Beth Haven Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Hannibal, Missouri.
- Location
- 2500 Pleasant Street, Hannibal, Missouri 63401
- CMS Provider Number
- 265108
- Inspections on file
- 23
- Latest survey
- June 30, 2025
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Beth Haven Nursing Home during CMS and state inspections, most recent first.
A resident, who was cognitively intact and valued making choices about food and drink, was verbally abused by an LPN after requesting coffee. The LPN refused the request, then confronted the resident in another wing, loudly yelling and pointing a finger in the resident's face in a demeaning manner. Multiple staff witnessed the incident and described the LPN's actions as verbal abuse, noting the resident's surprise and confusion.
A resident with multiple sclerosis experienced ongoing pain and discomfort due to the use of a manual wheelchair that was too small, which the resident had purchased independently. Despite reporting the issue to the DON and Social Services Director, and the facility's policy requiring accommodation of adaptive device needs, no timely occupational therapy evaluation or suitable replacement wheelchair was provided. Attempts to alleviate discomfort with a cushion were unsuccessful, and the resident continued to lack a properly fitting wheelchair.
The facility did not ensure proper coordination and communication with an external therapy provider, resulting in two residents not receiving agreed-upon therapy goals, implementation of at-home therapy programs, or necessary assistance with toileting and basic needs during therapy sessions.
The facility was cited for multiple deficiencies in food safety and sanitation practices. Observations revealed improper food storage, preparation, and service, with staff failing to follow hygiene protocols. The kitchen and dining areas had significant accumulations of debris and grease, and the facility's ice machine drains lacked necessary air gaps. Staff engaged in unsanitary practices, and cleaning schedules were not consistently followed.
The facility did not submit complete and accurate direct care staffing information to CMS through the PBJ for a specified period. The Administrator confirmed that the facility had not been submitting PBJ data, as the previous payroll clerk responsible had left, and the payroll service was expected to manage submissions.
The facility failed to ensure proper hand hygiene and infection control during resident care and medication administration, with staff not washing hands or changing gloves appropriately. Insulin administration procedures were not followed, as staff did not clean insulin pen tips before use. Additionally, the facility did not comply with TB testing requirements for employees, lacking documentation of two-step TSTs and annual testing. The facility also lacked a water management team and procedures to address Legionella risks.
The facility failed to provide residents with reasonable access to their personal funds on weekends. A resident reported being unable to access their funds during this time. The business office, which managed funds for 43 residents, was only open on weekdays, requiring residents to request funds in advance for weekend access. The facility did not provide a policy on the Resident Trust Fund, and the administrator was unaware of the requirement for access during typical banking hours.
The facility did not maintain a sufficient surety bond to protect the personal funds of 43 residents, with the bond amount being $25,000 instead of the required $39,000. Staff, including the Administrator, were unsure of who was responsible for managing the resident trust fund and ensuring the bond's adequacy.
The facility failed to develop comprehensive care plans for four residents, omitting critical elements such as dialysis care and the use of assistive devices like bed rails and mobility bars. Despite observations confirming the presence of these elements, the care plans did not reflect them, indicating a failure to adhere to the facility's policy.
The facility failed to follow professional standards, resulting in deficiencies for several residents. A resident did not receive ordered lab work, and there was missing documentation for wound care and blood glucose checks. Two residents had undocumented medication administrations, and another was not observed taking medications despite severe cognitive impairment. The DON was unaware of the extent of these documentation issues.
The facility failed to provide necessary incontinence and oral care for several residents. A resident with severe cognitive impairment did not receive proper perineal care or oral hygiene assistance. Another resident with similar needs was not cleaned properly and did not receive oral care due to staff constraints. A cognitively intact resident did not receive complete perineal care or oral hygiene, and another resident requiring substantial assistance was not cleaned adequately. Staff interviews confirmed the care expectations, which were not met.
The facility failed to ensure consistent documentation of code status for three residents, leading to discrepancies between residents' wishes and medical records. A resident's desire to be DNR was not reflected in their POS and EMR, while another resident's DNR status was not documented in their care plan or POS. A third resident's DNR status was indicated by a sticker and binder but not in their POS or face sheet. Staff relied on various sources for code status, contributing to inconsistencies.
The facility failed to secure harmful chemicals, leaving them accessible to residents. Observations revealed unsecured hazardous items, including cleaning sprays and chemicals, in various areas, such as the Gardens SCU and dining rooms. The administrator acknowledged that these items should be locked away.
The facility failed to serve meals according to the diet spreadsheet menu, resulting in residents not receiving the appropriate dietary items. Staff were unaware of specific dietary needs and did not have access to the diet spreadsheet menu, leading to the omission of required food items such as dinner rolls and pureed desserts.
The facility failed to serve food at safe and appetizing temperatures for residents on mechanical soft and pureed diets. Observations showed that food items were served at temperatures below the expected 135°F for hot foods and above 40°F for cold foods. The Dietary Manager confirmed the temperature expectations, but the facility did not meet these standards.
