CNA had a pattern of being rough with residents, and the incident was reported to nursing leadership. Another resident, who had moderate cognitive impairment, Parkinson's disease, and was dependent on staff for all activities of daily living, was observed receiving perineal care in a manner that was not gentle or respectful. The CNA providing care did not explain the procedure to the resident and scrubbed the resident's groin and perineal area vigorously, using an up and down motion, and did not communicate with the resident during the process. This was witnessed by another staff member, who described the care as rough and hurried. Facility policies required staff to provide care in a manner that upholds resident dignity and comfort, including gentle and person-centered perineal care. Interviews with staff and residents confirmed that the care provided did not meet these standards, as residents experienced rough handling, lack of communication, and discomfort during personal care tasks.
Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse when one resident was observed with their hand down the front of another resident's pants. The incident occurred in a common area and was witnessed by another resident, who reported it to staff at the nurses' station. Two staff members, a Certified Medication Technician (CMT) and a Certified Nurses Assistant (CNA), both observed the inappropriate contact and intervened by redirecting the resident and assisting the affected resident to the dining room. The resident who initiated the contact had a history of dementia, anxiety, and physical aggression, with severely impaired cognitive skills as indicated by a low BIMS score. The resident who was touched also had severely impaired cognitive skills, spastic quadriplegic cerebral palsy, and other significant medical and communication challenges, but was able to answer yes/no questions. Both residents' care plans documented behavioral histories, including sexually inappropriate behaviors for the resident who was touched. Interviews conducted after the incident revealed that neither resident recalled or reported the inappropriate contact, and both stated they felt safe in the facility. The staff involved had not previously witnessed inappropriate behavior of this nature from the resident who initiated the contact. The facility's abuse prevention policy defines sexual abuse as non-consensual sexual contact of any type with a resident and emphasizes the commitment to protect residents from abuse by anyone.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in a timely manner when staff became aware that a resident had sustained a right femur fracture. According to the facility's abuse, neglect, and exploitation policy, all alleged violations involving serious bodily injury must be reported to the administrator, state agency, and other required authorities immediately, but not later than two hours after the allegation is made. In this case, the resident, who had severe cognitive impairment, quadriplegia, and was dependent on staff for all activities of daily living, was found to have a right distal femur fracture with no known cause or mechanism of injury. The resident had a history of pain and required frequent pain management, but there were no documented falls or injuries in the six months prior to the incident. On the day the injury was discovered, the resident complained of new pain and swelling in the right knee after a shower, which led to a hospital evaluation and diagnosis of a displaced femur fracture. Staff interviews confirmed that no one knew how the injury occurred, and the resident had been fine prior to the shower. The Director of Nursing and Administrator both acknowledged that they were aware of the injury but did not report it as required, instead waiting for additional information from the hospital and corporate guidance. Despite the facility's policy and regulatory requirements, the injury of unknown origin was not reported to the appropriate authorities within the specified time frame. The Administrator and DON deferred reporting while awaiting further details, and the investigation did not reveal any specific event that could have caused the fracture. The failure to report the injury promptly constituted a deficiency in the facility's abuse reporting procedures.
Failure to Thoroughly Investigate and Document Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation and maintain adequate documentation following an incident in which a resident sustained a femur fracture of unknown origin. The resident, who had severe cognitive impairment, quadriplegia, aphasia, and was dependent on staff for all care and mobility, was found to have a right distal femur fracture after being sent to the emergency room for leg pain, swelling, and decreased oxygen saturation. Prior to the discovery of the fracture, the resident had been involved in a mechanical lift incident where the lift tipped and the resident was lowered to the floor, but no injuries were noted at that time and the event was only documented in the progress notes. The facility's policy required immediate and thorough investigation of possible abuse, neglect, or unexplained injuries, including identifying responsible staff, interviewing all involved parties, and providing complete documentation. However, the investigation into the resident's fracture consisted of a single-page document with brief staff interviews lacking dates, times, or written statements. The DON verbally interviewed staff but did not collect written statements or additional documentation, and was unable to identify which CNA was involved in the earlier mechanical lift incident. There was no evidence that all required investigative steps were followed or that the investigation was sufficiently documented. Interviews with staff and administration confirmed that no one knew how the fracture occurred, and that the investigation did not include written statements or comprehensive documentation. The administrator and DON both stated that they did not suspect abuse or neglect, but the lack of a thorough and well-documented investigation was contrary to facility policy and regulatory requirements for responding to injuries of unknown origin.
