Beloved Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hannibal, Missouri.
- Location
- 328 Munger Lane, Hannibal, Missouri 63401
- CMS Provider Number
- 265462
- Inspections on file
- 33
- Latest survey
- April 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Beloved Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of wandering exited the facility through unsecured, unalarmed doors and was missing for several hours before being found by police. Staff failed to complete required face checks and did not update the resident's care plan or elopement risk documentation, resulting in the resident leaving undetected and sustaining a skin tear.
The facility did not provide suitable and nourishing evening snacks to three residents who requested them, as identified through observations and interviews. This affected three residents out of a sample of 23, within a facility census of 83.
The facility failed to ensure safe transfer practices for two residents, leading to deficiencies in care. Staff did not use a gait belt for a resident's transfer from a wheelchair to a bed, resulting in a near-fall. Additionally, an inappropriate size of a mechanical lift pad was used for another resident, causing discomfort during the transfer. These incidents were identified during a review of 23 sampled residents.
The facility failed to prevent accidents and ensure safety for residents, leading to multiple incidents. A resident with a history of self-harm ingested batteries due to inadequate monitoring. Residents were transported unsafely in wheelchairs without footrests, and another was transported in a van without a seatbelt. Additionally, residents smoked near hazardous items, and harmful chemicals were accessible due to poor storage practices.
The facility failed to manage pain for three residents, including one with severe cognitive impairment and fractures, another with chronic pain, and a third with contractures. Staff did not consistently assess or document pain, nor administer medications promptly, leading to unmanaged pain and distress. Care plans were not updated to reflect necessary interventions, and staff interviews revealed a lack of consistent pain assessment.
The facility did not maintain a sufficient surety bond to protect resident funds. The Resident Trust Bank Statements showed an average monthly balance, and the A/R Aging Report indicated a balance of resident funds, but the approved bond was insufficient by $2,500. The Business Office Manager, new to the role, was unaware that A/R amounts affected the bond requirement.
The facility failed to post resident rights on the 100 Hall and did not review these rights with residents annually. During a resident council meeting, several residents reported that staff did not verbally review their rights. Observations confirmed the absence of posted rights, and interviews with staff revealed that the previous Activity Director did not discuss resident rights during meetings. The DON and Administrator expected these rights to be reviewed and posted, but this was not occurring.
The facility failed to conduct Nurse Aide Registry checks for nine out of ten newly hired employees, contrary to its policy on preventing abuse, neglect, and mistreatment. Interviews revealed that the HR representative and the Director of Nursing were unaware of the requirement to check all employees against the Nurse Aide Registry.
The facility failed to ensure that four NAs completed their training within the required timeframe, and one NA did not complete the necessary instructional training before resident interaction. The facility's policy lacked clarity on training completion timelines, and inadequate tracking by HR staff contributed to non-compliance with state regulations.
The facility failed to serve correct portion sizes and food items according to residents' dietary orders. Residents on pureed, mechanical soft, and regular diets received incorrect portions or items, such as insufficient pork servings and missing dinner rolls. The Dietary Manager confirmed that staff should follow the production sheet and spreadsheet for meal preparation.
The facility failed to maintain proper food safety and sanitation standards, with issues such as debris buildup in the walk-in cooler, inadequate freezer temperatures, unlabeled and improperly sealed food items, and wet dishware storage. Interviews revealed a lack of clear responsibility and oversight in maintaining these standards.
The facility failed to use resources effectively, impacting resident care and well-being. Deficiencies included lack of staff education on dementia, abuse, and neglect, failure to meet dietary requests, and issues with medication availability. Quality of care concerns were noted in pain management, infection control, and mobility services. The facility also had issues with staffing, record-keeping, and compliance with policies, including legionella management and resident rights. Changes in management contributed to the lack of systems in place.
The facility failed to ensure proper TB testing for employees, develop a Legionella Prevention Program, and maintain infection control practices. Employees were compensated before TST results were read, and the facility lacked a comprehensive water management program. Additionally, staff did not follow hand hygiene protocols during incontinence care, and a resident's urinary drainage bag was observed touching the floor.
Three residents in a LTC facility were unable to comfortably reach their food and drinks due to inadequate dining furniture and equipment. The residents, seated in reclining chairs, were positioned parallel to the tables, preventing them from sitting upright and facing the table. This led to difficulties in reaching meals, with some residents having to place plates on their laps. The table design further hindered chair positioning, and staff assistance was not timely provided.
The facility failed to segregate resident funds from its operating account, affecting six residents with a total of $29,602.51 held improperly. The Business Office Manager could not clarify the amounts listed in the Accounts Receivable Aging Report, indicating inadequate management of resident funds.
The facility failed to properly manage the resident trust fund account, resulting in inaccurate accounting and lack of monthly reconciliations. Quarterly statements were not provided to residents due to missing funds and unverified balances. The Business Office Manager found no prior reconciliations except for recent months, affecting 27 residents in a facility with a census of 87.
The facility failed to provide proper CMS ABN and NOMNC notices to three residents when discharging them from Medicare Part A services. Notices were incomplete, lacked necessary information, and were not given in advance. The Business Office Manager admitted to being new to the process and confirmed the absence of a policy for these notices.
The facility failed to maintain a clean and homelike environment, with observations of disrepair in resident rooms, persistent urine odors in common areas, and significant dust accumulation in bathroom vents. The Maintenance Director lacked a formal tracking system for repairs, and residents reported infrequent toileting assistance. Staff acknowledged the odors and inadequate cleaning practices, while vent cleaning was not consistently performed.
A Business Office Manager misappropriated $6,117.21 from resident funds for personal use, as discovered during an audit. The manager claimed to have distributed cash to residents, but lacked documentation to verify these transactions. Interviews with residents revealed inconsistencies, with some residents denying receipt of the funds. The manager was terminated following an internal investigation.
The facility failed to accurately code the MDS for several residents, leading to inconsistencies in assessments. A resident was marked as rarely understood despite being able to communicate effectively. Another resident's records lacked a PASARR despite severe cognitive impairment. A third resident was incorrectly marked as having a restraint, and a fourth resident's MDS failed to include a Parkinson's diagnosis and inaccurately documented antipsychotic use. The MDS coordinator relied on electronic records without direct observation.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. A resident with depression and schizophrenia exhibited suicidal ideations and aggression, but the care plan lacked interventions. Another resident with dementia and Parkinson's required assistance with ADLs, but the care plan did not specify the needed assistance. A third resident with PTSD and contractures experienced pain and communication issues, yet the care plan did not address these needs.
The facility failed to provide adequate assistance with ADLs for several residents, leading to deficiencies in personal hygiene, grooming, and nutrition. A resident did not receive a full shower for two weeks, resulting in greasy hair and discomfort. Another resident, with severe cognitive impairment, was observed with disheveled hair, long facial hair, and a strong urine odor, indicating a lack of proper incontinence care. Other residents experienced similar issues, including inadequate oral hygiene and grooming assistance.
The facility failed to provide adequate foot care for three residents, including a resident with severe cognitive impairment and another with diabetes. Long toenails were observed, causing discomfort and pressure, and there was a lack of coordination in scheduling podiatry appointments. Staff interviews revealed confusion over responsibilities for nail care and podiatrist referrals.
The facility failed to provide restorative nursing services to three residents, resulting in a decline in their range of motion and worsening contractures. A resident with severe cognitive impairment and functional limitations was not assessed for range of motion exercises. Another resident with hemiparesis and fractures did not receive necessary care, and a paraplegic resident was denied assistance with exercises. The facility lacked a restorative aide, leading to inadequate care.
The facility failed to assess and document bed rail use for two residents, leading to safety and compliance issues. One resident had no recent assessments or entrapment zone measurements, and the risks and benefits of bed rails were not discussed. Another resident's consent form was incomplete, and there were discrepancies between the assessed and observed bed rails. Interviews revealed a lack of proper procedures and documentation for bed rail assessments and consents.
The facility failed to provide sufficient nursing staff and restorative care, leading to unmet resident needs and increased pain. Residents reported delays in assistance, particularly during night shifts and weekends. The facility's staffing records showed significant understaffing compared to the plan, and residents with contractures did not receive necessary care due to the absence of a restorative aide.
The facility failed to ensure timely physician responses to pharmacist recommendations for dose reductions in medications for residents with mental health disorders. Despite repeated attempts to communicate these recommendations, the facility lacked a system to ensure they were addressed promptly, affecting residents with schizophrenia, anxiety, and bipolar disorder.