The facility failed to ensure outdoor garbage and grease containers were covered when not in use. A dumpster was found without a lid, and a grease container had its lid hanging off, with residue visible on the surrounding grass. The Dietary Manager and Administrator were unaware of these issues, and no staff were present in the area during the observation.
The facility failed to inspect bed frames, mattresses, and bed rails for potential entrapment risks for three residents. One resident with impaired cognition and two others with mobility issues were observed with bed rails or mobility bars, but no inspections were documented. The maintenance department was responsible for these inspections, which were expected to be done quarterly, but were not conducted.
The facility failed to maintain a pest-free environment in its kitchen and food storage areas. Observations showed open windows without screens, propped open doors, and uncovered dumpsters and grease containers, allowing potential pest entry. Mouse droppings and dead insects were found in various locations, indicating inadequate pest control measures. Interviews revealed a lack of awareness and reliance on glue traps, with a history of mouse issues.
A resident with multiple sclerosis experienced pain due to an ill-fitting wheelchair, which the facility failed to replace for six months. Additionally, another resident's call lights were repeatedly found out of reach, hindering their ability to request assistance. Staff interviews confirmed that call lights should always be accessible, and the Director of Nursing acknowledged the facility's responsibility to provide proper equipment and accessibility.
The facility failed to protect resident property, resulting in missing and damaged clothing items for three residents. Despite reporting the issues to staff, the facility did not locate or replace the items. Observations confirmed bleach stains and missing clothing, and the facility's policy on handling resident belongings was not effectively followed.
A resident with severe cognitive impairment was placed in a power recliner chair that functioned as an unintentional restraint, as they were unable to operate the chair's remote control to lower their feet. Staff confirmed the resident's inability to get up without assistance when the footrest was elevated, and there was no documented medical need or practitioner order for the restraint, violating the facility's policy.
The facility did not perform required Nurse Aide Registry checks for two newly hired employees, a Receptionist and a CMT, as documented in their files. The Human Resources staff was unaware of this requirement, and the administrator confirmed it was their responsibility to complete these checks.
The facility failed to ensure proper reconciliation of Schedule II through IV controlled substances, as evidenced by missing signatures on narcotic count sheets for several shifts. The review revealed multiple instances where either the on-coming or off-going nurse, or both, did not sign the narcotic count sheet, indicating that the shift-to-shift narcotic count was not completed by two qualified staff members. Interviews confirmed that without signatures, there was no way to confirm if the narcotic counts were conducted.
The facility failed to administer insulin correctly for two residents, leading to significant medication errors. An LPN and a CMT did not prime insulin pens before administration, and the CMT did not hold the pen against the resident's skin for the required time. Both residents had diabetes and were prescribed specific insulin doses. The DON confirmed the correct procedure was not followed.
The facility failed to ensure discontinued medications for a resident and medications for two discharged residents were destroyed or returned to the pharmacy timely. A Lantus insulin pen remained in the medication cart long after discontinuation, and a Prevnar20 vaccine and other medications were found in storage after residents were discharged. Staff were unaware of why these medications were not handled appropriately, and the DON confirmed the responsibility of nursing staff to manage such medications promptly.
The facility did not post daily staffing information for four days, as required by its policy. Observations showed no staffing sheets in visible areas, with information only found in a binder in the locked SCU. Interviews with staff confirmed the lack of compliance, with the Director of Nursing and Administrator acknowledging the requirement to post staffing details outside the Social Services door.
The facility did not ensure that the most recent survey results were accessible to residents and visitors. The survey results were placed in a location that was not easily visible, especially for residents in wheelchairs, and the signage was positioned too high. Residents and a family member were unaware of where to find the survey results, and the resident council confirmed the lack of awareness. The Administrator admitted the need for better signage and accessibility.
A resident with severe cognitive impairment and fragile skin was improperly transferred using a gait belt instead of a mechanical lift, as required by their care plan. Two CNAs, unaware of the resident's transfer needs, used a gait belt, resulting in the resident's feet dragging on the floor. The DON confirmed the resident should have been transferred with a mechanical lift, and the bruises observed on the resident's arms were likely due to the improper transfer.
The facility failed to investigate allegations of abuse and misappropriation involving three residents. A resident reported being slapped by a staff member, but the DON did not pursue further investigation. Two residents reported issues with pain medication administration, with discrepancies in documentation by an LPN. The facility's investigation lacked written statements, and results were not reported to the state agency in time.
The facility failed to maintain effective pest control, leading to mice and roaches in the east dining room and kitchen. A resident was observed eating in a dining room with a roach-infested refrigerator. Mouse droppings and debris were found in the kitchen's dry storage room. Staff were unaware of the pest issues, and the Administrator noted previous measures to store food in bins had lapsed.
An LPN in a facility misappropriated narcotics from two residents, one of whom was alert and denied receiving the medication, while the other experienced severe pain due to a missed dose. The LPN, on probation for a similar past incident, failed to follow protocols requiring a second staff member to sign out PRN narcotics.