Failure to Update and Follow Residents' Code Status
Penalty
Summary
The facility failed to ensure that the code status of two residents was correctly documented and followed according to the guardians' directives. For one resident, the guardian had instructed the facility staff to change the resident's code status to Do Not Resuscitate (DNR) upon admission. However, the facility did not update the resident's records to reflect this change, and when the resident stopped breathing, cardiopulmonary resuscitation (CPR) was initiated against the guardian's wishes. Despite the guardian's repeated requests to stop CPR, the facility continued the resuscitation efforts until the resident was declared deceased. Another resident's guardian had also requested a change in the resident's code status from full code to DNR. The Social Services Designee (SSD) was informed of this request, but the facility failed to update the resident's code status. As a result, the resident remained listed as full code, and the necessary documentation to reflect the guardian's wishes was not completed. Interviews with facility staff revealed a lack of communication and responsibility in updating and confirming residents' code statuses. The Business Office Manager, Registered Nurses, and SSD all had differing accounts of their roles and responsibilities in obtaining and documenting code status changes. The physician was not informed of the desired changes, and the facility's policies and procedures for handling code status updates were not followed, leading to the deficiencies identified in the report.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Multiple residents reported receiving food that was cold, unappetizing, and improperly handled. For instance, Resident #8 mentioned that their food was often sloshed together, breadsticks were soggy, and drinks were not covered, leading to spills. Similarly, Resident #2 and Resident #58 reported receiving cold food and uncovered drinks, with Resident #58 also noting that the food lacked taste and was not of the right consistency. Other residents, such as Resident #27 and Resident #56, complained about the food being tough, dry, and generally unappetizing. Resident #55 described the food as horrible and cold, while Resident #212 consistently received cold breakfasts. These observations were corroborated by staff interviews, where Certified Medication Technician B and Certified Nurse Aide A acknowledged that residents had complained about cold food and that there were struggles in serving food in a timely manner, especially during breakfast. Dietary staff also confirmed that room trays were often an issue, with food arriving cold due to delays in distribution. During a kitchen observation, it was noted that while food was initially cooked at appropriate temperatures, by the time it was served, it had significantly cooled down. For example, oatmeal that was initially 205.6 degrees was served at 104.5 degrees, and sausage patties that were 189.3 degrees were served at 119.5 degrees. A test tray at the end of meal service showed all food items were below the appropriate serving temperature of 135 degrees, with some items being as low as 87.4 degrees. Staff interviews revealed that there were ongoing issues with maintaining food temperatures, particularly for room trays, and that the facility was aware of these issues but had not yet fully addressed them. The Dietary Manager mentioned that they were aware of the complaints and had ordered insulated domes with metal heat plate inserts to help maintain acceptable serving temperatures for room trays.
Deficiencies in Food Service Safety and Hygiene Practices
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards of food service safety. Staff with facial hair did not wear beard coverings, and there were multiple instances of staff failing to wash their hands at appropriate times. Specifically, dietary aides and the housekeeping supervisor were observed not wearing beard restraints, and dietary staff did not wash their hands between tasks, after touching potentially contaminated surfaces, or when entering and exiting the kitchen. This lack of adherence to hygiene protocols was confirmed through interviews with the staff and the administrator, who acknowledged the deficiencies in hand hygiene practices and the availability of beard coverings. The facility also failed to properly label and date food items, which is essential for maintaining food safety. Observations revealed undated and opened food items in the walk-in cooler and spice cabinet, including bags of cheese, containers of beef base, and various spices. Interviews with the dietary manager and aides confirmed that food items should be labeled and dated when opened, but this practice was not consistently followed. The dietary manager admitted to not knowing the specific guidelines for discarding spices in a long-term care setting. Additionally, the facility did not maintain a clean and sanitary kitchen environment. Observations showed caked-on dust on the coils of the fan in the cooler and behind the stove, as well as crumbs on the kitchen floor. The dietary manager admitted to not having a cleaning log for kitchen tasks, and the administrator acknowledged that the cleanliness of the facility was a work in progress. The lack of a systematic approach to kitchen cleanliness and sanitation was evident, contributing to the overall deficiency in food service safety standards.
Failure to Maintain Resident Dignity and Timely Response to Call Lights
Penalty
Summary
The facility failed to treat each resident with respect and dignity and provide care in a manner that promotes their quality of life. Staff did not knock on resident doors before entering and failed to announce themselves to two residents. Additionally, staff left the bedroom door to the hallway open while providing peri-care to one resident, exposing the resident's genital area to the hallway. Another resident's call light was not answered in a timely manner, resulting in the resident being incontinent of urine. These actions affected four residents out of the 17 sampled residents, with a facility census of 66. Resident #35, who has significant cognitive deficits and requires assistance for activities of daily living, was observed with their room door open and privacy curtain partially drawn while receiving peri-care. This exposed the resident's genital area to the hallway. The nurse aide acknowledged the mistake and stated that the door should have been closed. The Director of Nursing and the Administrator confirmed that room doors should be closed during such care. Resident #21, who has no cognitive deficits but requires partial assistance for activities of daily living, had their call light on for 45 minutes before a CNA responded. The resident was found to be incontinent of urine due to the delay. The CNA admitted to being busy with another resident and stated that there is not enough help to answer call lights immediately. The Administrator also acknowledged the staffing issue. Additionally, two other residents reported that staff frequently entered their rooms without knocking or announcing themselves, which made them feel disrespected and undignified.
