Avalon View Health And Wellness
Inspection history, citations, penalties and survey trends for this long-term care facility in Liberty, Missouri.
- Location
- 1200 West College Street, Liberty, Missouri 64068
- CMS Provider Number
- 265437
- Inspections on file
- 43
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Avalon View Health And Wellness during CMS and state inspections, most recent first.
Three residents with cognitive impairments and rashes consistent with scabies were not placed on contact precautions as required by facility policy and physician orders. Staff did not use PPE or isolate affected individuals, and care plans did not address scabies treatment. Despite clinical diagnoses and recommendations from dermatology for isolation and contact precautions, the facility did not implement these measures, and staff were largely unaware of the outbreak or the need for infection control.
A resident with significant mobility limitations was transported in a facility van without being properly restrained with a seat belt, contrary to facility policy. The driver, new to the transportation role, failed to secure the seat belt, resulting in the resident sliding out of the wheelchair and falling during a sudden stop. The incident was confirmed by interviews with the resident, the driver, and facility staff, all indicating that required safety procedures were not followed.
A resident with severe cognitive impairment and behavioral issues was struck on the back by another cognitively impaired resident with a history of aggression while in the dining area. Staff were present and intervened after the incident, but the altercation resulted in visible redness to the affected resident's back.
The facility failed to maintain a sanitary and comfortable environment, with observations of urine odors, disrepair, and uncleanliness. Staff interviews revealed communication issues and inadequate systems for equipment maintenance and cleanliness. The Physical Therapy Assistant and Director of Physical Therapy were aware of wheelchairs in disrepair, but there was a discrepancy in ordering new equipment. Housekeeping staff reported insufficient staffing and lack of a task checklist, while the Maintenance Director relied on inconsistently used logbooks for repair requests.
The facility failed to provide adequate assistance with ADLs, including grooming, showering, and incontinence care, for several residents. Observations and interviews revealed that residents often went extended periods without showers, and incontinence care was not provided timely. Staffing shortages contributed to these deficiencies, impacting residents' hygiene and dignity.
The facility failed to provide an ongoing activities program for three residents, resulting in a deficiency. One resident with severe cognitive deficits had minimal engagement, often found in bed with the TV on mute. Another resident with significant cognitive impairment had no activity care plan, with limited engagement noted. A third resident with undetermined cognitive status also lacked a care plan, with sporadic engagement and an outdated activity calendar. Staff interviews revealed inconsistencies in activity planning and execution.
The facility failed to employ a qualified Activity Director, as the current director had not completed an approved training program and lacked necessary certifications. Despite having worked in housekeeping for twenty-five years, the director only trained for one day with an activity staff member and was not enrolled in any certification course. The Administrator acknowledged the deficiency and mentioned plans for the director to complete a course.
The facility failed to secure hazardous areas, including a clean utility room and biohazard room, in the memory care unit. Residents with cognitive impairments were observed near these unlocked areas, which contained open electrical boxes, oxygen tanks, and hazardous chemicals. Staff interviews revealed a lack of awareness and adherence to safety protocols.
The facility failed to ensure residents had accessible water at their bedside, affecting four residents. Despite policies requiring sufficient fluid provision, observations showed water was not consistently available. A resident with cognitive impairment and a UTI was observed without water, while another resident at risk for dehydration due to diuretic use reported infrequent water passing. Two other residents also experienced inadequate water availability, with one reporting water was passed only once a day.
The facility failed to provide trauma-informed care to two residents with a history of trauma, leading to re-traumatization and distress. One resident with PTSD was triggered by loud noises, while another exhibited paranoia and delusions without proper interventions. Staff were unaware of the residents' triggers, and no trauma-informed care training was provided in the past year.
The facility failed to provide sufficient nursing staff to meet residents' basic care needs, including repositioning, incontinent care, and bathing. Observations showed residents left unattended for hours without necessary care, and call lights were not answered promptly due to staff shortages. Interviews with staff confirmed that inadequate staffing affected the quality of care, leading to missed showers and delayed assistance with feeding and transfers.
The facility failed to properly store and label medications, affecting several residents. Medications were left unlocked and unattended, expired drugs were not removed, and some residents had medications at bedside without proper authorization. Staff interviews revealed confusion about responsibilities for medication security and cleanliness.