The facility failed to document the administration of controlled medications properly, leading to discrepancies in medication records for multiple residents. Medications were removed from the Nexus machine without proper documentation of administration or destruction, and some were removed without a physician's order. Staff interviews revealed that medications were sometimes left in carts, contrary to policy.
A resident with severe cognitive impairment and fragile skin was improperly transferred by staff using a gait belt and lifting under the arms, contrary to facility policy. This resulted in multiple bruises and skin tears. The resident's care plan required protective measures and mechanical lift use, but staff failed to adhere to these guidelines, as confirmed by interviews with CNAs and facility leadership.
A resident with arthritis and Alzheimer's was not provided with necessary adaptive eating equipment, such as a divided plate and curved utensils, despite being identified as needing them. Observations showed the resident struggled to eat without these aids, and staff interviews confirmed the oversight. The facility's dietary staff did not consistently follow dietary cards, leading to the deficiency.
Verbal Abuse of Resident by LPN Over Coffee Request
Penalty
Summary
A resident with diagnoses including nonrheumatic aortic valve stenosis, muscle weakness, and a history of falls, who was cognitively intact and able to make their needs known, requested a cup of coffee from an LPN. The LPN refused to provide the coffee, stating they would not make a cup just for the resident. The resident then went to another wing to seek assistance from other staff, expressing that it was important for them to make choices regarding food and drink. Upon learning that the resident had received coffee from another nurse, the LPN pursued the resident to the other wing, loudly and angrily confronting the resident in front of staff and other residents. Multiple witnesses reported that the LPN pointed their finger in the resident's face, yelled that the resident could not have coffee, and insisted that the resident was to listen to the LPN's instructions. The resident appeared surprised and expressed confusion about what they had done wrong. Staff present described the LPN's behavior as verbally abusive, noting the volume, tone, and physical proximity during the confrontation. Facility staff, including CNAs and a GPN, corroborated the account of the LPN's loud and demeaning behavior, with statements indicating that the LPN's actions were considered verbal abuse. The incident was reported to the Director of Nursing, who initiated an investigation. The facility's policy on abuse and neglect emphasized residents' rights to be free from abuse, including verbal abuse, but did not provide a specific definition of verbal abuse. The events described constituted a failure to protect the resident from verbal abuse by staff.
Failure to Provide Properly Fitting Wheelchair for Resident with MS
Penalty
Summary
The facility failed to ensure that a resident with multiple sclerosis had a properly fitting wheelchair that did not cause pain or discomfort. The resident, who was cognitively intact and dependent on staff for transfers, used a manual wheelchair that was too small and caused significant discomfort, particularly due to the resident's condition which resulted in one hip being higher than the other. The resident had purchased the wheelchair independently upon admission, without adequate guidance, and later reported that the chair was too short and painful to use. Despite the resident's complaints and the facility's policy requiring ongoing evaluation and accommodation of adaptive device needs, there was no documentation of an alternative plan or timely evaluation for a new wheelchair. The resident's care plan emphasized the need for physical comfort and maintenance of function within the limits of progressive MS, but the facility did not arrange for an occupational therapy evaluation or provide a suitable replacement wheelchair. Attempts to address the discomfort by providing a cushion were unsuccessful, as the cushion exacerbated the problem due to the chair's improper size. Interviews with facility staff, including the DON and Social Services Director, confirmed awareness of the resident's discomfort and the facility's responsibility to provide appropriate equipment. However, the Social Services Director had not successfully scheduled an occupational therapy evaluation, and the resident continued to lack a properly fitting wheelchair. The deficiency remained uncorrected from a previous survey, with no evidence of effective action taken to resolve the resident's ongoing discomfort.
Failure to Coordinate and Communicate with Therapy Provider
Penalty
Summary
The facility failed to ensure that residents received physical, occupational, and speech therapy services through a properly coordinated arrangement between the facility and the external therapy provider. This deficiency was identified through interviews and record reviews, which revealed a lack of communication and coordination between the facility and the therapy provider. As a result, there was no agreement on therapy goals, and the facility did not ensure that residents' at-home therapy programs were implemented while in the facility. Additionally, residents did not receive necessary assistance with toileting and basic needs during therapy sessions. These failures affected two residents who were receiving outpatient therapy services at the time, in a facility with a census of 65.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility was found to have multiple deficiencies in food storage, preparation, and service, failing to adhere to professional standards for food safety. Observations revealed that food items were not securely sealed, labeled, or stored according to manufacturer's instructions, and raw meats were improperly thawed. Additionally, staff did not practice proper hand hygiene, glove usage, or hair restraint, and personal food and beverages were consumed in food preparation areas. Surfaces and equipment were not maintained free from grease and debris, and proper sanitization procedures were not demonstrated, with staff unsure of chemical sanitizer levels. Further observations highlighted unsanitary conditions in the storage and handling of dishes and utensils. The facility's ice machine drains lacked an air gap, posing a risk of backflow contamination. The kitchen and dining areas were found to have significant accumulations of food debris, grease, and trash, with equipment and surfaces not properly cleaned or maintained. The dietary manager acknowledged these issues, noting that cleaning schedules were not consistently followed, and external companies were relied upon for certain cleaning tasks. Staff were observed engaging in unsanitary practices, such as failing to wash hands after handling dirty items, touching personal items, and not using proper hair restraints. The dietary manager confirmed that staff should not eat or drink in food preparation areas and should follow proper handwashing protocols. The facility's maintenance supervisor and administrator were unaware of the lack of air gaps in the ice machine drains, which are necessary to prevent potential contamination.