Failure to Respect Resident Choice for Outdoor Access
Penalty
Summary
The facility failed to respect and facilitate the rights of two residents to make choices about significant aspects of their lives, specifically the ability to go outside unsupervised. Resident #45, who is cognitively intact and has a preference for going outside to get fresh air, reported that staff did not assist in facilitating this preference unless they were escorted. Similarly, Resident #212, who is also cognitively intact and has a history of waking up early to watch the sunrise, stated that they could not go outside alone and required supervision at all times. Both residents did not have care plans addressing their preferences for outdoor activities. During a group meeting, several residents expressed that they were not allowed to go outside unless accompanied by staff, and non-smokers had even fewer opportunities to go outside. Interviews with staff, including the Housekeeping Supervisor, Nurse Aide, Director of Nursing, and the Administrator, confirmed that residents were required to be supervised while outside due to safety concerns and staff availability. The facility did not have a courtyard available, and the landscape was described as sloping, which contributed to the decision to restrict unsupervised outdoor access.
Insufficient Surety Bond for Resident Funds
Penalty
Summary
The facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The review of the facility's Resident Trust Bank Statements for the period from May 2023 through May 2024 showed an average monthly balance of $27,000.00. However, the Department of Health and Senior Services approved bond list revealed that the facility only had a $1,000.00 approved bond, making it insufficient by $22,000.00. During an interview, the Business Office Manager admitted that the facility had recently changed ownership and was unaware that the bond had not been reassessed since the new company took control. The Business Office Manager also acknowledged that the bond should be sufficient to cover the resident funds.
Failure to Provide Accessible Ombudsman Information
Penalty
Summary
The facility failed to protect resident rights by not providing accessible information regarding the State Long Term Care Ombudsman program and the State Survey Agency. The facility's policy mandates that residents receive a list of pertinent state regulatory and informational agencies, including the ombudsman program and the State Survey Agency. However, an observation on 5/7/24 revealed that the ombudsman poster was hung on a wall in the day room, but it was not visible to residents sitting in wheelchairs. Additionally, during a group interview, residents expressed that they did not know what an ombudsman was, where the information was posted, or how to reach the ombudsman. Twelve residents also did not know how to formally file a complaint with the state survey agency. During an interview on 5/9/24, the Administrator confirmed that the ombudsman contact information was posted in the day room but admitted to not knowing how residents had been educated on reaching the ombudsman representative or the state survey agency. The facility census at the time was 66, indicating a significant number of residents potentially affected by this deficiency.
Failure to Clarify Code Status and Invoke DPOA Properly
Penalty
Summary
The facility failed to clarify the code status of two residents and did not ensure the Durable Power of Attorney (DPOA) for Health Care Decisions for another resident was properly invoked. Resident #16's DPOA required activation by two physicians, but only one physician had declared the resident incapacitated. Despite this, the resident's DNR order was signed by the DPOA and a physician, and the resident's medical records indicated a DNR status. The Social Services Designee and the Administrator confirmed the requirement for two physicians to declare incapacity, which was not met in this case. For Resident #45, there was a discrepancy between the resident's signed DNR sheet and the physician's orders, which indicated a full code status. Similarly, Resident #214 had a signed DNR sheet, but the physician's orders showed a full code status. Interviews with staff revealed inconsistencies in how code status information was communicated and recorded, with some staff relying on stickers on room doors and others checking electronic medical records or care plans. The Director of Nursing and the Administrator both acknowledged that the code status in physician's orders should match the advance directives. The Social Services Designee was responsible for ensuring that advance directive paperwork was scanned and recorded accurately. However, the discrepancies in the code status documentation for Residents #45 and #214, as well as the improper activation of the DPOA for Resident #16, indicate a failure to adhere to the facility's policies and procedures regarding advance directives and code status documentation.
Facility Fails to Maintain Cleanliness, Temperature Control, and Adequate Linen Supply
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents. Observations revealed multiple areas with significant cleanliness issues, including cobwebs, dust, dirt, and debris on vents, handrails, and floors. Additionally, the facility had damaged and worn-out furniture, such as cracked dining room chairs and peeling love seats. The facility also did not maintain comfortable temperatures in common areas, with temperatures ranging from 65.8 to 84.7 degrees Fahrenheit, causing discomfort to residents who were observed covered in blankets and complaining about the cold or heat. Interviews with staff indicated that the air conditioning units were not functioning correctly, and there was a lack of clarity regarding cleaning responsibilities between housekeeping and maintenance staff. The facility also failed to provide a sufficient amount of bed linens, towels, and washcloths. Observations and interviews with residents and staff revealed that the facility often ran out of necessary linens, forcing staff to use fitted sheets instead of top sheets and causing delays in providing clean towels for resident showers. The Dietary and Laundry Manager confirmed the shortage of linens and the challenges in maintaining an adequate supply due to missing items and limited laundry staff availability. Staff expressed frustration with the lack of access to linen supplies, which hindered their ability to provide proper care to residents. Resident #8, who had cognitive skills intact and required assistance with daily activities, reported not receiving a clean top sheet despite requesting one. The resident was covered with a fitted sheet instead, highlighting the facility's failure to meet basic hygiene and comfort needs. Interviews with various staff members, including the Maintenance Supervisor, Housekeeping Aide, and Certified Medication Technicians, further corroborated the issues with cleanliness, temperature control, and linen shortages. The Administrator and Director of Nursing acknowledged the deficiencies and the ongoing problems with maintaining a sufficient supply of linens.