The facility failed to accommodate the dietary preferences of three residents on mechanically altered diets. Despite expressing a dislike for gravy, these residents were consistently served meals with gravy. The dietary manager was unaware of these preferences and had not interviewed residents about their likes or dislikes. The DON acknowledged that residents should have a choice in their meals and expected the dietary manager to be aware of preferences and offer substitutions.
The facility failed to ensure pneumococcal immunizations were offered, administered, or documented for several residents, as required by policy. A resident with asthma and Alzheimer's had no record of being offered the vaccine, while another resident's refusal was undocumented. The facility's vaccination list was incomplete, and staff interviews revealed awareness of the issue but no completed audits or physician orders.
The facility failed to educate and document COVID-19 vaccination for two residents. One resident with memory problems had no record of being offered the vaccine or receiving education, consent, or documentation of contraindications. Another resident with impaired cognition refused the vaccine, but there was no record of when the refusal occurred or if education was provided. Interviews revealed that the immunization process was not fully implemented.
The facility failed to ensure that call lights were accessible to residents, affecting two residents who were unable to reach their call lights when assistance was needed. One resident, who required extensive assistance, was left feeling helpless as they could not reach the call light while in a reclined chair. Another resident with cognitive impairments was repeatedly observed with the call light out of reach, despite staff acknowledging the need for accessibility. The Director of Nursing and Administrator confirmed that call lights should be within reach at all times.
The facility failed to ensure that three employees completed required communication training as identified in the facility assessment. The Certified Medication Technicians and a Certified Nursing Assistant did not have documentation of completing communication training upon hire or annually. Interviews revealed that the facility expected education to be completed on hire and annually, but the HR staff was new and not tracking prior education. The facility was working on an education calendar, but it was not complete.
The facility failed to ensure all employees received required training on resident rights, as identified in their facility assessment. Documentation was lacking for three employees, including two CMTs and one CNA, indicating non-compliance with training requirements. Interviews revealed that the HR department was not tracking prior education due to staffing changes, and the DON had not evaluated staff training compliance. An education calendar was being developed but was incomplete.
The facility failed to provide required training on abuse, neglect, exploitation, and misappropriation of resident property to three staff members, as mandated by the facility's assessment and policy. The Director of Nursing and a Registered Nurse acknowledged the deficiency, citing issues with tracking and scheduling training due to new HR staff and incomplete education planning.
The facility failed to ensure all employees completed mandatory infection control training, as identified in the facility assessment. A review of employee files for two CMTs and two CNAs showed a lack of documentation for completed training. The facility's infection control policies lacked a comprehensive training program, and infection control was not included in new hire education. Interviews with the DON and an RN revealed gaps in the training process, with HR not tracking prior education and uncertainty about staff completion of required trainings.
The facility failed to ensure that all staff completed required compliance and ethics training, as identified in the facility assessment. Documentation was lacking for two CMTs and one CNA, despite the facility's requirement for such training upon hiring and annually. Interviews revealed inadequate tracking and recording of training by HR, and an incomplete education calendar contributed to the deficiency.
The facility failed to provide the required 12 hours of annual in-service education for CNAs and CMTs, including essential training on abuse prevention and dementia care. Two CMTs did not complete necessary training, and documentation lacked details on training content. Interviews revealed gaps in training management, with incomplete tracking and evaluation of staff education.
The facility failed to ensure effective behavioral health training for staff, as identified in their facility assessment. Documentation was lacking for two CMTs and two CNAs, despite the facility's resident population having mental illness and behavior concerns. The DON and RN A acknowledged gaps in training documentation and planning, contributing to the deficiency.
The facility failed to maintain resident dignity and provide adequate assistance for two residents. One resident was left in the dining room with urine under their chair and later found inadequately dressed and exposed in their room. Another resident, who required assistance with eating, was left struggling to feed themselves, resulting in food all over their body. Staff interviews confirmed these actions were not in line with facility expectations.
The facility failed to complete comprehensive MDS assessments within required timeframes for three residents, as mandated by CMS. One resident lacked a comprehensive assessment since admission, another had an incomplete admission assessment, and a third had only the identification section completed. The DON expected timely completion as per the RAI manual.
The facility failed to complete Significant Change in Status Assessments (SCSA) for two residents who experienced significant changes in their conditions. One resident showed a decline in cognitive function and daily living activities, while the other had significant weight gain and new medications. The Director of Nursing expected the MDS Coordinator to complete these assessments, but they were not conducted, indicating a deficiency in compliance with federal requirements.
A resident with multiple psychiatric diagnoses continued to receive an incorrect dose of diazepam due to the facility's failure to update the medication order after a physician approved a reduction. The resident's POS and MAR were not updated, resulting in the administration of the original higher dose.
The facility failed to assist two residents in obtaining vision services despite their requests. One resident waited over a year for an eye doctor appointment, while another needed an updated prescription but was not scheduled for a visit. Communication breakdowns among staff, including the transportation staff, LPN, and DON, contributed to the deficiency.
A resident with an abscessed tooth did not receive necessary dental services due to a lack of communication and follow-up within the facility. Despite a physician's orders for antibiotics, pain medication, and a dental appointment, no appointment was scheduled. Staff interviews revealed that the nurse who initially handled the case had left, and there was no coordination between the Social Services Director and the transportation/central supply staff to arrange the appointment. The DON was unaware of the resident's dental needs.
The facility failed to ensure that all staff completed the required QAPI process training, as identified in the facility assessment. Two Certified Medication Technicians (CMTs) had no documentation of completed QAPI training despite being employed for over a year. Interviews revealed that the HR department was not tracking prior education due to new staff, and the facility was in the process of creating an education calendar to include all required training topics.
The facility failed to provide residents with easy access to survey results and complaint investigations, as the survey binder was located in a secure area requiring staff assistance for access. Additionally, the binder was incomplete, missing several Statements of Deficiency and Plans of Correction from 2021 to 2024. The administrator acknowledged the binder's inaccessibility and lack of updates.
The facility failed to provide written notice of transfer to residents and their representatives, and did not notify the State Ombudsman when residents were transferred to the hospital. This deficiency involved multiple residents who were transferred for medical and psychological reasons, with no documentation of the required notices. Interviews revealed a lack of awareness and responsibility among staff for sending these notices.
The facility failed to provide a written notice of the bed hold policy to residents and/or their representatives during hospital transfers for four residents. This deficiency was identified during a review of 20 sampled residents and one additional resident. Interviews with staff revealed a lack of awareness and responsibility for sending bed hold notices, contributing to the deficiency.
The facility did not submit complete and accurate direct care staffing information to CMS through the PBJ for a specified period. The new BOM faced difficulties accessing the system, leading to missed deadlines. The Administrator acknowledged the BOM's responsibility but noted challenges due to staff turnover. No PBJ policy was provided upon request.
A facility failed to provide an admission agreement to a resident's guardian upon admission. The facility's admission packet included various sections and attachments, but the admission contract was missing. The guardian confirmed not signing an agreement, and the administrator admitted responsibility for the oversight, indicating a lapse in the admission process.
Failure to Secure Exit Doors and Complete Resident Monitoring Leads to Elopement
Penalty
Summary
A resident identified as at risk for elopement, with a history of cognitive impairment, mental illness, and previous wandering activity, was able to leave the facility without staff knowledge. The resident exited through interior, alarmed, coded double doors from the dining room to the front entrance, and then through the front entrance doors, neither of which had their alarms activated or secured at the time. The resident walked approximately one mile, crossing multiple lanes of traffic, and eventually fell by the roadside before being assisted by a passerby and returned to the facility by police. Staff failed to complete required face checks every two hours, as documented in the electronic charting system, with missed checks at midnight and 2:00 A.M. The resident was not discovered missing until 2:45 A.M., resulting in the resident being out of the facility for approximately four hours. Interviews revealed that staff were aware of the need for face checks and door security, but these procedures were not followed on the night of the incident. Additionally, the resident's care plan and elopement risk documentation were not updated to reflect current interventions or monitoring requirements, and the resident was not included in the facility's elopement risk book at the nurses' desk. Observations confirmed that the alarm systems on both the interior and exterior doors were not properly activated, allowing the resident to exit undetected. The facility's elopement policy required immediate action and staff training, but there was no written policy regarding the frequency of face checks or securing entrance doors at night. The resident, who was independently mobile and had a diagnosis of schizophrenia, was able to leave the facility and was found with a skin tear after the incident.