The facility failed to provide adequate dietary staffing, resulting in significant delays in meal service for residents. Observations showed that meals were served much later than scheduled, with residents left waiting without drinks or utensils. Staff from other departments had to assist with meal service, indicating a shortage of dietary staff. Meal times were not posted, and there was no policy regarding dietary staffing.
The facility failed to ensure food was palatable, attractive, and at a safe temperature. Observations showed staff did not check food temperatures or follow recipes, leading to complaints from residents about cold, poorly prepared meals. Interviews with staff revealed unmet expectations for temperature checks and recipe adherence.
The facility failed to maintain professional standards in kitchen sanitation and food handling, with staff neglecting to properly clean and sanitize equipment, maintain a clean kitchen, and adhere to handwashing protocols. Observations showed unsanitary conditions, improper food storage, and lack of hair and beard coverings, posing potential risks to residents.
The facility failed to maintain a safe and sanitary environment, with issues such as cobwebs, rusted doors, and debris-filled light fixtures. Observations also noted broken window blinds, loose air conditioning units, and mold-like substances on shower curtains. Interviews revealed understaffing in housekeeping and reliance on a logbook for maintenance requests, with the administrator acknowledging the need for further improvements.
The facility failed to maintain resident dignity and provide adequate care, as evidenced by incidents where a resident was left walking in a hallway in a pull-up brief, another was unable to return to bed due to a lack of clean sheets, and a third was left waiting to be dressed in personal clothes. These incidents highlight issues with staff responsiveness and linen supply, impacting the residents' dignity and quality of life.
Three residents were denied access to their personal funds after business hours and on weekends due to the facility's failure to maintain sufficient cash on hand. The Business Office Manager and Administrator acknowledged delays in cash availability, particularly when the Administrator was off work, leading to instances where residents could not access their money.
A facility failed to ensure consistent documentation of a resident's code status across clinical records. The resident had multiple health conditions and was listed as full code in physician's orders and care plan, but a DNR status was noted in an external form. Staff interviews revealed awareness of the discrepancy, which was corrected by an RN during the survey.
The facility failed to maintain confidentiality for two residents. One resident's DPOA document was given to an unauthorized person due to lack of identity verification by the administrator. Another resident's medication packaging with personal information was found outside the facility due to a tipped-over shred box. These incidents indicate a failure to protect residents' confidential information.
The facility failed to develop comprehensive care plans for two residents, neglecting to address specific medical and activity needs. One resident with severe cognitive deficits and a tracheostomy lacked a care plan for tracheostomy care and activity preferences. Another resident with cognitive impairments and mobility issues had no activity preferences included in their care plan, despite having conditions like anxiety and depression.
A resident with severe contractures and limited cognitive abilities was not consistently provided with a cervical collar as ordered by their physician. The collar, meant to be worn during the day, was repeatedly found on the bedside table, dirty and unused. Staff interviews indicated the collar was sometimes taken for cleaning, but there was no documentation of refusal or unavailability. The facility's DON and Administrator expected adherence to physician's orders, highlighting a deficiency in care provision.
The facility failed to maintain an effective pest control program, resulting in a fly infestation in a resident's room. The resident, who had significant cognitive and physical impairments, was unable to swat the flies away. Despite the facility's use of an outside pest control company, the issue persisted, and the facility did not provide pest control invoices to verify services.
A deficiency was found where a resident's right to retain and use personal possessions was not honored, as documented under Event ID 45RI12.