Failure to Ensure Residents Knew How to File a Grievance
Penalty
Summary
The facility failed to ensure residents knew how to file a grievance, as evidenced by interviews and observations. During a group meeting, all thirteen residents present stated they did not know how to file a formal grievance or who the grievance officer was. Observations showed that the grievance forms were placed in a red folder on the wall, which was inaccessible to residents in wheelchairs. Additionally, staff members, including the housekeeping supervisor, Dietary Manager, Nurse Aide, and Licensed Practical Nurse, were unaware of the facility's grievance process or the location of the grievance forms. The Administrator confirmed that the grievance folder was not accessible to wheelchair-bound residents and was unsure if residents were educated about the grievance process. The facility's policy on resident rights indicated that residents have the right to voice grievances without discrimination or reprisal and should be informed on how to file a grievance. However, the lack of knowledge among residents and staff about the grievance process and the inaccessibility of grievance forms for wheelchair-bound residents indicate a failure to adhere to this policy. The Administrator also mentioned that the facility had a corporate compliance line but was unsure if this information was provided to residents. The Social Service Designee was expected to educate residents about the grievance process during the 48-hour care plan meeting, but it was unclear if this was effectively communicated to all residents.
Failure to Conduct Required Background Checks and Registry Verifications
Penalty
Summary
The facility staff failed to check the Certified Nurse Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator, which is a marker given by the federal government to individuals who have committed abuse or neglect. This deficiency affected three of ten sampled staff members: a Certified Medication Technician (CMT), a Dietary Aide, and a Licensed Practical Nurse (LPN). Specifically, the employee files for these staff members showed that necessary background checks, including the Family Care Registry and Employee Disqualification List (EDL) checks, were either not completed or were completed significantly after the date of hire. Interviews with the Business Office Manager, Director of Nursing, and the Administrator revealed that background checks and registry checks should be completed before hiring employees. However, the facility did not follow these procedures consistently. The Business Office Manager, who started in the position recently, confirmed that Family Care Registry checks should be done before hiring, but acknowledged that the facility did not perform periodic background checks on employees. The Director of Nursing and the Administrator both stated that background checks and Nurse Aide Registry checks should be completed prior to employment, but this was not done for the affected staff members.
Failure to Provide Proper Transfer/Discharge Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to residents or their responsible parties, which included the reason for the transfer, the effective date, the location, and information regarding appeal rights. Additionally, the facility did not notify the State Long-Term Care Ombudsman of the transfers and discharges. This deficiency affected two residents, one of whom had a stroke, Alzheimer's disease, and other significant health issues, and another who was hospitalized for sepsis and pneumonia. The facility did not have a policy for the transfer or discharge of residents, and staff were unaware of the requirements for notifying the Ombudsman and providing appeal rights information. Resident #27, who had cognitive impairments and multiple health conditions, was found on the floor with a large hematoma and was transferred to the hospital. The medical record did not contain a transfer or discharge letter for the resident or their responsible party. Interviews with staff revealed that they were unaware of the need to include appeal rights and notify the Ombudsman. Resident #14, who was cognitively intact but dependent on staff for most activities, was hospitalized for sepsis and pneumonia. The medical record also lacked a transfer or discharge letter. Interviews with the new Administrator and Director of Nursing indicated that they were not aware of the requirement to notify the Ombudsman or provide a notice of transfer and discharge. The facility did not have a transfer packet or policy in place to ensure compliance with these requirements.
Failure to Inform Residents of Bed Hold Policy
Penalty
Summary
The facility failed to ensure that staff informed residents and their family/legal representatives of the bed hold policy at the time of transfer or discharge to the hospital for two of the 17 sampled residents. Resident #27, who had cognitive impairments and multiple diagnoses including stroke and Alzheimer's disease, was sent to the hospital after a fall. There was no documentation in the medical record that the resident or the responsible party was provided with written information explaining the facility's bed-hold policy. During an interview, an LPN stated that they were not aware of any bed hold letter/notice that needed to be sent with the resident. Similarly, Resident #14, who was cognitively intact but had multiple severe medical conditions including quadriplegia and chronic pain, was hospitalized for over a week due to sepsis and pneumonia. The resident did not recall receiving a bed hold notice at the time of hospitalization. The medical record also lacked documentation of a bed hold notice. Interviews with the Director of Nursing and the Administrator revealed that they were unaware of the bed-hold policy and could not find any discharge packet that included a bed-hold notice.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) assessments within the required time frames for three residents (Resident #214, #216, and #212) upon their admission. Resident #214 was admitted with diagnoses including rheumatoid arthritis and generalized muscle weakness, but the MDS was not completed until after the required deadline. Similarly, Resident #216, who had diagnoses including neurocognitive disorder with Lewy bodies and chronic pain syndrome, also had a delayed MDS submission. Resident #212, with conditions such as dependence on renal dialysis and diabetes, did not have an MDS completed within the required timeframe either. The State RAI Coordinator confirmed that the MDS assessments for these residents were submitted late and the facility received errors for these delays. Additionally, the facility did not provide a policy regarding comprehensive assessments, which is a requirement for ensuring timely and accurate resident evaluations. The Social Service Designee and the Administrator acknowledged the delays and attributed them to staffing changes and errors made by the previous Regional MDS Coordinator. The facility's failure to complete these assessments on time indicates a lapse in adhering to federally mandated assessment protocols, which are crucial for developing appropriate care plans for residents.