Removal Plan
- In-service education was provided for all facility staff including updated elopement policies, face check policies and door monitoring policies.
- Staff completed elopement risk assessments for all residents.
- The elopement risk and code white procedure books were updated with current risk assessments and code white procedures.
Failure to Provide Suitable Evening Snacks
Penalty
Summary
The facility failed to ensure that staff offered suitable and nourishing evening snacks to three residents who wished to have a snack. This deficiency was identified through observation, interviews, and record reviews. The issue affected three residents out of a sample of 23, within a facility census of 83. The report highlights that the facility did not meet the residents' needs, preferences, and requests for snacks outside of scheduled meal times.
Failure in Safe Transfer Practices
Penalty
Summary
The facility failed to ensure safe transfer practices for two residents, leading to deficiencies in care. For Resident #5, staff did not use a gait belt during the transfer from a wheelchair to a bed, resulting in a near-fall incident. Additionally, for Resident #12, staff used an inappropriate size of a mechanical lift pad that was not suitable for the resident's weight, causing discomfort and complaints of pain during the transfer process. These incidents were identified during a review of 23 sampled residents, with the facility census being 83.
Facility Fails to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to prevent accidents and ensure safety for several residents, leading to multiple incidents. Resident #6, with a history of self-harm and swallowing batteries, was able to access and ingest batteries from remote controls in his room, despite being on a 1:1 supervision plan after a previous incident. The staff were not adequately trained or informed about the need to monitor and secure batteries, and there was no routine check for such items in the resident's room. This oversight resulted in the resident swallowing four batteries and requiring hospital treatment. Additionally, the facility did not ensure safe transportation practices for residents in wheelchairs. Residents #7, #15, and #20 were transported without footrests on their wheelchairs, which posed a risk of injury. Furthermore, Resident #3 was transported in the facility van while sitting on a walker, which was not secured with a seatbelt, increasing the risk of harm during transport. These actions indicate a lack of adherence to safety protocols and inadequate staff training on proper transportation methods. The facility also failed to maintain a safe environment regarding smoking and chemical storage. Residents were observed smoking near hazardous items such as a propane tank and oxygen cylinders, contrary to safety guidelines. Additionally, an unlocked shed containing harmful chemicals like nail polish remover was accessible to residents, posing a potential risk of ingestion. The facility lacked policies and oversight to prevent these hazards, contributing to an unsafe environment for residents.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for three residents, leading to significant deficiencies in care. Resident #19, who had severe cognitive impairment and a history of fractures, experienced ongoing pain due to improper sling placement and lack of timely pain medication administration. Despite showing clear signs of distress, such as grimacing and moaning, staff did not consistently assess or document the resident's pain, nor did they administer pain relief promptly. The resident's care plan was not updated to reflect the new interventions needed after the fractures were identified, and there was a lack of follow-up on the effectiveness of administered pain medications. Resident #36, who was cognitively intact and had a diagnosis of chronic pain, reported experiencing constant pain rated at an eight or nine on a scale of ten. Despite this, the resident's pain was not adequately assessed or managed, as staff consistently documented a pain score of zero and did not administer any PRN pain medications. The resident expressed that staff did not inquire about their pain, which affected their ability to sleep and focus. Resident #80, with severe cognitive impairment and contractures, also did not receive appropriate pain management. The resident displayed signs of pain during care, such as grimacing and moaning, but staff failed to recognize and address these indicators. The resident's care plan did not include pain management strategies, and staff did not administer prescribed pain medications. Interviews with staff revealed a lack of consistent pain assessment and documentation, contributing to the residents' unmanaged pain.
Insufficient Surety Bond for Resident Funds
Penalty
Summary
The facility failed to maintain a sufficient surety bond to ensure the protection of resident funds. A review of the facility's Resident Trust Bank Statements for the period from November 2023 through October 2024, excluding March 2024, showed an average monthly balance of $5,470.41. Additionally, the Accounts Receivable (A/R) Aging Report dated November 19, 2024, indicated that the facility held a balance of resident funds amounting to $29,602.51. However, the Department of Health and Senior Services approved bond list revealed that the facility only had a $50,000 approved bond, which was insufficient by $2,500.00. During an interview, the Business Office Manager, who was new to the role, admitted to not knowing that the A/R amounts would increase the bond amount needed.
Failure to Post and Review Resident Rights
Penalty
Summary
The facility failed to ensure that resident rights were posted on the 100 Hall, a locked, secured unit, and did not review resident rights with residents at least annually. During a resident council meeting, seven out of eight residents reported that staff did not verbally go over or review resident rights with them. Observations on multiple occasions confirmed that resident rights were not posted in the 100 Hall. The facility's policy required that resident rights be communicated both orally and in writing in a language understood by the resident and reviewed annually with each resident or their representative. Interviews with the Social Services Director and the Director of Nursing revealed that the previous Activity Director, who was responsible for conducting resident council meetings, did not review resident rights with residents. The Director of Nursing expected resident rights to be discussed during these meetings and reviewed annually, with documentation signed and scanned into the resident's chart. However, it was confirmed that currently, no staff member was verbally reviewing resident rights with residents. The Administrator also expected resident rights to be posted on the 100 Hall and discussed during resident council meetings.
Failure to Conduct Nurse Aide Registry Checks for New Hires
Penalty
Summary
The facility failed to review the Nurse Aide Registry for a Federal Indicator, which would disqualify an individual from working in the facility, for nine out of ten newly hired employees reviewed. This oversight was identified during interviews and record reviews. The facility's policy on Abuse and Neglect, dated December 28, 2023, states that the facility will not employ individuals convicted of abuse, neglect, or mistreatment. However, the employee files for various positions, including a Maintenance Director, CNAs, a CMT, an RN, housekeepers, a business office manager, and a laundry aide, showed no documentation of a completed Nurse Aide Registry check. During interviews, the Human Resources representative stated that all new hires are checked through the Family Care Safety Registry and other background checks, but was unaware that all employees should be checked against the Nurse Aide Registry. The Director of Nursing was also not aware of the process for new hire checks or the necessity of the Nurse Aide Registry checks. The administrator confirmed that the Nurse Aide Registry check should be completed for all newly hired nurse aides or CNAs.
Failure to Ensure Timely Completion of Nurse Aide Training
Penalty
Summary
The facility failed to ensure that four nurse aides (NAs) completed a nurse aide training program within four months of their employment. Specifically, NAs U, Q, V, and W did not have documentation of completing CNA training or receiving CNA certification, despite being employed for periods ranging from five to eleven months. Additionally, NA F did not complete the required 16 hours of instructional training before interacting with residents, as mandated by the facility's policy. The facility's policy requires NAs to be enrolled in a state-approved training program and to complete 16 hours of instructional training covering essential topics before any resident interaction. However, the policy did not specify the timeframe for completing the course or the consequences of non-completion. Interviews with the Director of Nursing and RN A revealed that the previous HR staff did not adequately track the training progress of NAs, leading to a lack of compliance with training requirements. The HR coordinator, who had only been employed for a week, was unaware of the role of a nurse assistant, indicating a lack of continuity and oversight in the HR department. The Administrator acknowledged the change in HR staff and the previous HR's failure to track training effectively. This lack of oversight and documentation resulted in the facility's non-compliance with state regulations regarding nurse aide training and certification.