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 from July 1, 2024, to September 30, 2024. This deficiency was identified during a review of the CMS PBJ Staffing Data Report dated January 28, 2025, which showed that the facility did not report staffing data for the specified period. During an interview on February 5, 2025, the Administrator acknowledged that the facility had not been submitting their PBJ information. The responsibility for submission was previously held by a payroll clerk who had since left employment, and the facility's payroll service was supposed to handle the PBJ submissions once their contract began.
Infection Control and TB Testing Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene and infection control practices among staff during resident care and medication administration. Observations revealed that staff did not wash their hands or change gloves appropriately after direct contact with residents, particularly during personal care activities such as toileting and dressing. For instance, a CNA was observed assisting a resident with incontinence care without washing hands or changing gloves between tasks, and another CNA failed to perform hand hygiene after removing gloves. These lapses in hand hygiene were confirmed by staff interviews, where CNAs acknowledged the need for handwashing but admitted to not following the protocol. Additionally, the facility did not adhere to proper procedures for insulin administration. Staff were observed failing to clean the tips of insulin pens with alcohol before attaching needle caps and administering insulin to residents. This was a repeated issue among different staff members, who either forgot or were unaware of the requirement to disinfect the insulin pen tips. Interviews with the staff involved confirmed these oversights, and the DON expressed expectations for proper disinfection and glove use during insulin administration. The facility also failed to comply with tuberculosis (TB) testing requirements for employees. Several employee files lacked documentation of a two-step Tuberculin Skin Test (TST) prior to employment, and annual TB testing was either not completed or not documented correctly in millimeters of induration. The administrator acknowledged the oversight, attributing it to recent staff turnover in the Infection Preventionist position, which led to lapses in tracking and administering TB tests. Furthermore, the facility did not have an active water management team or a detailed water flow map to address Legionella risks, and the Maintenance Director was unaware of the necessary procedures to prevent waterborne pathogens.
Lack of Weekend Access to Resident Funds
Penalty
Summary
The facility failed to ensure residents had reasonable access to their personal funds, particularly on weekends. This deficiency was identified during an interview with a resident who reported being unable to access their funds on weekends. The facility managed funds for 43 residents, and the business office, responsible for handling these funds, was only open Monday through Friday from 8:00 A.M. to 4:00 P.M., with no banking hours on Saturdays. Residents were required to request funds in advance if they needed access on weekends. The facility did not provide a policy regarding the Resident Trust Fund when requested, and the administrator was unaware that residents should have access to their funds during typical banking hours.
Inadequate Surety Bond for Resident Funds
Penalty
Summary
The facility failed to maintain a sufficient surety bond to protect the personal funds of 43 residents held in the resident trust fund account. The facility's surety bond was $25,000, while the average monthly balance of the residents' personal funds required a bond of at least $39,000. The facility census was 71. During interviews, staff members, including the Admissions/Social Services staff, Accounts Receivable staff, and the Administrator, were unsure of who was responsible for managing the resident trust fund and ensuring the adequacy of the surety bond. The Administrator admitted to not reviewing the bond to confirm its adequacy.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for four residents, as required by their policy. Resident #47, who had been on dialysis for about three years, did not have any focus, goal, or intervention for dialysis care in their care plan, despite having a physician's order for follow-up with a nephrologist during dialysis days. This oversight was confirmed during an interview with the resident, who stated they attended dialysis treatment three times weekly. Resident #68, who had severely impaired cognition and was dependent on staff for mobility, had a care plan that did not address the use of side rails, despite observations showing the resident in bed with bilateral 1/4 rails in the upright position. Similarly, Residents #14 and #10, both of whom had mobility issues and were at risk for falls, had care plans that failed to address the use of bed mobility bars, even though observations confirmed the presence of these bars on their beds. Interviews with the Care Plan/MDS Coordinator, the DON, and the Administrator revealed that care plans should reflect the care needs of residents, including the use of assistive devices like bed rails and mobility bars, as well as specific treatments like dialysis. The lack of documentation for these elements in the care plans indicates a failure to adhere to the facility's policy of developing and implementing comprehensive, person-centered care plans.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to adhere to professional standards of practice for several residents, resulting in multiple deficiencies. For Resident #55, the facility did not obtain necessary lab work, including Hemoglobin A1c, CBC, and CMP, as ordered by the physician. Additionally, there was a lack of documentation for wound care treatments and blood glucose checks on several occasions. The Care Plan/MDS coordinator acknowledged the oversight in tracking lab orders and had only recently begun addressing this issue. Resident #46 experienced similar issues with missing documentation for medication administration and wound care treatments. The MARs for December 2024 and January 2025 showed multiple instances where doses of clonazepam and Tylenol were not documented as administered. The resident's care plan indicated the need for these medications to manage anxiety and pain, yet the facility failed to ensure consistent documentation and administration. Resident #19 also faced deficiencies in medication administration, with missing documentation for lorazepam doses in both December 2024 and January 2025. Furthermore, Resident #65, who had severe cognitive impairment, was not observed taking medications during a medication pass, contrary to facility policy. The Director of Nursing expressed expectations for staff to follow physician orders, complete treatments, and document all actions, but was unaware of the extent of missing documentation in the MARs and TARs.