Failure to Implement Contact Precautions and Infection Control for Scabies
Penalty
Summary
The facility failed to follow its own policy and physician orders regarding the implementation of contact precautions and infection control measures to prevent the spread of scabies among residents in the special care unit. Three residents with cognitive impairments and rashes consistent with scabies were not placed on contact precautions as required by facility policy and physician recommendations. Observations revealed that these residents were not isolated, and staff did not use personal protective equipment (PPE) such as gloves or gowns when providing care or engaging in activities with them. There were no signs posted to indicate the need for contact precautions, and PPE was not made available near the affected residents' rooms. Medical records and interviews confirmed that the residents had been diagnosed or treated for scabies, with orders for Ivermectin and, in some cases, topical Permethrin. Despite these diagnoses and orders, the residents' care plans did not address scabies or its treatment, and staff were largely unaware of the scabies outbreak or the need for infection control measures. The dermatologist's office provided written recommendations for isolation and contact precautions, but these were not implemented by the facility. Staff interviews indicated a lack of awareness about the contagious nature of the rashes and the need for PPE, with several staff members stating they would have used precautions if they had known about the scabies diagnosis. The facility's infection control nurse and DON stated that no contact precautions were implemented because there was no definitive diagnosis of scabies via skin scraping, despite clinical diagnoses and treatment orders from dermatology. All residents in the memory care unit were treated prophylactically after a staff member reported a rash and was prescribed Permethrin, but the facility did not enforce isolation or contact precautions at any point. The lack of communication and failure to follow established protocols led to the deficiency in infection control practices.
Failure to Properly Restrain Resident During Transportation
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all care and had significant mobility limitations due to central cord syndrome and bilateral lower extremity contractures, was not properly restrained during transportation in the facility van. The facility's transportation policy required that all residents be properly secured with seat belts and wheelchair restraints during transport, and that drivers be trained and competent in these procedures. On the day of the incident, the designated transportation driver, who was new to the role, failed to apply the seat belt to the resident's wheelchair, although the wheelchair was locked in place with hooks. During the transport, the driver had to stop suddenly at a red light, causing the resident to slide out of the wheelchair and fall forward onto the floor of the van, hitting the left side of the face/forehead on the back of the driver's seat. The resident reported not having a seat belt on and stated that this was the first time with this particular driver. The driver admitted to forgetting to apply the seat belt and was not fully aware of the seat belt procedure, as prior training had not included this step. The resident was assessed after the incident and did not report new pain or visible injury at the time, but later mentioned some pain around the eye without bruising or cuts. Interviews with facility staff confirmed that the transportation driver had not completed the required competency demonstration for securing residents prior to the incident. The driver had only been shown how to use the wheelchair hooks and was not instructed on the use of seat belts. The facility's policy and staff statements indicated that all residents should be properly restrained during transport, but this was not followed in this case, resulting in the resident's fall and injury during transportation.
Resident-to-Resident Physical Abuse in Dining Area
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of wandering and rummaging entered the dining area and walked by another resident's table. The second resident, who also had severe cognitive impairment and a history of physical aggression, yelled at the first resident to go away and then struck the resident on the back. This resulted in visible redness to the back of the resident who was struck. At the time of the incident, the first resident had diagnoses including dementia with agitation, depression, low back pain, mood disorder, and dysphagia, and was known to require supervision during meals due to behavioral issues. The second resident had diagnoses of aphasia, diabetes mellitus type 2, seizures, mild cognitive impairment, and dementia, and was identified as having the potential for physical aggression related to anger. Both residents were in the dining area when the altercation occurred, and staff were present in the room assisting with breakfast preparations and medication administration. The facility's policies defined abuse to include resident-to-resident altercations resulting in physical harm, and the care plans for both residents identified behavioral risks and the need for staff intervention to prevent escalation. Despite these identified risks and interventions, the altercation occurred, resulting in physical harm to one resident.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment, as evidenced by multiple observations of disrepair and uncleanliness. Observations included a strong odor of urine in the special care unit and hallways, peeling baseboards, scuffed doors, and resident wheelchairs with torn armrests and caked-on dirt. Privacy curtains in several rooms were stained, torn, or missing hooks, and dirty dishes were left in common areas. Additionally, dead bugs were found in hand sanitizer dispensers, and floors were observed to be sticky and dirty. Interviews with staff revealed a lack of effective communication and systems for maintaining equipment and cleanliness. The Physical Therapy Assistant and Director of Physical Therapy acknowledged awareness of wheelchairs in disrepair, but there was a discrepancy in ordering new equipment, as the Central Supply Manager had not received recent orders. The Corporate Nurse admitted to a system breakdown in replacing wheelchairs. Housekeeping staff reported being unable to complete all necessary tasks due to insufficient staffing and lack of a task checklist. The Maintenance Director and Housekeeping Supervisor described their expectations for cleanliness and repair, but there was a lack of coordination and follow-through. The Maintenance Director relied on logbooks for repair requests, which were not consistently utilized. The Administrator expected daily cleaning and collaborative efforts between housekeeping and maintenance, but acknowledged that while progress had been made, more improvements were needed. Overall, the facility's failure to ensure a clean and well-maintained environment was due to inadequate systems and communication among staff and departments.