Incomplete and Inaccurate Care Plans for Residents
Penalty
Summary
The facility failed to ensure that residents had complete, accurate, and individualized care plans to address their specific needs. For Resident #162, the care plan did not include necessary details such as assistance with ADLs, use of side rails, hospice services, use of a catheter, or use of oxygen. Despite the resident having an unwitnessed fall and the presence of side rails on the bed, these were not documented in the care plan. Additionally, there was no progress note about the fall, and the use of side rails was not ordered by the physician or included in the care plan. Resident #45's care plan was also incomplete, missing details about side rails, shower preferences, activity preferences, and pressure ulcers. The resident had a side rail installed to assist with bed mobility but had not used it since moving to a recliner due to leg swelling. The resident expressed a preference for showers twice a week, but the shower logs showed that only 2 out of 9 scheduled showers were provided. The resident also had a pressure ulcer and cellulitis, which were not adequately addressed in the care plan. For Resident #216, the care plan was not completed despite the resident being admitted to the facility and having significant medical needs, including impaired cognition, chronic pain, and the use of antipsychotic medications. The resident's representative reported not participating in any care plan meetings, and the facility had not provided team collaboration or communication regarding the resident's care. Similarly, Resident #214's care plan was incomplete, only addressing do-not-resuscitate orders despite the resident having multiple medical conditions and requiring assistance with various ADLs. The facility's Social Service Designee and Administrator acknowledged the deficiencies, noting a lack of formal training and oversight in the care plan process.
Failure to Provide Adequate ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene. This deficiency affected multiple residents, including those who did not receive complete perineal care and those who missed scheduled showers. For instance, one resident reported going two weeks without a shower, feeling filthy and neglected, while another resident's hair appeared dull and greasy, indicating a lack of proper hygiene care. Staff interviews revealed that showers were often missed due to insufficient staffing and a lack of necessary supplies like towels and washcloths. Additionally, the designated shower aide was frequently reassigned to other duties, further exacerbating the issue. In another instance, a resident with severe cognitive impairment and incontinence was observed sitting in a Broda chair with a puddle of urine underneath. The staff failed to provide thorough perineal care, did not clean the resident's chair, and used a clean incontinent brief that had fallen on the floor. The staff also did not wash their hands before and after providing care, and the resident's room was left with urine on the floor, covered by a fall mat. Interviews with the staff confirmed that they were aware of the proper procedures but failed to follow them due to time constraints and staffing issues. Another resident, who was dependent on staff for repositioning and toileting, was observed being left in a Broda chair for extended periods without being repositioned, offered food or drinks, or taken to the restroom. The resident was visibly distressed, crying, and expressing discomfort, but staff did not promptly address these needs. The facility's failure to provide adequate care and assistance with ADLs, including repositioning, toileting, and maintaining personal hygiene, was evident across multiple cases, highlighting significant deficiencies in the care provided to residents.
Improper Transfer Techniques and Gait Belt Use
Penalty
Summary
The facility staff failed to use proper techniques to reduce the possibility of accidents and injuries during the use of a gait belt transfer for Resident #9 and properly transfer two residents, Resident #21 and Resident #4, in a manner to prevent accidents. Resident #21, who had no cognitive deficits and required partial to moderate assistance for standing and transfers, was observed being transferred by a CNA without the use of a gait belt, causing discomfort and potential harm. The resident reported that the improper technique sometimes caused pain, especially when staff did not use a gait belt, pulling on the resident's pacemaker and twisting the skin. Resident #4, who had significant cognitive deficits and required substantial to maximum assistance with ADLs, was observed being repositioned in a dining room chair by a CNA without the use of a gait belt. The CNA used their forearm under the resident's armpit to pull and drag the resident, causing the resident to grunt loudly in discomfort. The resident's care plan indicated the need for a gait belt to assist with transfers and ambulation due to the resident's tendency to lean to one side. Resident #9, who had severe cognitive impairment and required substantial to maximal assistance with transfers, was observed being transferred by two CNAs using a gait belt incorrectly placed under the resident's breasts. The gait belt slid up between the resident's shoulder blades during the transfer, indicating improper technique. Interviews with the CNAs revealed a lack of understanding of the correct placement and use of the gait belt, contributing to the unsafe transfer practices observed.