Deficiency in Incontinence and Oral Care
Penalty
Summary
The facility failed to provide necessary care and services for incontinence and oral care for several residents. Resident #43, who had severe cognitive impairment and was dependent on staff for toileting and personal hygiene, was observed not receiving proper perineal care. The CNA assisting the resident did not clean the resident's front genital area and failed to offer or assist with oral care, despite the resident's care plan indicating the need for such assistance. Resident #46, also with severe cognitive impairment and dependent on staff for personal hygiene, was observed with a saturated incontinence brief. The CNA and LPN assisting the resident did not clean the resident's front genitalia and did not provide oral care. The CNA admitted to not providing oral care due to working alone and trying to get residents to breakfast. Resident #5, who was cognitively intact but dependent on staff for toileting, was observed not receiving complete perineal care. The CNA did not cleanse all areas of the resident's skin in contact with urine and did not offer or perform oral care. Additionally, Resident #175, who required substantial assistance with toileting, did not receive proper perineal care as the CNA did not clean the resident's front perineal area. Interviews with staff confirmed the expectations for perineal and oral care, which were not met in these instances.
Inconsistent Documentation of Code Status for Residents
Penalty
Summary
The facility failed to ensure that the medical records accurately and consistently indicated the residents' code status for three residents out of a sample of 18. This deficiency was identified through observation, interviews, and record reviews. For Resident #7, there was a discrepancy between the resident's wishes and the documented code status. The resident was cognitively intact and expressed a desire to be a Do Not Resuscitate (DNR), but the Physician Order Sheet (POS) and Electronic Medical Record (EMR) indicated a Full Code status. The resident's care plan and the code status binder, however, showed a DNR status, highlighting inconsistencies in documentation. Resident #31's records also showed inconsistencies. The face sheet and POS did not document any code status, while a purple heart sticker on the resident's name plate indicated a DNR status. The resident and their Power of Attorney confirmed the resident's wish to be a DNR, but this was not reflected in the care plan or POS. This lack of documentation could lead to confusion in an emergency situation. For Resident #46, the annual Minimum Data Set (MDS) indicated severe cognitive impairment, and the resident's Durable Power of Attorney (DPOA) was responsible for decisions. The POS and face sheet lacked documentation of the resident's code status, although a purple heart sticker and the code status binder indicated a DNR. The care plan confirmed the DNR status, but the EMR did not reflect this. Interviews with staff revealed a reliance on various sources for code status information, including name plates, binders, and EMRs, which contributed to the discrepancies observed.
Failure to Secure Harmful Chemicals in Facility
Penalty
Summary
The facility failed to ensure that harmful chemicals were kept in locked cabinets and were not accessible to residents. During an observation of the dietary and sanitation areas, several hazardous items were found unsecured in various locations within the facility. In the Gardens Special Care Unit, which caters to residents with dementia, an unlabeled cup with a pink paste, another with a blue liquid, and three cans of heavy-duty cleaning spray were found in an unlocked cabinet. Additionally, a gallon jug of concentrated descaler and delimer was found on an open shelf, and its label warned of severe skin burns and eye damage. In the west dining room, a can of disinfectant and sanitizing spray was found in an unlocked cabinet, and in the west kitchenette, a can of stainless steel cleaner and polish was similarly unsecured. Lastly, a can of furniture polish spray was found in an unlocked cabinet in the Helping Hands dining room. The facility's administrator acknowledged that cleaning supplies and chemicals should be secured and inaccessible to residents.