Inadequate Assistance with ADLs and Hygiene in LTC Facility
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, including grooming, showering, and incontinence care. Nine residents did not receive showers at least twice a week as required, and one resident did not receive necessary shaving and nail care. Observations revealed that residents often went extended periods without showers, with some residents receiving only a few showers over several months. Interviews with residents confirmed their dissatisfaction with the infrequency of showers, and staff interviews indicated that staffing shortages contributed to the inability to meet residents' hygiene needs. In addition to inadequate showering, the facility failed to provide timely incontinence care for two residents. Observations showed that these residents were left in soiled conditions for extended periods without being offered toileting assistance. Staff interviews revealed that while there was an expectation for residents to receive incontinence care every two hours, this was not consistently achieved due to busy schedules and insufficient staffing. The facility's failure to meet residents' ADL needs was further compounded by inadequate staffing, as reported by multiple staff members. The shower aide was frequently reassigned to other duties, leaving residents without necessary hygiene care. The administrator acknowledged that the facility's goal of offering showers twice weekly was not consistently met due to staffing challenges, impacting residents' overall care and dignity.
Deficiency in Resident Activity Engagement
Penalty
Summary
The facility failed to provide an ongoing activities program to support the needs of three residents, leading to a deficiency in meeting their individual activity preferences and needs. Resident #153, who had severe cognitive deficits and multiple medical conditions, was observed to have minimal engagement in activities. Despite having preferences for activities such as television, music, and family visits, the resident's activity records showed limited interaction, primarily involving passive activities like music playing and television being on without sound. Observations confirmed the lack of meaningful engagement, with the resident often found in bed with the television on mute. Resident #93, also with significant cognitive impairment and medical complexities, had no care plan for activities. The resident's activity records indicated frequent instances of being asleep or minimally engaged, with occasional interactions such as staff reading or talking to the resident. Observations showed the resident often in bed with the television on mute, despite a noted preference for specific TV shows. The lack of a structured activity plan contributed to the resident's limited engagement. Resident #52, with undetermined cognitive status and multiple diagnoses, had no care plan for activity preferences. The resident's activity records showed sporadic engagement, primarily involving passive activities like listening to music or being read to. Observations revealed a lack of activity engagement during certain periods, and the activity calendar in the resident's room was outdated. Interviews with staff highlighted inconsistencies in activity planning and execution, contributing to the deficiency in providing a comprehensive activities program for the residents.
Facility Lacks Qualified Activity Director
Penalty
Summary
The facility failed to employ a qualified activity professional to oversee its activity program, as required by regulations. The designated Activity Director had been in the position for one year but had not completed an approved activity professional training program. The facility's policy outlined that an Activity Director should be licensed or registered by the state and meet specific qualifications, such as being eligible for certification as a therapeutic recreation specialist or having completed a state-approved training course. However, the current Activity Director did not meet these qualifications, having worked in housekeeping for twenty-five years and only trained for one day with an activity staff member at a sister facility. During interviews, the Activity Director admitted to not having been trained in activities and not being enrolled in any certification course. The Administrator acknowledged the need for the Activity Director to have certifications and mentioned that the facility had purchased a course for the Activity Director to participate in, with the coursework anticipated to be completed in the following month. Despite these intentions, the deficiency remained as the Activity Director was not qualified at the time of the survey.