Failure to Maintain Resident Hydration Status
Penalty
Summary
The facility failed to ensure staff maintained the hydration status for three of the 17 sampled residents and all residents who attended the group meeting. Specifically, staff did not pass fresh ice water to the residents as required. Resident #2, who had diagnoses including seizure disorder, depression, and coronary artery disease, reported that staff rarely passed fresh ice water each shift, and their water pitcher was less than half full without any ice. Resident #8, who had diagnoses including anxiety, depression, and anemia, also reported that staff did not pass fresh ice water every shift, and their water pitcher lacked ice. Resident #56, with diagnoses including cancer, anxiety, depression, pneumonia, respiratory failure, and COPD, similarly reported that staff did not pass fresh ice water every shift, and their water pitcher was less than half full without a lid or ice. During a group interview, residents confirmed that they often had to ask for fresh ice water, and some reported that staff did not pass water at all. Interviews with facility staff, including a Certified Medication Technician (CMT) and a Certified Nurse Aide (CNA), revealed that fresh ice water was not passed every day due to insufficient staffing. The CMT stated that fresh ice water was usually only provided if a resident specifically requested it. The CNA confirmed that fresh ice water was not passed every shift. The Administrator and the Director of Nursing (DON) acknowledged that staff should be passing fresh ice water every shift and sometimes twice a shift, but this was not consistently happening. The facility's policy for assisted nutrition and hydration emphasized the importance of providing sufficient fluid intake to maintain proper hydration and health, but this policy was not being followed in practice.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in the management of oxygen concentrators and tubing. For Resident #7, who has a history of traumatic brain injury and chronic obstructive pulmonary disease (COPD), the oxygen concentrator was observed to be set at 2 liters per nasal cannula (2L/NC) instead of the ordered 3L/NC, and the humidified water bottle was empty. Additionally, the oxygen tubing was not dated, which is a critical step in ensuring timely replacement and hygiene. The resident's care plan and physician's orders were not followed accurately, contributing to the deficiency observed during the surveyor's visit on 5/6/24. For Resident #56, who has diagnoses including cancer, pneumonia, anxiety, depression, respiratory failure, and COPD, similar issues were noted. The resident's oxygen concentrator had an empty humidified water bottle, and the oxygen tubing was not dated and was found lying on the floor. The filter on the oxygen concentrator was covered in gray lint, indicating it had not been cleaned properly. The nebulizer tubing and mask were also not replaced as per the monthly schedule. Interviews with staff revealed a lack of knowledge regarding the frequency of changing and dating the tubing, as well as cleaning the filters, further highlighting the facility's failure to adhere to proper respiratory care protocols.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility staff failed to assess residents for risk of entrapment from bed rails prior to installation and did not ensure the bed's dimensions were appropriate for the residents' size and weight. Additionally, the staff did not complete side rail assessments or obtain a physician's order prior to installation for five of the seventeen sampled residents. This deficiency was observed in residents who had varying degrees of cognitive and physical impairments, including those with neurocognitive disorders, quadriplegia, and chronic pain syndromes. The facility census was 66, and no policy on side rails was provided by the facility. Resident #45, who was cognitively intact and had impairments on one side, had a bed rail installed without a proper assessment or physician's order. The resident requested the side rail to assist with turning in bed, but the care plan did not include the use of bed rails. Similarly, Resident #216, who had a neurocognitive disorder and was dependent on staff for mobility, had side rails installed without any documented assessment or physician's order. The resident's bed was not lowered to the ground, increasing the risk of injury. Other residents, such as Resident #14 and Resident #1, also had side rails installed without proper assessments or physician's orders. Resident #14, who was cognitively intact but dependent on staff for most activities of daily living, requested side rails to help with turning in bed. Resident #1, who had severe cognitive loss and was dependent on staff for mobility, had a full side rail installed without padding, posing a risk of injury. The facility's maintenance supervisor admitted to installing bed rails without conducting any assessments or measurements, and the administrator acknowledged that side rail assessments should be completed upon admission but were not being done properly.
Staffing Shortages Lead to Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of six out of 17 residents. This deficiency was evidenced by delayed responses to call lights, lack of assistance with toileting, failure to reposition residents, inadequate feeding assistance, and failure to provide showers twice a week. Residents reported long wait times for call lights, especially on weekends, and inconsistent shower schedules due to staff shortages. Observations confirmed these issues, with one resident waiting over an hour for assistance to use the bathroom, resulting in incontinence and embarrassment. Resident #21, who was cognitively intact and required partial assistance for activities of daily living (ADLs), reported waiting over an hour for call light responses, particularly on weekends. Observations showed an 18-minute delay in answering the resident's call light, leading to an incident of incontinence. Similarly, Resident #57, who had significant cognitive deficits and was dependent on staff for ADLs, was observed not being repositioned or offered food and drinks for extended periods, despite being in a Broda chair for several hours. Other residents, such as Resident #45, #50, and #39, also experienced issues with shower schedules and personal hygiene due to staff shortages. The facility's Director of Nursing and other staff members acknowledged the staffing issues, noting that shower aides were often pulled to cover other shifts, leading to missed showers and delayed care. Additionally, Resident #216, who required assistance with eating, was not fed in a timely manner, with family members having to step in to ensure the resident received meals. The facility's failure to provide adequate staffing resulted in unmet resident needs and compromised care quality.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure staff administered medications with a medication error rate of less than 5%, resulting in a medication error rate of 24%. This affected six of the 17 sampled residents. The errors included improper administration of eye drops, nasal sprays, and insulin injections, as well as mishandling of oral medications. Certified Medication Technician (CMT) A and Licensed Practical Nurse (LPN) A were observed making multiple errors during medication administration, including not applying lacrimal pressure for eye drops, touching the tip of the eye dropper to residents' eyelashes, not following manufacturer guidelines for nasal sprays, and not priming insulin pens before administration. Additionally, CMT A was observed picking up dropped medications from the floor and cart with bare hands and administering them to a resident, which is against facility policy and professional standards of practice. Resident #39 was prescribed Dorzolamide-timolol ophthalmic drops for cataracts, but CMT A did not apply lacrimal pressure after administration. Resident #51, who was prescribed Polymyxin b sulf-trimethoprim ophthalmic drops for an eye infection, experienced multiple errors during administration, including the tip of the eye dropper touching the resident's eyelashes and the failure to apply lacrimal pressure. Resident #6, who was prescribed Fluticasone nasal spray for allergy symptoms, did not receive the medication according to manufacturer guidelines, as CMT A did not shake the bottle, have the resident blow their nose, or close one side of the nostril before administration. Resident #34, who had multiple prescriptions for various conditions, experienced a medication error when CMT A dropped medications on the floor and cart, picked them up with bare hands, and administered them to the resident. Resident #56 and Resident #47, both diagnosed with diabetes, did not receive their insulin injections according to manufacturer guidelines, as LPN A did not prime the insulin pens before administration. These deficiencies indicate a lack of adherence to medication administration policies and professional standards of practice, resulting in a high medication error rate and potential harm to residents.