Deficiencies in Dietary Service and Portion Control
Penalty
Summary
The facility failed to ensure that staff prepared and served the correct portion sizes and food items to residents according to their specific dietary orders. For residents with a physician's order for a pureed diet, staff served 3 ounces of pureed pork and cabbage instead of the required 4 ounces and did not prepare or serve pureed dinner rolls as specified. Similarly, for residents on a mechanical soft diet, staff served 2 ounces of ground pork instead of 4 ounces, large leaves of cabbage instead of chopped cabbage, and mashed potatoes instead of potato salad. Additionally, soft dinner rolls were not prepared or served as directed. For residents on a regular diet, staff failed to serve dinner rolls as specified in the diet spreadsheet. The Dietary Manager, who had been in the position since September 2024, acknowledged that staff should refer to the production sheet and spreadsheet when selecting serving utensils and that all food items listed for each diet should be prepared and served according to the spreadsheet. Despite meeting with the cook prior to each meal to ensure preparation of all menu items, these deficiencies in meal preparation and service were observed during the lunch meal service.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in several areas of its kitchen and food storage facilities. Observations revealed that the walk-in cooler had fan shrouds with a buildup of fuzzy debris, and the chest freezer was not maintaining a temperature low enough to keep food items frozen solid. Additionally, food items were found unlabeled, undated, and improperly sealed, with some items exposed to air. Dishware was improperly stored while still wet, and the ice machine had a buildup of black debris, indicating a lack of regular cleaning and maintenance. Interviews with the Dietary Manager and Maintenance Supervisor highlighted a lack of clear responsibility and oversight in maintaining these standards. The Dietary Manager was unaware of who was responsible for cleaning certain equipment and monitoring temperatures, and there was no policy manual for the kitchen or dietary department. The Maintenance Supervisor was also unsure about responsibilities related to the ice machine's water filter. These lapses in management and oversight contributed to the deficiencies observed during the survey.
Facility Fails to Ensure Effective Resource Use and Resident Care
Penalty
Summary
The administration of the facility failed to use resources effectively to ensure the highest practicable well-being of each resident. Key deficiencies included the lack of yearly staff education on dementia care, abuse and neglect, and required training hours for certified nursing assistants. The facility did not maintain an education calendar, and no staff member was monitoring education hours. Additionally, the facility failed to submit payroll-based journal data timely and did not meet residents' dietary requests consistently. Medication orders were not followed through, and medications were not always available as ordered. Quality of care issues were noted in the management of foot care, prevention of decline in mobility, and range of motion, as well as inadequate pain management and infection control measures. The facility also failed to provide reasonable accommodation of residents' needs and preferences, did not complete Advance Beneficiary Notices as required, and failed to maintain accurate records for residents' trust accounts. There were issues with staffing sufficiency, oversight of transfer notices, and timely completion of required assessments. The facility did not follow its legionella policy, lacked a water management team, and failed to monitor water temperatures for legionella management. Additionally, the facility did not ensure pneumonia vaccines were offered and administered, and failed to provide dental, podiatry, and vision appointments as ordered. The facility was unable to provide requested policies, and the administrator acknowledged that many systems were not in place due to changes in management.
Deficiencies in TB Testing, Legionella Prevention, and Infection Control
Penalty
Summary
The facility failed to ensure that Tuberculin Skin Tests (TST) were completed and documented in accordance with tuberculosis testing requirements for long-term care employees. Specifically, six out of ten employee files reviewed showed that the first-step TST was not read on or prior to the employee's start date, which is the first date of paid compensation. The facility's policy required that the first-step TST be administered on the first day of preorientation training and read on the third day, but employees were compensated before the TST results were read. Human Resources staff were unaware that paid compensation should not occur until the TST was read. The facility also failed to develop and implement a comprehensive Legionella Prevention Program. The existing Water Management Program only addressed actions in the event of an outbreak and lacked regular monitoring and maintenance instructions. There was no evidence of completed Legionnaire flushing logs, temperature checks, mixer valve inspections, or water management team meetings. The Maintenance Director admitted to not checking cold water temperatures, not flushing unused bathtubs, and not being aware of the water management program requirements. The Infection Preventionist and Director of Nursing confirmed the absence of a water management program. Additionally, the facility did not ensure proper hand hygiene and urinary catheter care. During incontinence care for a resident, a CNA failed to wash hands before donning gloves, placed soiled wipes on the resident's mattress, and did not change gloves after providing perineal care. Another resident with a urinary catheter had their drainage bag touching the floor, which was observed on multiple occasions. The facility's policies required hand hygiene before and after resident contact and keeping urinary drainage systems off the floor, but these were not followed.
Inadequate Dining Furniture and Equipment for Residents
Penalty
Summary
The facility failed to provide adequate dining furniture and equipment for three residents, resulting in their inability to comfortably reach their food and drinks during mealtimes. The residents, who were seated in reclining chairs on wheels, were positioned parallel to the dining tables, preventing them from sitting upright and facing the table. This positioning forced the residents to twist their bodies to reach their meals, with some having to place their plates on their laps to feed themselves. The tables' design, with supports in the center, further hindered the ability of the chairs to roll up to the table, exacerbating the issue. Resident #36, who was cognitively intact and required supervision and touch assistance with eating, was observed struggling to reach food and silverware due to the positioning of the geri-chair. The resident's attempts to feed themselves were hampered by shaking hands, and staff assistance was not provided in a timely manner. Similarly, Resident #80, with severe cognitive impairment and functional limitations, was unable to reach drinks and certain food items due to the same positioning issues. The resident's contractures further limited their ability to access items on the table. Resident #10, with moderately impaired cognition and diabetes, also faced difficulties reaching food while seated in a partially reclined broda chair. The resident had to stretch to reach their dessert and required assistance to access their entree. Interviews with staff revealed that the positioning of the chairs was due to the table design, and there was a lack of policy for choices and self-determination. The Director of Nurses acknowledged that residents should be positioned upright and that alternative solutions, such as over-the-bed tables, should be provided if necessary.
Failure to Segregate Resident Funds from Operating Account
Penalty
Summary
The facility failed to ensure that resident funds were placed in an account separate from the facility's operating account, resulting in a deficiency. This issue affected six residents, with a total of $29,602.51 held inappropriately in the operating account. During a review of the facility's Accounts Receivable Aging Report, it was found that the personal funds of these residents were not refunded in a timely manner. The Business Office Manager was unable to provide clarification on the amounts listed in the report, indicating a lack of proper management and oversight of resident funds.
Deficiency in Resident Trust Fund Management
Penalty
Summary
The facility failed to maintain a proper system for managing the resident trust fund account, which led to deficiencies in accounting and reporting. The facility did not maintain accurate records of all monies held in the resident trust fund account and failed to reconcile these accounts monthly. Additionally, the facility did not provide quarterly statements to the residents or their financial guardians. The Business Office Manager (BOM) #2 reported that there were no reconciliations available from the previous BOM, except for those from September and October 2024. Furthermore, BOM #2 was unable to provide quarterly statements due to discrepancies found during an audit, which included missing funds and unverified resident balances. The facility managed funds for 27 residents, with a total census of 87.
Failure to Provide Proper Medicare Notices
Penalty
Summary
The facility failed to provide appropriate CMS Skilled Nursing Facility Advance Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) to three residents when initiating discharge from Medicare Part A services before benefit days were exhausted. For Resident #245, the ABN was incomplete, lacking options selection and was signed by the resident instead of the DPOA, without a date. The NOMNC was also incomplete, missing the resident's name, QIO number, and dates of issuance and signing. Resident #391's ABN was similarly incomplete, with options left blank and signed by the DPOA on the day services ended, not in advance. The NOMNC had an incorrect year, lacked the resident's name, and was signed on the discontinuation date. For Resident #246, the facility could not locate any ABN or NOMNC. The Business Office Manager acknowledged the absence of a policy for ABN and NOMNC notices and admitted to being new to the process. She confirmed that notices should be given three days prior to service discontinuation to inform residents or their representatives about payer changes. The manager also noted that if residents were unable to understand or make decisions, their guardian or DPOA should sign the notices. The facility census was 87, and the Director of Nursing confirmed via email that the facility had no policy for these notices, relying instead on regulatory guidelines.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment, as evidenced by several observations of disrepair and cleanliness issues. Multiple resident rooms had ceilings with peeling paint and discoloration, indicating a lack of maintenance. Additionally, a room had a hole in the wall with irregular paint, suggesting incomplete repairs. Interviews with the Maintenance Director revealed a lack of formal tracking for repair needs, relying instead on memory, and an absence of work orders for certain areas, despite visible disrepair. The facility also struggled with persistent strong urine odors in common areas and resident rooms. Observations noted the presence of these odors in the dining room and B hall, with residents and staff confirming the issue. One resident reported infrequent toileting assistance, leading to saturated clothing and contributing to the odor. A CNA acknowledged the urine smell and suggested inadequate cleaning of wheelchairs and linens as potential causes, with no current efforts to address the odors. Furthermore, the facility had a significant issue with dust accumulation in bathroom vents across multiple rooms and common areas. The Maintenance Director admitted to not having cleaned or dusted the vents recently, despite a policy of monthly deep cleaning and weekly dusting. The staff responsible for cleaning resident rooms were also expected to assist with vent cleaning, but this was not consistently happening, leading to the observed deficiencies.