Unsafe Access to Hazardous Areas in Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe environment for residents, as evidenced by multiple observations of unlocked rooms containing hazardous materials and equipment. Specifically, the memory care unit had an unlocked clean utility room with open electrical boxes, oxygen tanks, and cleaning supplies, as well as an unlocked biohazard room containing sharps and hazardous chemicals. Additionally, the area behind the nurses' desk was found to be unlocked, with a bottle of drug destroyer and a multipurpose cleaner accessible. These conditions were observed over several days, with no staff present to supervise or secure these areas. Resident #3, who has severe cognitive impairment and uses a wheelchair, was observed propelling themselves near the unlocked clean utility and biohazard rooms. Despite their cognitive and physical limitations, no staff were present to prevent the resident from accessing these hazardous areas. Similarly, Resident #89, also with severe cognitive impairment and mobility issues, was seen near the unlocked biohazard room and nurses' station without staff supervision. Resident #67, with moderate cognitive impairment, was observed walking near the unlocked rooms, again with no staff nearby to ensure their safety. Interviews with staff members, including CNAs, LPNs, the Maintenance Director, and the Administrator, revealed a lack of awareness and adherence to safety protocols. Staff were unsure if the doors should be locked, and some indicated that the doors had been unlocked for an extended period. The Maintenance Director and Administrator acknowledged that these areas should be secured to prevent resident access to hazardous materials, but the necessary actions to ensure this were not taken.
Failure to Provide Accessible Water to Residents
Penalty
Summary
The facility failed to ensure that residents had water at their bedside that was easily accessible, affecting four out of 23 residents sampled. The facility's policy for hydration requires that residents be offered sufficient fluids consistent with their needs and preferences to maintain proper hydration and health. However, observations and interviews revealed that water was not consistently available at the bedside for the affected residents, and staff did not pass water as frequently as required by the facility's policy. Resident #90, who has minor cognitive impairment and is dependent on staff for eating, was observed multiple times without water at the bedside. Despite being on antibiotics for a urinary tract infection and having a care plan indicating a risk for dehydration, the resident's water needs were not adequately met. The resident's daughter reported that when water was requested, flavored water was provided instead of the preferred unflavored water. Resident #12, who is cognitively impaired and at risk for dehydration due to diuretic use, also did not have water readily available. The resident reported that water was not passed often, and observations confirmed the absence of water in the room. Similarly, Resident #49, who is cognitively intact but requires assistance with eating, reported that water was passed only once a day, and observations showed insufficient water in the resident's cup. Resident #87, who is cognitively intact and has diabetes mellitus, reported that it took over a week for the facility to change out water, and observations confirmed the lack of water and ice being passed regularly.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed care to two residents with a history of trauma, leading to re-traumatization and distress. Resident #49, diagnosed with PTSD, was exposed to loud noises from other residents yelling, which triggered memories of past abuse. Despite the resident's care plan identifying loud noises as a trigger, no interventions were implemented to mitigate this. Interviews with staff revealed a lack of awareness about the resident's triggers, indicating a communication breakdown within the facility. Resident #87, who had experienced multiple traumatic events, exhibited behaviors such as paranoia and delusions, believing staff were casting spells on him/her. The care plan did not identify any specific triggers for this resident, and staff interviews showed a lack of understanding of the resident's needs and triggers. The resident was known to be triggered by certain staff members and would become agitated, yet no interventions were in place to address these issues. The facility's failure to provide trauma-informed care was compounded by the lack of staff training on the subject. Training logs showed no trauma-informed care training had been provided in the past year, and staff interviews confirmed this gap. The Social Services Director attempted to communicate trauma triggers to staff, but the process was ineffective, leading to inadequate care for residents with trauma histories.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the basic care needs of several residents, including assistance with repositioning, incontinent care, basic hygiene, and bathing. Observations revealed that residents were left unattended for extended periods without being offered toileting or repositioning, despite being dependent on staff for these activities. For instance, one resident with severe cognitive impairment and incontinence was observed sitting in a wheelchair for several hours without receiving necessary care, such as toileting or repositioning, which was not in accordance with their care plan. Additionally, the facility did not provide timely responses to call lights, as reported by multiple residents during a Resident Council meeting. Residents expressed that call times could take an hour or longer, particularly at night and on weekends when staffing levels were low. This delay in response was attributed to the staff being overworked and short-handed, impacting the residents' ability to receive timely assistance with their needs. Interviews with staff members, including CNAs, LPNs, and the Director of Nursing, confirmed that staffing shortages were a significant issue affecting the quality of care provided. Staff reported being unable to meet the care needs of residents due to insufficient numbers, leading to missed showers, inadequate pericare, and delayed assistance with feeding and transfers. The facility's inability to maintain adequate staffing levels resulted in compromised resident care and unmet basic needs.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with accepted professional principles, affecting five residents. Medications were not stored in locked compartments, and unauthorized staff and residents had access to them. The medication cart was observed to be left unlocked and unattended multiple times, and expired medications were not removed or destroyed as required. Additionally, some medication labels were illegible, and there was a lack of clarity among staff regarding responsibilities for maintaining the cleanliness and security of medication carts. Resident #12, who was cognitively impaired, had an albuterol inhaler at their bedside without a physician's order or a self-administration assessment. The resident's care plan did not include provisions for self-administration of medication, and staff interviews revealed confusion about whether the resident was allowed to keep the inhaler at bedside. Observations showed multiple inhalers at the resident's bedside, some of which were empty or lacked visible numbers, indicating improper monitoring and storage. Resident #154, with moderate cognitive loss and multiple diagnoses, had medications at their bedside without a physician's order or self-administration assessment. Observations showed gabapentin and nystatin powder in the resident's room, despite the resident not being present. Interviews with staff confirmed that the resident should not have had medications at bedside, highlighting a failure to adhere to the facility's medication storage policy.