Failure to Prime Insulin Pens Leads to Medication Errors
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when staff did not prime insulin pens for two residents, resulting in three significant medication errors out of the 25 sampled medications. The facility's policy for medication administration requires medications to be administered as ordered and in accordance with manufacturer specifications. However, during observations, an LPN did not prime the insulin pens before administering insulin to two residents, despite the manufacturer's guidelines stating that the pen should be primed with 2 units before each injection. This failure was observed during the administration of Novolog, Lantus, and Victoza insulin pens. Resident #56, who has a diagnosis of diabetes and requires set-up assistance with ADLs, received an insulin injection without the pen being primed. Similarly, Resident #47, who has diagnoses of diabetes, congestive heart failure, and a cardiac pacemaker, also received insulin injections from unprimed pens. The LPN involved stated that they did not believe priming was necessary. The Director of Nursing and the Administrator confirmed that staff are expected to follow manufacturer guidelines, which include priming the insulin pens before each use.
Insufficient Staffing for Meal Service
Penalty
Summary
The facility failed to ensure sufficient staffing to serve meals to residents in a timely manner, affecting three residents. Resident #216, diagnosed with neurocognitive disorder with Lewy bodies, generalized osteoarthritis, and chronic pain syndrome, was observed multiple times with untouched, cold meals. Interviews with the resident's family and staff confirmed that the resident was not being assisted with meals, and family members had to step in to ensure the resident was fed. There was no documentation of the resident's meal intakes in the electronic medical record, and staff admitted to not having enough time to assist or document due to staffing shortages. Resident #16, who had moderately impaired cognition and required substantial assistance with eating, received a lunch tray that sat untouched for over 23 minutes before staff assisted. The resident did not receive supper the previous night, and staff had to prepare a peanut butter and jelly sandwich as an alternative. Staff interviews revealed that the delay in assistance and missed meals were due to insufficient staffing and new staff being unfamiliar with residents. Resident #8, who had intact cognition and required setup assistance with eating, also reported not receiving supper the previous night. The charge nurse had to prepare a peanut butter and jelly sandwich for the resident. The Dietary Manager and Administrator acknowledged issues with meal service, citing staff turnover, lack of training, and insufficient staffing as contributing factors. The Administrator confirmed that five residents did not receive their dinner trays on the specified night and that insufficient staffing had caused issues with meal service and resident assistance.
Lack of Comprehensive QAPI Plan
Penalty
Summary
The facility failed to have a Quality Assurance and Performance Improvement (QAPI) plan and did not have a plan that contained all required elements, affecting all 66 residents. The Administrator, who started on 3/14/24, was unable to locate any policies and procedures for QAPI. The facility had only conducted one QAPI meeting, attended by all department heads, the staffing coordinator, and the dietary/housekeeping supervisor. The Administrator also mentioned having monthly discussions with the Medical Director.