Failure to Follow Diet Spreadsheet Menu
Penalty
Summary
The facility failed to meet the nutritional needs of its residents by not adhering to the diet spreadsheet menu during meal preparation and service. On the specified date, the facility was observed to have not served dinner rolls, soft dinner rolls, pureed dinner rolls, or pureed frosted chocolate cake to residents on regular, mechanical soft, and pureed diets, despite these items being listed on the diet spreadsheet menu. The dietary staff, including [NAME] L and [NAME] Z, prepared and placed food items onto trays but did not include the required items for the residents' specific diet orders. Interviews with staff revealed a lack of awareness and communication regarding the specific dietary needs of residents. [NAME] Z was under the impression that the pureed dessert was on a different cart, while Direct Service Aide J admitted to not knowing what items each resident should receive and not having access to a diet spreadsheet menu. The Dietary Manager confirmed that staff were expected to follow the physician-ordered diet orders and the diet spreadsheet menus, which was not done in this instance.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food items at a safe and appetizing temperature and taste for residents on mechanical soft and pureed diets. The facility's recipe binders lacked recipes and associated temperature guidelines for specific food items such as mechanical soft or pureed potato salad, spinach, and pork loin. On the day of the survey, the facility substituted pork loin for pork schnitzel and German potato salad for regular potato salad without ensuring proper temperature guidelines were followed. Temperature logs showed that while cooking temperatures were adequate, the temperatures of the food items served to residents were not maintained at safe levels. Observations in the dining room revealed that the mechanical soft and pureed food items were served at temperatures below the expected 135 degrees Fahrenheit for hot foods and above 40 degrees Fahrenheit for cold foods. For instance, mechanical soft potato salad was served at 61.2 degrees Fahrenheit and tasted warm, while pureed spinach was served at 108.7 degrees Fahrenheit and tasted cool. Interviews with residents and the Dietary Manager confirmed that the expectation was for hot foods to be served at a minimum of 135 degrees Fahrenheit and cold foods at less than 40 degrees Fahrenheit. However, the facility failed to meet these standards, resulting in food being served at inappropriate temperatures.
Improper Disposal of Garbage and Grease
Penalty
Summary
The facility failed to ensure that outdoor garbage and grease collection containers were properly covered when not in use. During an observation, a dumpster was found to be approximately 25% full of trash without a lid on the top and front. Additionally, a grease container, about 90% full, had its lid hanging off to the side, with a water bottle floating on the grease surface. Residue was visible on the grass around the grease container. No staff were present in the area at the time of observation. Interviews revealed that the Dietary Manager was unaware of the grease container's lid issue and mentioned that the dumpster never had lids. The Administrator was also unaware that the new dumpster, received after changing garbage disposal companies, lacked the ability to close its openings. The grease container was periodically emptied by a contracted company.
Failure to Inspect Bed Safety Features for Entrapment Risks
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails to identify potential entrapment hazards for three residents. Resident #68, who had severely impaired cognition and was dependent on staff for mobility, was observed with bed rails in the raised position, yet there was no documentation of inspections for entrapment risks. Similarly, Resident #14, who was cognitively intact but required substantial assistance with mobility and had a history of falls, was observed with mobility bars on the bed without any record of inspection for potential entrapment. Resident #10, also cognitively intact but dependent on staff for bed mobility and at risk for falls, was observed with mobility bars on the bed, again with no evidence of inspection for entrapment risks. Interviews with the Maintenance Director and the Director of Nursing revealed that the maintenance department was responsible for measuring entrapment zones, but these measurements were not being conducted. The Administrator expected these measurements to be completed quarterly, indicating a lapse in the facility's maintenance program.
Pest Control Deficiency in Facility's Food Areas
Penalty
Summary
The facility failed to maintain an environment that deters pests from entering critical areas such as the kitchen, satellite dining rooms, kitchenettes, and food storage areas. Observations revealed that windows in the kitchen were open without screens, and an exterior door near the dumpster and grease collection container was propped open, allowing potential pest entry. The dumpster was partially full and uncovered, and the grease container was nearly full with its lid hanging off. Additionally, the door to the emergency food/water storage and dietary walk-in cooler and freezer room was propped open, further compromising the facility's pest control measures. Mouse droppings were found in various locations, including a laundry basket near bulk bins of rice and oats, around boxes of fry oil, and on the floor and shelves in the dry storage room. Dead insects resembling cockroaches were also found in the kitchenette near the east dining room. Interviews with the Dietary Manager and Administrator revealed a lack of awareness and inadequate pest control measures, such as missing dumpster lids and reliance on glue traps provided by the pest control company. The facility had a history of mouse issues, and maintenance staff had not yet replaced damaged windows or installed screens.
Deficiencies in Wheelchair Fit and Call Light Accessibility
Penalty
Summary
The facility failed to provide a properly fitting wheelchair for a resident with multiple sclerosis, leading to discomfort and pain. The resident, who was tall and used a manual wheelchair, was observed sitting awkwardly in a chair that was too small, causing pain in the right hip. Despite being aware of the issue, the Care Plan/MDS Coordinator acknowledged that the process to obtain a suitable wheelchair had been ongoing for six months without resolution. The facility lacked a specific staff member responsible for acquiring necessary equipment, and the absence of a therapy department further complicated the situation. Another deficiency was identified when a resident's call lights were consistently found out of reach, compromising the resident's ability to request assistance. The resident, who had moderately impaired cognition and required assistance with mobility, was observed multiple times with call lights either wrapped around a wall outlet or lying on the floor, making them inaccessible. Interviews with staff, including an LPN and a CNA, confirmed that call lights should always be within reach of residents. The Director of Nursing acknowledged the facility's responsibility to ensure residents have proper equipment and that call lights are accessible. However, the lack of a designated staff member to manage equipment needs and the absence of a therapy department contributed to the ongoing issues with the resident's wheelchair and the inaccessibility of call lights.