Inadequate Dietary Staffing Leads to Delayed Meal Service
Penalty
Summary
The facility failed to adequately staff the kitchen with enough dietary staff to ensure meals were served to residents in a timely manner, potentially affecting all 104 residents. Observations over several days revealed significant delays in meal service, with lunch service starting and completing much later than the scheduled times. On multiple occasions, residents were left waiting in the dining room without drinks or meals, and there was a lack of utensils and condiments available for residents to use with their meals. The facility's meal serving policy was not adhered to, as residents were not checked on at regular intervals, and additional fluids were not consistently offered. The report highlights specific instances where meal service was delayed, such as on one day when the first meal was served 69 minutes late on average. Staff from other departments, including corporate staff and environmental services, were observed assisting with meal service, indicating a shortage of dietary staff. Additionally, there were inconsistencies in the type of utensils provided, with some residents receiving metal silverware and others receiving plastic utensils. The facility did not have a policy regarding dietary staffing, and meal times were not posted anywhere in the facility, contributing to the disorganization and delays in meal service.
Deficiencies in Food Service and Temperature Control
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Observations revealed that staff did not check the temperature of cooked foods, and recipes were not followed for several residents. Specifically, during the preparation of beef tacos and Spanish rice, the cook did not measure ingredients accurately, failed to perform temperature checks at critical points, and did not follow the recipe instructions. The taco meat was observed to be watery and bland, and the Spanish rice was initially in a soupy state before being placed on the steam line without a final taste test or temperature check. Interviews with residents and the resident council highlighted significant dissatisfaction with the food service. Residents reported that meals were often cold, poorly prepared, and not served on time. Some residents mentioned receiving moldy hamburger buns and unidentifiable menu items, while others noted that the food was difficult to chew or too salty. The resident council expressed that food service was their number one complaint, with issues such as meals being burnt, meal tickets not being followed, and utensils not being provided promptly. Interviews with facility staff, including the Dietary Manager and Registered Dietician, revealed expectations for temperature checks and recipe adherence that were not met. The Administrator also expressed expectations for proper food service, including the availability of cream, sugar, and utensils for coffee, as well as clean napkins for each meal. However, these expectations were not consistently met, contributing to the deficiencies observed in the facility's food service.