Failure to Implement QAA Plans of Action
Penalty
Summary
The facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies as part of their Quality Assessment and Assurance (QAA) committee. This affected all the residents in the facility, which had a census of 66. The facility did not provide a policy regarding their QAA process or committee and was unable to provide records of the QAA and Quality Assurance/Performance Improvement (QAPI) plan. During an interview, the Administrator, who started on 3/14/24, stated she was unable to locate the policy and procedures for QAPI and mentioned that they had only conducted one QAPI meeting. The meeting included all department heads, the staffing coordinator, and the dietary/housekeeping supervisor. The Administrator also mentioned that she talks to the Medical Director monthly.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to have an Infection Prevention program, including policies and procedures for infection control. During an interview, the Administrator admitted that there was no one currently responsible for the infection prevention program, and many policies were missing. The Assistant Director of Nursing was designated to handle the infection prevention program, but the facility was still working on updating and implementing necessary policies and procedures. For Resident #34, the Certified Medication Technician (CMT) failed to follow proper medication administration protocols. The CMT knocked over a medication cup, causing medications to fall on the floor and the top of the medication cart. The CMT then picked up the medications with bare hands and placed them back into the medication cup, which was then given to the resident. This action violated the facility's policy, which states that medications should not be touched with bare hands and that any medication that falls on the floor should be destroyed. For Resident #9, the facility staff failed to follow acceptable infection control practices during personal care. The Certified Nurses Aides (CNAs) did not wash their hands between glove changes and used a clean incontinent brief that had fallen on the floor. Additionally, they did not clean up a puddle of urine from the floor before placing a fall mat over it and did not clean the resident's Broda chair. These actions were against the facility's expectations and infection control standards. Similarly, for Resident #35, the CMT used bare hands to pull apart medication capsules and place them in pudding, which was then administered to the resident, violating the facility's medication administration policy.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program to address antibiotic use protocols and a system to monitor antibiotic use. The facility, with a census of 66, did not provide a policy regarding infection control and prevention. A resident with no cognitive deficit, dependent for activities of daily living, and diagnosed with cerebral infarction, cardiovascular disease, muscle spasms, and cystitis, was prescribed antibiotics for a urinary tract infection. However, the facility did not have a system in place to map or track infections, and no one was responsible for completing these tasks. The Administrator confirmed that the Director of Operations was running reports off-site, but there was no active Antibiotic Stewardship Program at the time of the survey. An Assistant Director of Nursing had been hired but had not yet started and would be responsible for the IPCP and Antibiotic Stewardship.
Lack of Staff Training Documentation on Abuse and Neglect
Penalty
Summary
The facility failed to maintain documentation showing that staff received training on abuse, neglect, exploitation, misappropriation of resident property, dementia management, and resident abuse prevention. The facility census was 66. During interviews, a Nurse Aide (NA) and a Certified Medication Technician (CMT) both reported not receiving any abuse and neglect training at the facility. Another Certified Nurse Aide (CNA) mentioned having received such training. The Administrator, who had been in the role since March, acknowledged that no abuse and neglect training had been conducted during their tenure and could not locate any inservice sheets from previous training sessions. The Business Office Manager also could not find any documentation of the required training.
Failure to Provide Required In-Service Education
Penalty
Summary
The facility failed to ensure that nurse aides received a minimum of 12 hours of in-service education per year, including training on abuse, neglect, and dementia care. This deficiency was identified through interviews and record reviews, which revealed that three randomly selected nurse aides did not have documentation of the required training. The facility's policy mandated staff training on these topics, but the administrator and business office manager could not locate any records of such training. Interviews with the nurse aides confirmed that they had not received the necessary training on abuse, neglect, or dementia care since the current administrator took over in March.
Failure to Complete Comprehensive Discharge Summary
Penalty
Summary
The facility staff failed to complete a comprehensive discharge summary for a resident who was discharged home with a Home Health agency for nursing, Physical Therapy, and Occupational Therapy. The resident had multiple diagnoses, including diverticulosis of the intestine, Type 2 diabetes mellitus, mild neurocognitive disorder with behavioral disturbance, dementia with psychotic disturbance, alcohol dependence, acute metabolic acidosis, and hallucinations. Despite the detailed care plan and progress notes indicating the discharge process, there was no discharge summary completed for the resident. During an interview, the Administrator admitted that no one was currently responsible for completing discharge summaries and was unsure who took over the responsibility after the last Minimum Data Set (MDS) Coordinator left. The facility also did not provide a policy regarding the discharge process, indicating a lack of clear procedures and accountability in ensuring comprehensive discharge documentation.
Failure to Provide Personalized Dementia Care Plan
Penalty
Summary
The facility failed to ensure a resident diagnosed with dementia had a personalized plan of care to address their specific needs. The resident, admitted on 4/22/24, had a primary diagnosis of neurocognitive disorder with Lewy bodies and exhibited severely impaired cognition. Despite this, the facility did not complete a comprehensive Minimum Data Set (MDS) assessment or develop a care plan that included specific nursing interventions, activities, or behavioral strategies for dementia care. The baseline care plan only addressed general care needs and did not provide detailed interventions for managing the resident's dementia-related behaviors, such as agitation, aggression, and hallucinations. The resident's medical records and staff interviews revealed multiple instances of combative and aggressive behavior, including hitting, biting, and yelling at staff during care. Staff attempted to manage these behaviors with as-needed medications like Haldol and Zyprexa, but there was no evidence of a structured approach to dementia care. Interviews with staff members, including CNAs and LPNs, indicated a lack of training on dementia care and specific strategies for interacting with this resident. Staff reported that they had not received any guidance or training from the facility on how to manage the resident's behaviors effectively. The facility's administration acknowledged the deficiencies in dementia care training and care plan development. The Social Service Designee and Administrator confirmed that the facility did not have a dedicated MDS coordinator to oversee care plans and that staff were not adequately trained in dementia care. The facility also lacked documentation of any dementia care training provided to staff. This lack of a structured care plan and appropriate training led to inadequate management of the resident's dementia-related behaviors, resulting in distress for the resident and challenges for the caregiving staff.
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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