Failure to Protect Resident Property in Laundry Services
Penalty
Summary
The facility failed to ensure the protection of resident property, specifically clothing items sent to the laundry, resulting in missing and damaged items for three residents. Resident #4 reported missing ten pairs of gray socks and a cover-up, which were labeled with their name, and received items back with bleach stains. Resident #59 was missing several pairs of jogger pants, also labeled, and had no clean pants available, affecting their willingness to shower. Resident #67 reported missing three gray t-shirts, labeled with their name, which had been missing for several months. Interviews with the residents revealed that they had reported the missing items to CNAs and laundry staff, but the facility had not located or replaced the missing items. Observations confirmed the presence of bleach stains on Resident #4's clothing and the absence of pants for Resident #59. The laundry aide and housekeeping supervisor were unaware of the missing items and bleach stains, and the facility's process for handling missing items was not effectively communicated or executed. The facility's policy required staff to treat residents' belongings with respect and inventory them upon admission. However, the policy was not adequately followed, as evidenced by the lack of updated inventory lists and the failure to address residents' concerns about missing and damaged clothing. The Director of Nurses and Administrator acknowledged the expectation for residents to receive all their laundered items back and for the facility to replace any lost or damaged items, but these expectations were not met in practice.
Failure to Evaluate Recliner as Restraint for Resident
Penalty
Summary
The facility failed to evaluate the use of a power recliner chair as a restraint for a resident who was mentally and physically incapable of using the chair's remote control. The resident, who was severely cognitively impaired and had a history of traumatic brain injury, was observed in a reclined position with feet elevated, unable to lower them independently. The facility's policy on restraints requires that any device restricting a resident's movement be evaluated and documented, which was not done in this case. Observations showed the resident becoming restless and attempting to get up from the recliner with the footrest raised, indicating distress and an inability to move freely. Interviews with staff, including CNAs and the Director of Nursing, confirmed that the resident could not operate the recliner control due to cognitive and physical limitations. The staff acknowledged that the recliner functioned as an unintentional restraint, as the resident could not get up without assistance when the footrest was elevated. The facility's policy clearly states that restraints should only be used for medical symptoms and not for staff convenience or fall prevention. However, there was no documentation of a medical need for the restraint, nor was there an order from a practitioner. The lack of assessment and documentation regarding the recliner's restraining properties led to the deficiency, as the resident was effectively restrained without proper evaluation or justification.
Failure to Conduct Nurse Aide Registry Checks for New Hires
Penalty
Summary
The facility failed to conduct necessary checks against the Nurse Aide Registry for two newly hired employees, which is a requirement to ensure that individuals with a Federal Indicator are not employed. The first case involved a Receptionist hired on 04/10/24, whose employee file lacked documentation of a completed Nurse Aide Registry check. Similarly, a Certified Medication Technician (CMT) hired on 01/26/24 also had no documentation of such a check in their file. During interviews, the Human Resources staff admitted to being unaware of the requirement to perform Nurse Aide Registry checks, while the administrator acknowledged the necessity of these checks and indicated that it was the responsibility of Human Resources to ensure they were completed.
Failure to Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure proper reconciliation of Schedule II through IV controlled substances, as evidenced by missing signatures on the narcotic count sheets for several shifts. The review of the narcotic count sheets for the [NAME] Unit, Team 1, revealed multiple instances where either the on-coming or off-going nurse, or both, did not sign the narcotic count sheet, indicating that the shift-to-shift narcotic count was not completed by two qualified staff members. This lack of documentation was confirmed by interviews with the LPN and the Director of Nursing, who both acknowledged that without signatures, there was no way to confirm if the narcotic counts were conducted. The facility also did not provide a policy regarding Controlled Substances or Narcotic Reconciliation when requested. During interviews, the Director of Nursing and the administrator both stated that two qualified staff members should conduct the narcotic counts together at each shift change and immediately sign the count sheet to document the completion of the count. The failure to adhere to these procedures resulted in a lack of accountability for the narcotic medications, which included Morphine sulfate, Hydrocodone, Alprazolam, Clonazepam, and Ativan.