Deficiencies in Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as evidenced by multiple deficiencies in the kitchen's sanitation and food handling practices. Observations revealed that staff did not manually clean and sanitize kitchen equipment properly, as they failed to check temperatures or test sanitizing solution concentrations in the three-compartment sink. Additionally, sanitizing buckets were not changed out after four hours of use, and the kitchen lacked visible sanitizing buckets during meal service times. These lapses in procedure were confirmed by interviews with the Dietary Manager and Registered Dietician, who expressed expectations for regular temperature checks and visible sanitizing buckets. The facility's kitchen was found to be in an unsanitary state, with excessive dust and dirt on ventilation ducts, sticky floors, and accumulation of debris on various surfaces. Observations noted old food debris in ovens, food splatter on equipment, and missing paint with dirt buildup near the sink area. The dry storage room and cleaning closet were also cluttered and dusty, posing potential contamination risks. The Dietary Manager acknowledged these issues but considered the kitchen clean and up to their standards, despite the visible dirt and grime. Handwashing practices were inadequate, with staff failing to wash hands after handling raw meat or before donning gloves. The handwashing sink only provided hot water, and staff were observed using the same gloves for multiple tasks, increasing the risk of cross-contamination. Additionally, there was no policy on hair and beard coverings, and staff were observed without proper coverings. Food storage practices were also deficient, with unlabeled and undated items found in the freezer and storage areas, contrary to the facility's policy.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors. Observations revealed numerous issues, including large cobwebs with dead bugs, rusted exit doors, gouged and nicked wallpaper, and light fixtures filled with dead bugs and debris. Additionally, there were brown water stains on ceiling tiles, dirt and debris on mechanical hand sanitizer drip trays, and broken window blinds held together with zip ties. The facility's air conditioning units were loose from the wall, and the ceiling vents were covered with dirt and dust. The shower room curtain was found with dirt, debris, and a black mold-like substance, and baseboards were warped, curved away from the wall, and missing in some areas. Interviews with staff revealed that the housekeeping department was understaffed, with one person unable to complete all necessary tasks. There was no checklist for completed tasks, and the maintenance director relied on a logbook for repair requests. The maintenance director had been employed for four months and conducted weekly walk-through inspections with administration. The administrator expected the facility to be clean and odor-free, with vents, floors, and ceilings cleaned collaboratively by housekeeping and maintenance. Despite some progress in cleanliness, the facility acknowledged that more work was needed to address these deficiencies.
Failure to Maintain Resident Dignity and Adequate Care
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by several incidents involving inadequate care and attention to personal needs. One resident was observed walking down a hallway wearing only a white pull-up brief without pants, passing by staff and other residents without being assisted or covered. This resident, who was cognitively intact and required assistance with personal hygiene and dressing, was eventually taken to the therapy room without any intervention to address their state of undress. Another resident expressed feelings of being degraded by staff, who treated them as if they could not think for themselves. This resident, who was frequently incontinent and required assistance with personal care, reported being woken up at 4:00 A.M. to use the bathroom, only to find that there were no clean sheets available for their bed afterward. This situation forced the resident to remain awake and unable to return to sleep, highlighting issues with the facility's linen supply, as confirmed by staff interviews. A third resident, who was cognitively intact and had specific preferences for their daily routine, was left waiting to be dressed in their personal clothes. Despite expressing a desire to be dressed by 8:30 A.M., the resident remained in a hospital gown due to a lack of clean pants, as staff were observed discussing the issue outside the resident's room. These incidents collectively demonstrate a failure to provide adequate and respectful care, impacting the residents' dignity and quality of life.
Residents Denied Access to Personal Funds After Hours
Penalty
Summary
The facility failed to ensure residents had access to their personal funds after business hours and on weekends, impacting three residents. Resident #83, with moderately impaired cognition and diagnoses including depression and diabetes, reported not always having access to money because the facility had not gone to the bank. Resident #28, also with moderately impaired cognition and conditions such as COPD and dementia, stated they did not have full access to their money. Resident #5, who was cognitively intact, mentioned being denied money when the facility had not gone to the bank. The Business Office Manager (BOM) explained that residents typically request money from the receptionist, with a turnaround time of one day. However, cash was not disbursed on holidays, and there was uncertainty about weekend access. The BOM noted that the facility had increased the cash on hand due to previous shortages. The Administrator confirmed that funds were available during banking hours, but delays occurred when they were off work, as no other staff were designated to obtain cash. This led to instances where residents were denied access to personal funds due to insufficient cash on hand.