Misappropriation of Resident Funds by Business Office Manager
Penalty
Summary
The facility failed to protect resident funds from misappropriation, as evidenced by the actions of Business Office Manager (BOM) #1, who removed and used resident funds totaling $6,117.21 for personal use. This deficiency was identified during an audit of the resident trust account, which revealed discrepancies in the account balances and missing receipts for large sums of money allegedly distributed to residents. BOM #1 claimed to have given cash to several residents, but there was no documentation or signed receipts to verify these transactions. Interviews with residents revealed inconsistencies in BOM #1's claims. For instance, one resident stated they never received the $3,000 allegedly given to them by BOM #1 and that they managed their own finances through a private bank account. Other residents either did not recall receiving the amounts claimed by BOM #1 or were unsure about the transactions. The lack of proper documentation and the inability of BOM #1 to provide a satisfactory explanation for the missing funds led to further investigation. The facility's internal investigation, conducted by BOM #2 and the Administrator (ADM) #1, confirmed the discrepancies in the resident trust account. BOM #1 was unable to provide any receipts or documentation to support their claims of cash distribution to residents. As a result, BOM #1 was terminated from their position. The facility reported the findings to the state agency and law enforcement for further action.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for four residents, leading to inconsistencies in their assessments. For Resident #30, the MDS showed discrepancies in the cognition and communication sections, where the resident was marked as rarely understood, yet staff assessments indicated independence in decision-making. During an interview, the resident was able to communicate effectively, contradicting the MDS documentation. Resident #80's records showed a lack of documentation for a Preadmission Screening and Resident Review (PASARR), despite the resident having severe cognitive impairment and multiple diagnoses. The MDS entries did not reflect the resident's admission and discharge accurately, and there was no evidence of a PASARR being completed, which is required for residents with mental illness. Resident #19 was incorrectly marked as having a bedrail restraint, although observations and staff interviews indicated that the bedrail did not restrict the resident's movement. For Resident #65, the MDS failed to include a diagnosis of Parkinson's Disease and inaccurately documented the use of antipsychotic medication, which was not prescribed or administered. The MDS coordinator admitted to relying on electronic records and was unaware of the inaccuracies, while the Director of Nursing noted that the MDS assessments were completed offsite without direct observation.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #241, who was cognitively intact and diagnosed with depression and schizophrenia, exhibited behaviors such as suicidal ideations and physical aggression. Despite these behaviors being documented in progress notes, the care plan was not updated to include interventions to prevent harm or address these behaviors, as required by the PASARR Level II Evaluation. Resident #7, diagnosed with dementia, Parkinson's disease, and dysphagia, required assistance with activities of daily living (ADLs). However, the care plan did not specify the type of assistance needed for transfers, bathing, toileting, incontinence care, eating, dressing, mobility, and oral hygiene. Observations showed that the resident required assistance from one to two staff members for these activities, but the care plan lacked this critical information. Resident #80, with severe cognitive impairment and diagnosed with PTSD and contractures, experienced pain and communication issues. The care plan did not address the resident's pain management, communication needs, or the impact of contractures on functional range of motion. Observations revealed that the resident experienced pain during movement, and staff noted the need for specific communication strategies to provide effective care. Despite these observations, the care plan was not updated to include necessary interventions for pain management and communication.
Inadequate Assistance with ADLs in LTC Facility
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for six residents, leading to deficiencies in personal hygiene, grooming, and nutrition. Resident #36, who was cognitively intact and dependent on staff for various ADLs, did not receive a full shower for two weeks, resulting in greasy hair with white flakes. The resident expressed dissatisfaction with the partial bed baths offered instead of full showers, which left them feeling unclean and itchy. Additionally, the resident struggled to feed themselves due to shaking hands and was not adequately assisted by staff, leading to food spillage and hunger. Resident #80, with severe cognitive impairment and total dependence on staff for ADLs, was observed with disheveled hair, long unkempt facial hair, and long fingernails with debris. The resident emitted a strong urine odor, and their clothing was soiled, indicating a lack of proper incontinence care and personal hygiene. The resident's family member confirmed the persistent urine smell and noted the resident's preference for being clean-shaven, which was not being met. Other residents, such as Resident #19, #67, #10, and #83, also experienced inadequate care. Resident #19, with severe cognitive impairment and total dependence on staff, was frequently left in urine-soaked conditions, as noted by their roommate and durable power of attorney. Resident #67 did not receive proper incontinence care, as staff failed to clean all soiled areas. Resident #10, with moderately impaired cognition, did not receive assistance with oral hygiene, resulting in yellowed teeth with food buildup. Resident #83, who required assistance with grooming, was not consistently shaved according to their preference, leading to discomfort and itching.
Deficiency in Foot Care for Residents
Penalty
Summary
The facility failed to ensure proper foot care for three residents, leading to deficiencies in maintaining foot health. Resident #19, who has severe cognitive impairment and is dependent on staff for personal hygiene, had long toenails that were not trimmed as per the guardian's request for podiatrist-only care. The resident's care plan indicated the need for podiatrist appointments, but the last recorded visit was several months prior, and the resident was not on the current podiatry list. Licensed Practical Nurse (LPN) B acknowledged the oversight, and the resident's durable power of attorney was unaware of the last podiatrist visit. Resident #80, with severe cognitive impairment and dependent on staff for all activities of daily living, had very long fingernails with debris and toenails causing pressure on other toes. The resident's family member expected routine nail care, which was not provided. Resident #44, who is cognitively intact and diabetic, reported needing a podiatrist visit due to long toenails causing discomfort. Despite requesting assistance, the resident's toenails remained thick and long, causing pressure between toes. Interviews with staff revealed a lack of coordination in scheduling podiatry appointments, with confusion over responsibilities between nursing and transportation staff.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services to three residents, leading to a decline in their range of motion and the development or worsening of contractures. Resident #80, who had severe cognitive impairment and functional range of motion limitations, was not assessed by the Restorative Nursing department upon admission, and no range of motion exercises were prescribed. Observations showed that the resident had severe contractures and was in pain during care, yet no range of motion exercises were provided by the staff. Resident #19, who had severe cognitive impairment and a history of hemiparesis, had a care plan that initially included passive range of motion exercises, but this was later canceled. The resident suffered fractures in the right shoulder and wrist, which were not addressed in the care plan, and there was no documentation of restorative nursing services or range of motion exercises being provided. Observations indicated that the resident was in pain and had significant edema, yet the facility did not have a restorative aide to provide necessary care. Resident #4, a paraplegic, expressed a desire for restorative nursing to prevent contractures in the legs, but the facility did not have a restorative program. The resident reported that staff refused to assist with range of motion exercises, claiming the resident was independent. The facility's lack of a restorative aide resulted in the absence of a structured program to address the residents' needs, leading to further decline in their physical conditions.
Deficiencies in Bed Rail Assessment and Documentation
Penalty
Summary
The facility failed to properly assess and document the use of bed rails for two residents, leading to deficiencies in safety and compliance. For Resident #20, the facility did not conduct a comprehensive assessment of the risk of entrapment before installing bed rails. The resident's medical records lacked documentation of any recent assessments or entrapment zone measurements, and there was no evidence that the risks and benefits of the bed rails were discussed with the resident. The resident, who had moderately impaired cognition and was at high risk for falls, was observed with assist rails in the upright position, but the facility did not have a policy for entrapment risks and bed rail use. Resident #19's situation also highlighted significant deficiencies. The resident's informed consent form for bed rail use was incomplete, with both consent boxes left blank and no staff signature or date. The resident's care plan and medical records were inconsistent, showing discrepancies between the type of rails assessed and those observed. The resident, who had severe cognitive impairment and required substantial assistance, was observed with padded half rails, although the assessment indicated quarter rails. The facility did not document any evaluation of bed rail use or entrapment risk assessments, and the resident's DPOA was not informed of the risks and benefits of bed rails. Interviews with the DON and LPN revealed that the facility lacked proper procedures and documentation for bed rail assessments and consents. The DON admitted that side rail assessments should be completed quarterly, and consents should be obtained from the resident or their representative. However, the facility did not have a policy for entrapment risks, and staff were not aware of who conducted the assessments or when they were re-evaluated. This lack of documentation and assessment led to the improper use of bed rails, posing potential safety risks to the residents.