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure consistent documentation of a resident's code status across all parts of the clinical record. This deficiency was identified for one resident out of a sample of 23, in a facility with a census of 104. The resident in question had multiple diagnoses, including mild cognitive impairment, diabetes, kidney failure, high blood pressure, GERD, and obstructive uropathy. The resident's physician's orders indicated a full code status, while an Outside the Hospital Do Not Resuscitate Order form signed later showed a DNR status. Additionally, the resident's care plan, which was undated, also listed the resident as full code. During interviews, a CNA and an RN both referred to the resident's code status as full code, but the RN noticed the discrepancy during the interview and changed the status to DNR. The Director of Nursing and Administrator stated that the protocol for handling an unresponsive resident involves checking the code book and chart to determine the code status.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records for two residents. For Resident #80, the deficiency occurred when a staff member provided a copy of the resident's Durable Power of Attorney (DPOA) document to an unauthorized individual who falsely claimed to be the designated family member. The administrator admitted to not verifying the identity of the individual by asking for photo identification, which led to the unauthorized disclosure of the resident's protected information. This incident was confirmed through interviews with the actual family member and the administrator, who acknowledged the breach of confidentiality. For Resident #153, the breach of confidentiality was observed when empty medication packaging with the resident's personal information was found outside the facility. The packaging was visible due to a tipped-over locked shred box located behind the D hall unit. The administrator confirmed that resident information should not be exposed and visible outside the facility. These incidents highlight the facility's failure to implement adequate security measures to protect residents' confidential information, as outlined in their HIPAA policy.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in meeting their needs. Resident #153, who has severe cognitive deficits and multiple medical conditions including respiratory failure and a tracheostomy, did not have a care plan addressing their activity preferences or the care of their tracheostomy. Despite having specific medical orders for tube site care and tracheostomy maintenance, these were not reflected in the resident's care plan, indicating a lack of comprehensive planning to address the resident's complex needs. Similarly, Resident #52, who has cognitive impairments and is dependent on a wheelchair, did not have their activity preferences included in their care plan. The resident's diagnoses include anxiety disorder, aphasia, depression, and respiratory failure, yet the care plan only included general encouragement for social interaction and emotional support without specific activity preferences. The facility's failure to incorporate these elements into the care plans demonstrates a deficiency in providing person-centered care tailored to the residents' individual needs.
Failure to Apply Cervical Collar as Ordered
Penalty
Summary
The facility staff failed to adhere to physician's orders regarding the application of a cervical collar for a resident who was dependent on staff for mobility and care. The resident, who had severe contractures and was non-verbal with limited cognitive abilities, was observed multiple times without the cervical collar that was ordered to be worn during the day. The collar was found on the bedside table, dirty and discolored, indicating it had not been applied as required. The resident's care plan and physician's orders specified the need for the cervical collar to be worn during the day and removed at night for skin checks, but these instructions were not consistently followed. Interviews with facility staff, including an occupational therapist and a registered nurse, revealed that the cervical collar was not applied on several occasions, allegedly due to it being taken for cleaning. However, there was no documentation of the resident refusing the collar or any indication that the collar was unavailable for extended periods. The Director of Nursing and the Administrator both expressed expectations that staff should follow physician's orders unless a resident refused care, which should be documented. The failure to apply the cervical collar as ordered represents a deficiency in the provision of care according to professional standards.
Ineffective Pest Control Program Leads to Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and roaches. Observations on [NAME] Hall revealed large cobwebs with dead bugs at the corner of the exit door and multiple flies in room B1. A resident in room B1, who had significant cognitive and physical impairments, was observed with flies flying around their room. The resident was unable to swat the flies away due to their condition, which included aphasia, muscle weakness, lack of coordination, epilepsy, and Rett syndrome. The resident's representative reported that flies had been a persistent issue since the resident's admission, and they had resorted to purchasing fly strips to address the problem. Interviews with facility staff, including the Maintenance Director and the Administrator, confirmed that pest control was managed by an outside company that visited monthly to check and spray for pests. However, the facility did not provide pest control invoices to verify these services. The Administrator acknowledged the presence of flies in the facility and expressed an expectation for the facility to be as free of pests as possible. Despite these measures, the facility's pest control program was ineffective in preventing the infestation of flies, particularly in the resident's room.
Failure to Respect Resident's Personal Possessions
Penalty
Summary
The deficiency involves the failure to honor a resident's right to be treated with respect and dignity and to retain and use personal possessions. The report indicates that surveyors found an incident where a resident's personal possessions were not respected or properly managed. Specific details about the resident's medical history or condition at the time of the deficiency are not provided in the report. The event was documented under Event ID 45RI12.
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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