Understaffing and Lack of Restorative Care in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient and competent nursing staff to meet resident needs, as evidenced by consistent understaffing compared to the facility's assessment. Residents reported delays in call light responses, particularly during night shifts and weekends. The facility's staffing records showed significant discrepancies in the number of shifts covered by Certified Medication Technicians (CMTs) and Licensed Practical Nurses (LPNs) compared to the staffing plan. This understaffing led to unmet resident needs, including delays in assistance and care. The facility also failed to provide restorative nursing care to residents with contractures, as it did not employ a restorative aide. Residents with severe cognitive impairments and physical limitations, such as those resulting from strokes or paraplegia, did not receive necessary range of motion exercises or assessments. The lack of a restorative nursing department meant that residents with contractures did not receive appropriate care to manage their conditions, leading to increased pain and discomfort. Specific residents experienced significant issues due to the lack of restorative care. One resident with severe contractures and cognitive impairments was observed in pain during care, with no range of motion exercises provided. Another resident with fractures and edema did not receive proper positioning or pain management, and their care plan lacked necessary interventions. A third resident, a paraplegic, expressed a desire for restorative nursing to prevent contractures, but the facility's lack of a restorative program left their needs unmet.
Failure to Ensure Timely Physician Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to provide documentation of a policy and procedure for monthly drug regimen reviews and did not ensure timely physician responses to pharmacist recommendations for three residents. The pharmacist identified irregularities in the medication dosages for residents with mental health disorders, recommending dose reductions. However, the facility lacked a system to ensure these recommendations were addressed promptly by the physicians. Resident #50, diagnosed with schizophrenia and anxiety disorder, was receiving hydroxyzine 50 mg three times daily. The pharmacist recommended a dose reduction, but the physician's response was left blank, and repeated attempts to obtain a response were unsuccessful. Similarly, Resident #33, with schizophrenia and bipolar disorder, was on olanzapine 10 mg three times daily. The pharmacist suggested a dose reduction, but the recommendation was repeatedly refaxed without a timely response from the physician. Resident #242, diagnosed with schizophrenia and anxiety disorder, was receiving olanzapine 10 mg in the morning and 15 mg at bedtime. The pharmacist recommended a dose reduction, but the physician's response was initially left blank. After several attempts to obtain a response, the practitioner eventually disagreed with the recommendation due to the resident's history of self-harm and hospitalizations. The Director of Nurses confirmed that the facility continued to fax recommendations without addressing the lack of response with the medical director for further guidance.
Failure to Accommodate Dietary Preferences for Residents
Penalty
Summary
The facility failed to accommodate the dietary preferences of three residents, all of whom were on a mechanically altered diet. Resident #83, who was cognitively intact, expressed a dislike for gravy on their food, yet was consistently served mashed potatoes with gravy. Despite informing staff of this preference, the dietary manager was unaware of the resident's dislike and continued to serve meals with gravy. Similarly, Resident #53, who was also on a mechanical soft diet, repeatedly received meals with brown gravy, which they disliked. Despite communicating this to several staff members, the issue persisted, and the resident was served an enchilada covered in gravy, which they found unappetizing. Resident #74, with moderately impaired cognition, also reported that the kitchen staff consistently added gravy to their meals, despite their expressed dislike. The dietary manager, who had been in the position since September 2024, admitted to not having a list of residents' preferences and had not interviewed residents about their likes or dislikes. The Director of Nursing (DON) acknowledged that residents should have a choice in their meals and expected the dietary manager to be aware of residents' preferences and offer substitutions when necessary.
Failure to Administer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that staff provided education and offered, administered, or obtained signed refusals for pneumococcal immunizations for four residents. Specifically, the facility did not track immunization history for at least one resident. The facility's policy required that pneumococcal vaccines be administered to all residents unless contraindicated or refused, and that a log be maintained to record the immunization process. However, the review found that the facility did not adhere to these procedures. Resident #7, who had diagnoses including asthma, Alzheimer's disease, and chronic viral hepatitis C, was found to have no documentation of pneumococcal immunization being offered or administered. The resident's electronic medical record lacked evidence of education, consent, signed refusal, or immunization history. Similarly, Resident #18's records showed that while their immunization was up to date, there was no documentation of education or signed consent/refusal form. Resident #74, who had moderately impaired cognition, refused the Prevnar 20 immunization, but there was no documentation of a dated and signed refusal or education. Resident #44, who had diagnoses including heart failure, renal insufficiency, and chronic obstructive pulmonary disease, also had no documentation of education, consent form, signed refusal, or history of pneumococcal immunization. The facility's PNA vaccination list was undated and did not include Residents #7, #44, and #74. Interviews with the Infection Preventionist and the Director of Nurses revealed that they were aware of the need to review and update immunization records but had not completed the necessary audits or obtained specific orders from physicians.
Failure to Educate and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to ensure that two residents were educated and offered the COVID-19 vaccine, as well as failed to obtain consent or refusal for the immunization. Resident #7, who had a guardian and was noted to have short and long-term memory problems, showed no documentation of any COVID-19 immunizations in their medical record. There was also no evidence that the facility offered the vaccine, provided education, obtained consent, or documented any contraindications for the immunization after the resident's admission. Similarly, Resident #74, who was their own responsible party and had moderately impaired cognition, had no documentation of COVID-19 immunizations in their record. Although the resident refused the vaccine, there was no documentation indicating when the refusal occurred. Additionally, there was no evidence that the resident was provided with education regarding the risks and benefits of the COVID-19 immunization. Interviews with the Infection Preventionist and the Director of Nurses revealed that they were responsible for ensuring immunizations were up to date, but an audit to identify residents needing immunizations had not been completed, and the process for obtaining orders and consents was not fully implemented.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to maintain a functional call light system accessible to residents, affecting two residents in a sample of 20. Resident #67, who required extensive assistance for activities of daily living and was dependent on staff for transfers, was observed in a reclined Broda chair unable to reach the call light, which was at the foot of the bed. The resident screamed for help for several minutes without staff response until the surveyor intervened. This left the resident feeling helpless and uncomfortable. Resident #28, diagnosed with dementia and other cognitive impairments, was repeatedly observed with the call light inaccessible, either under the mattress or on the floor. Despite staff acknowledging the need for the call light to be within reach, it was consistently not provided. Similarly, Resident #68, with a history of psychotic disorder and at risk for falls, was observed with the call light hanging over the footboard, out of reach. Interviews with the Director of Nursing and the Administrator confirmed that call lights should be within reach of all residents at all times.
Failure to Complete Required Communication Training for Staff
Penalty
Summary
The facility failed to ensure that all employees completed required communication training, as identified in the facility assessment, for three employees in a sample of four employee files reviewed. Specifically, the Certified Medication Technician (CMT) D, CMT J, and Certified Nursing Assistant (CNA) R did not have documentation of completing communication training either upon hire or annually. The facility's assessment outlined specific training needs, including communication with older adults with dementia and other regulatory-required trainings, but there was no evidence that these trainings were completed for the mentioned employees. Interviews with the Director of Nursing (DON) and Registered Nurse (RN) A revealed that the facility expected employee education to be completed on hire and annually, coordinated by Human Resources (HR). However, the HR staff was new and not tracking prior education, and the DON had not evaluated if all staff were up to date on required education. The facility was in the process of creating an education calendar to include all required subjects, but it was not complete at the time of the survey.
Deficiency in Staff Training on Resident Rights
Penalty
Summary
The facility failed to ensure that all employees received training on resident rights, as identified in their facility assessment. Specifically, there was no documentation or evidence of the required training being completed for three out of four employees reviewed, including two Certified Medication Technicians (CMT D and CMT J) and one Certified Nursing Assistant (CNA R). The facility's assessment outlined specific training needs, including 0.50 hours of resident rights training required by Medicare Rules of Participation for all employees, both at the time of hire and annually. However, the employee education files for CMT D, CMT J, and CNA R lacked documentation of this training, indicating a failure to adhere to the facility's training schedule and requirements. Interviews with the Director of Nursing (DON) and Registered Nurse (RN) A revealed that the facility's human resources department, which was responsible for coordinating and recording new hire training, was not tracking prior education due to a change in staff. Additionally, the DON admitted to not having evaluated whether all staff were up to date on required education. The facility was in the process of creating an education calendar to include all required training topics, but it was not yet complete at the time of the survey. This lack of documentation and oversight led to the deficiency in ensuring staff were properly trained on resident rights as mandated by regulations.
Failure to Provide Required Training on Abuse and Neglect
Penalty
Summary
The facility failed to provide necessary training for abuse, neglect, exploitation, and misappropriation of resident property to three employees, including two Certified Medication Technicians (CMTs) and one Certified Nurse Assistant (CNA). This deficiency was identified through interviews and record reviews, which revealed that these employees did not receive the required training on identification, reporting, and prevention of such incidents, as mandated by the facility's assessment and policy. The facility's policy and assessment outlined specific training requirements for new hires and annual training, which were not met for these employees. The Director of Nursing (DON) acknowledged that employee education was expected to be completed upon hiring and annually, as directed by the facility assessment. However, the Human Resources department, responsible for coordinating and recording new hire training, failed to track prior education due to a new staff member. Additionally, the Registered Nurse (RN) assisting with education confirmed that the facility was in the process of creating an education calendar to include all required subjects, but it was not yet complete. This lack of training compliance was identified in a facility with a census of 87 residents.
Failure to Ensure Completion of Infection Control Training
Penalty
Summary
The facility failed to ensure that all employees completed mandatory education on infection control, as identified in the facility assessment. The review of employee files for four staff members, including two Certified Medication Technicians (CMTs) and two Certified Nurse Assistants (CNAs), revealed a lack of documentation or evidence of completed infection control training. The facility's infection control policies did not include a comprehensive training program covering essential areas such as the facility's surveillance system, standard and transmission-based precautions, and occupational health policies. Additionally, infection control was not included in the new hire education topics. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) highlighted gaps in the facility's training processes. The DON acknowledged that employee education was expected to be completed on hire and annually, but the new Human Resources (HR) staff was not tracking prior education. The RN mentioned that the facility was in the process of creating an education calendar to cover all required subjects, but it was not yet complete. The RN also noted uncertainty about whether staff had completed the required trainings, and that HR was responsible for recording new hire training.
Failure to Ensure Compliance and Ethics Training for Staff
Penalty
Summary
The facility failed to ensure that all staff completed the required compliance and ethics training, as identified in the facility assessment. Specifically, there was no documentation or evidence of completion of this training for two Certified Medication Technicians (CMT D and CMT J) who had been employed for over a year, and one Certified Nurse Assistant (CNA R) who was newly hired within the last year. The facility's assessment outlined the necessity for compliance and ethics training for all employees, both upon hiring and annually, but the records for these employees did not reflect completion of this requirement. Interviews with the Director of Nursing (DON) and Registered Nurse (RN) A revealed that the facility's process for tracking and recording training was inadequate. The DON acknowledged that employee education was expected to be completed as directed by the facility assessment, but noted that the Human Resources (HR) department, which was responsible for coordinating and recording new hire training, had not been tracking prior education effectively. Additionally, the facility was in the process of developing an education calendar to ensure all required training topics were covered, but this was not yet complete. The lack of a comprehensive system to ensure compliance with training requirements contributed to the deficiency identified by the surveyors.
Deficiency in Staff Training and Education
Penalty
Summary
The facility failed to ensure that each Certified Nurse Aide (CNA) and Certified Medication Technician (CMT) received the required 12 hours of in-service education per year, as mandated by their individual performance reviews and hire dates. The report highlights that two CMTs, who had been employed for over a year, did not meet this requirement. Specifically, neither CMT J nor CMT D completed the necessary training on abuse prevention, dementia care, or care for cognitively impaired residents. The documentation lacked details on the agenda, depth, or scope of the training sessions attended by these staff members. The facility's assessment and policies outlined specific training requirements, including abuse prevention and dementia care, which were not fulfilled. The assessment indicated that all staff, including CNAs and CMTs, were expected to complete training on preventing, recognizing, and reporting abuse, as well as care for cognitively impaired residents. However, the records for CMT D and CMT J showed incomplete training hours and missing essential topics, such as dementia care and abuse prevention, which are critical for the resident population. Interviews with the Director of Nursing (DON) and Registered Nurse (RN) A revealed gaps in the facility's training management. The DON acknowledged that employee education was expected to be completed on hire and annually, but there was no evaluation to ensure compliance. RN A mentioned that while she provided some new hire training, the tracking of all employee training was not comprehensive. The facility was in the process of developing an education calendar to address these deficiencies, but it was not yet complete at the time of the report.
Deficiency in Behavioral Health Training for Staff
Penalty
Summary
The facility failed to implement an effective training program for both new and existing staff, as identified in their facility assessment. Specifically, the facility did not have documentation or evidence that required behavioral health training was completed for two Certified Medication Technicians (CMT D and CMT J) and two Certified Nurse Assistants (CNA I and CNA R). These employees' education records lacked evidence of behavioral health training, which is crucial given the facility's resident population with mental illness and behavior concerns. The facility assessment, dated 09/26/24, outlined the services offered, including managing psychiatric symptoms and behavior, and identified common diagnoses among residents, such as major depressive disorder, schizophrenia, and bipolar disorder. Despite this, the facility did not include specific behavioral health training in their assessment. The Director of Nursing (DON) acknowledged that employee education was expected to be completed on hire and annually, but the facility had not ensured this was done. Interviews with the DON and RN A revealed that the facility's human resources staff were new and had not tracked prior education, and there was uncertainty about whether staff had completed the required trainings. The facility was in the process of creating an education calendar to include all required subjects, but it was not complete at the time of the survey. This lack of documentation and planning contributed to the deficiency in staff training, particularly in behavioral health, which is essential for the care of the facility's resident population.
Failure to Maintain Resident Dignity and Provide Adequate Assistance
Penalty
Summary
The facility failed to provide care that enhanced resident dignity and recognized individuality for two residents. Resident #20, who required substantial assistance for transfers and personal hygiene, was observed sitting in a wheelchair in the dining room with a large puddle of urine under the chair. Despite the strong smell of urine, multiple staff members walked past without addressing the situation. The resident remained in this condition for 30 minutes before being taken to their room, where they were found wearing visibly urine-soiled pants and a saturated incontinence brief. On another occasion, the resident was observed in their room wearing only a wet shirt, an incontinence brief, and socks, with the privacy curtain not drawn, leaving them exposed to their roommate and the hallway. Resident #36, who was cognitively intact and required supervision and some assistance with eating, was observed struggling to feed themselves. The resident's plate was placed on their stomach, and they attempted to eat with shaking hands, resulting in food particles all over their face, stomach, and chair. Despite the resident's visible difficulty and expressed need for assistance, staff did not offer help until much later, and even then, the assistance was inadequate. The resident expressed embarrassment and a desire for help, as they were unable to reach their food and felt like a child with food all over them. Interviews with staff, including a CNA and the Director of Nursing, confirmed that the observed situations were not in line with the facility's expectations for resident care. Staff acknowledged that residents should not be left in the dining room with urine under their chairs and should not be dressed inadequately or left exposed. Additionally, staff should assist residents with eating to maintain their dignity and ensure they are clean and well-groomed.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required timeframes for three residents, as mandated by the Centers for Medicare and Medicaid Services (CMS). For one resident, there was no evidence of a comprehensive assessment being completed since their admission assessment. Another resident's admission assessment was opened but not completed or submitted by the due date. Additionally, a third resident's admission MDS was incomplete, with only the identification section filled out, and no comprehensive assessment was completed. The Director of Nursing acknowledged the expectation for the MDS Coordinator to complete assessments within the required timeframes as directed by the Resident Assessment Instrument (RAI) manual. The facility's census was 87, and the deficiencies were identified during a review of records and interviews, highlighting a failure to adhere to federal requirements for timely and complete resident assessments.
Failure to Complete Significant Change Assessments for Residents
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for two residents, which is a federally mandated assessment required when there is a significant change in a resident's condition. For Resident #36, the facility did not conduct an SCSA despite the resident experiencing a decline in cognitive function, becoming dependent on staff for eating and upper body dressing, and requiring a mechanically altered diet. Observations showed the resident struggling to feed themselves, with food scattered on their face, stomach, and chair, indicating a significant decline in their ability to perform daily activities. Resident #80 also did not receive an SCSA despite significant changes in their condition. The resident experienced a significant weight gain, healed wounds, and was prescribed new medications, including antipsychotic and anticoagulant medications. These changes were not reflected in a significant change assessment, which is necessary to ensure the resident's care plan is updated to address their current needs. The Director of Nursing acknowledged that the MDS Coordinator is expected to complete significant change assessments as directed by the RAI manual. However, the failure to conduct these assessments for the two residents indicates a deficiency in the facility's compliance with federal requirements for monitoring and updating resident care plans in response to significant changes in their health status.
Failure to Update Medication Order for a Resident
Penalty
Summary
The facility failed to follow a physician's order to decrease a psychotropic medication for one resident. The resident, who had diagnoses including anxiety, bipolar disorder, depression, and schizophrenia, was supposed to have their bedtime dose of diazepam reduced from 10 mg to 5 mg as per a physician's agreement with a pharmacist's recommendation. However, the staff did not update the resident's Physician Order Sheet (POS) or Medication Administration Record (MAR) to reflect this change. As a result, the resident continued to receive the original 10 mg dose at bedtime from the date the new order was obtained until the deficiency was identified. The Director of Nursing acknowledged that the nurse responsible for the resident's care should have updated the POS and MAR with the new orders once the physician approved the pharmacist's recommendation.
Failure to Assist Residents in Obtaining Vision Services
Penalty
Summary
The facility failed to assist two residents in obtaining necessary vision services, despite their requests for appointments. Resident #44, who is cognitively intact and responsible for their own care, had been waiting for over a year to see an eye doctor. The resident expressed difficulty in seeing both near and far, impacting their ability to read and see the clock. Although the transportation staff was aware of the resident's request, no appointment was made at the location covered by the resident's insurance. The transportation staff claimed to be unaware of the resident's request for an appointment. Resident #33, who has a guardian, had a physician's order for an ophthalmic consult, but was not scheduled for a vision appointment when a provider visited the facility. The resident reported a change in vision and the need for an updated prescription for their glasses. The transportation staff indicated that appointments are typically arranged by them upon notification from nursing staff, but Resident #33 was not scheduled for an appointment. The Director of Nursing and Social Services Director were also unaware of the residents' requests for vision appointments, indicating a breakdown in communication and procedure within the facility.
Failure to Provide Dental Services for Resident with Abscessed Tooth
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services after being diagnosed with an abscessed tooth. The resident, who had a legal guardian, was seen by a primary care physician who noted complaints of jaw pain and swelling due to a dental abscess. The physician ordered antibiotics and pain medication and planned for a dental appointment. However, there was no documentation of a dental appointment being scheduled for the resident since the diagnosis. Interviews with various staff members revealed a lack of communication and follow-up regarding the resident's need for a dental appointment. The nurse who initially rounded with the physician no longer worked at the facility, and there was no evidence that the Social Services Director was contacted for guardian authorization. The transportation/central supply staff member, responsible for scheduling appointments, was not informed of the resident's need for a dental appointment. The Director of Nurses was also unaware of the resident's need for dental care, and the resident had not had a dental appointment since admission.
Failure to Complete QAPI Training for Staff
Penalty
Summary
The facility failed to ensure that all staff completed the required Quality Assurance Performance Improvement (QAPI) process training, as identified in the facility assessment. Specifically, there was no documentation or evidence that two Certified Medication Technicians (CMT D and CMT J), who had been employed for over a year, completed the QAPI training. The facility's assessment outlined the necessity for staff training, education, and competencies to provide adequate care for the resident population, including a review of the QAPI plan in November and December sessions. However, the records for these employees showed no evidence of completed QAPI training. Interviews with the Director of Nursing (DON) and Registered Nurse (RN) A revealed that employee education was expected to be completed upon hiring and annually, as directed by the facility assessment. The DON noted that the Human Resources (HR) department, which was responsible for coordinating and recording new hire training, was not tracking prior education due to new staff. Additionally, RN A mentioned that the facility was in the process of creating an education calendar to include all required training topics, but it was not yet complete. The DON also acknowledged that she had not evaluated whether all staff were up to date on required education after returning to the facility.
Survey Results Inaccessibility and Incomplete Documentation
Penalty
Summary
The facility failed to make the results of the most recent survey and complaint investigations readily accessible to residents. During a resident council meeting, seven out of eight residents expressed that they were unaware of their right to view the results of annual inspections or complaint investigations, nor did they know where these results were kept. Observations revealed that the survey results were located in a secure area behind a locked door, requiring a four-digit pin for access, which residents could not enter without staff assistance. This setup effectively restricted residents' access to the survey binder. Additionally, the survey binder was found to be incomplete, lacking documentation of several Statements of Deficiency (SOD) and Plans of Correction (POC) from various dates spanning from 2021 to 2024. The administrator confirmed that there was only one survey binder in the building, located by the front door, and acknowledged that the binder was not up to date. The locked A-hall unit also did not have a survey binder accessible to residents, further limiting their ability to review survey results and complaint investigations.
Failure to Provide Written Notice of Transfer and Notify Ombudsman
Penalty
Summary
The facility failed to provide written notice of transfer to residents and their representatives, as well as notify the State Ombudsman, when residents were transferred to the hospital. This deficiency was identified in the cases of four residents who were transferred to the hospital for various medical and psychological reasons. The facility did not have a policy in place to address the requirement for written notification of transfer, which contributed to the oversight. Resident #68 was transferred to the hospital after complaining of chest, neck, and heel pain. The resident's family member was listed as the responsible party, but there was no evidence that a written notice of transfer was provided. Similarly, Resident #242, who had a guardian, was transferred multiple times due to suicidal ideation and self-harm attempts, yet no written notice of transfer was documented. Resident #33, also with a guardian, was transferred to the hospital following a request from the guardian due to the resident's suicidal ideation, but again, no written notice was provided. Resident #31, who had a guardian, was transferred to the hospital on several occasions due to medical emergencies such as shortness of breath and congestive heart failure exacerbation. In each instance, there was no documentation of a written notice of transfer being provided to the resident or their representative. Interviews with facility staff, including the Director of Nursing and the Social Services Director, revealed a lack of awareness and responsibility for sending the required notices, and the State Ombudsman confirmed that they had not received transfer logs beyond March 2024.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a written notice of the bed hold policy to residents and/or their representatives at the time of transfer to the hospital for four residents. This deficiency was identified during a review of 20 sampled residents and one additional resident. The facility was unable to provide a bed hold policy when requested, indicating a systemic issue in communicating this important information to residents and their representatives. Resident #242, who had a guardian as their responsible party, was transferred to the hospital multiple times due to suicidal ideation and self-harm attempts. On each occasion, there was no documentation that the facility staff provided the resident or their guardian with a copy of the bed hold policy. Similarly, Resident #33, who also had a guardian, was transferred to the hospital for evaluation due to suicidal ideation, and again, there was no documentation of the bed hold policy being provided. Resident #31, with a legal guardian, was transferred to the hospital multiple times for various medical issues, including respiratory distress and anxiety. Each time, there was no documentation of the bed hold policy being provided. Resident #68, whose family member was their responsible party, was transferred to the hospital for pain evaluation, and the facility failed to notify the resident's guardian of the bed hold policy in writing. Interviews with facility staff, including the Social Services Director and the Director of Nurses, revealed a lack of awareness and responsibility for sending bed hold notices, contributing to the deficiency.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) through the Payroll Based Journal (PBJ) for the period of April 1, 2024, through June 30, 2024. The CMS PBJ Staffing Data Report dated November 12, 2024, showed no staffing data reported for this period. During interviews, the Business Office Manager (BOM), who was new to the facility, stated she had difficulty signing into the system and missed the deadline for data submission. The Administrator indicated that it was the BOM's responsibility to submit the PBJ data, but due to turnover in the BOM role, there were difficulties in getting new staff signed into the CMS system. The facility also failed to provide a policy regarding PBJ upon request.
Failure to Provide Admission Agreement to Resident's Guardian
Penalty
Summary
The facility failed to provide an admission agreement to the guardian of a resident upon their admission. The review of the facility's admission packet revealed that it included various sections such as payment agreements, resident and facility responsibilities, and several attachments related to policies and consents. However, the facility was unable to locate an admission contract for the resident in question, and the guardian confirmed that they did not believe they had signed such an agreement. Interviews conducted with the resident's guardian and the facility's administrator highlighted the lack of a specific staff member assigned to explain and manage the admission agreements. The administrator acknowledged that he would have been responsible for the resident's admission contract, indicating a lapse in the facility's admission process. This deficiency was identified during a review of 20 sampled residents, with the facility census being 87.
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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