Failure to Administer Insulin Correctly for Two Residents
Penalty
Summary
The facility failed to administer insulin according to the manufacturer's recommendations for two residents, leading to significant medication errors. Resident #22, who had a diagnosis of diabetes, was prescribed Humalog 75/25 Insulin, 40 units subcutaneously in the evening. During an observation, an LPN administered the insulin without priming the pen, which is a necessary step to ensure the correct dose is delivered. The LPN admitted to forgetting to prime the pen before administering the insulin. Similarly, Resident #20, also diagnosed with diabetes, was prescribed Lispro insulin, seven units three times daily. A CMT administered 40 units of insulin without priming the pen and did not hold the pen against the resident's skin for the required five seconds as per the manufacturer's instructions. The CMT was unaware of the need to prime the pen or the specific duration to hold the pen against the skin. The Director of Nursing confirmed that insulin pens should be primed with two units before preparing the ordered dose and held against the skin for five seconds during administration.
Failure to Timely Destroy or Return Discontinued and Discharged Residents' Medications
Penalty
Summary
The facility failed to ensure that discontinued medications for one resident and medications for two discharged residents were destroyed or returned to the pharmacy in a timely manner. For Resident #52, a Lantus insulin pen was found in the medication cart 153 days after the medication order was discontinued. The Certified Medication Technician (CMT) acknowledged that the insulin pen should have been removed and destroyed as soon as the order was discontinued, as the resident was no longer using insulin pens due to having an insulin pump. For Resident #301, a vial of Prevnar20 vaccine was found in the medication storage room refrigerator after the resident had been discharged. The CMT and Licensed Practical Nurse (LPN) interviewed were unaware of why the medication had not been returned to the pharmacy. Similarly, for Resident #300, medications including Ipratropium Bromide/Albuterol Sulfate nebulizer treatment and Miralax were found in the medication storage room after the resident had been discharged. The CMT did not know why these medications had not been sent home with the resident or returned to the pharmacy. The Director of Nursing (DON) confirmed that nursing staff was responsible for destroying or returning medications that were no longer in use immediately after the occurrence.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to post daily staffing information for four consecutive days during the survey period, despite having a policy in place that requires such postings. The policy, last revised in August 2022, mandates that within two hours of the beginning of each shift, the number of licensed and unlicensed nursing personnel responsible for resident care must be posted in a prominent location accessible to residents and visitors. This information should include the facility name, current date, resident census, shift schedule, and the total number of nursing staff working each shift. Observations during the survey revealed that no daily staffing sheets were posted in visible areas such as the vestibule, front hall, common areas, nursing stations, or outside office doors. Instead, a binder containing staffing information was found on a desk in the locked special care unit (SCU), inaccessible to residents and visitors. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the lack of compliance with the posting requirement. The LPN indicated that the charge nurse in the SCU was responsible for filling out the staffing sheet and placing it in a binder, but did not believe it was posted elsewhere in the facility. The Director of Nursing and the Administrator both stated that the daily staffing information should be posted outside the Social Services door for residents and families to view. The Administrator also confirmed that SCU staff were responsible for completing and posting the staffing sheet. This failure to post staffing information as required by the facility's policy constitutes a deficiency in compliance with regulatory standards.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to make the most recent survey results easily accessible to residents and visitors, as required. Observations revealed that the survey results were placed in a location that was not easily visible or accessible, particularly for residents in wheelchairs. A sign indicating the location of the survey results was posted on a bulletin board at the front entrance, but it was positioned higher than eye level, making it difficult to read. Additionally, the filing cabinets containing the survey results were located behind the nurse's station, with no visible signage directing residents or visitors to them. Interviews with residents and a family member confirmed that they were unaware of where to find the survey results, and the resident council meeting further highlighted that residents were not informed about the location of these documents. The Administrator acknowledged that the signage should be at eye level and that the results should be accessible for private review.
Improper Transfer Technique Used for Non-Weight Bearing Resident
Penalty
Summary
The facility failed to provide a safe transfer for a resident who was supposed to be transferred using a mechanical lift, as per their care plan. Instead, two CNAs used a gait belt to transfer the resident from a recliner to a wheelchair, despite the resident being non-weight bearing. This action was contrary to the facility's policy, which mandates the use of a mechanical lift for residents who cannot bear weight. The CNAs involved were not aware of the requirement to use a mechanical lift for this resident, indicating a lack of communication or training regarding the resident's care plan. The resident in question had a care plan that specified the use of a mechanical lift for transfers to prevent skin injury, as the resident had fragile skin and was at risk for skin tears. The resident's cognitive function was severely impaired, and they were diagnosed with Alzheimer's disease and dementia, requiring assistance with personal care and mobility. During the observed transfer, the resident's feet dragged on the floor, and they did not bear weight, which was inconsistent with the care plan and facility policies. Interviews with the staff revealed that there was a misunderstanding or lack of awareness about the resident's transfer requirements. One CNA mentioned that they were trained to use a gait belt and hook their arms under the resident's arms, which was not appropriate for this resident. The Director of Nursing confirmed that the resident should have been transferred with a mechanical lift and acknowledged that the bruises observed on the resident's arms were likely related to the improper transfer technique used by the staff.
Failure to Investigate Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to conduct a thorough investigation following allegations of abuse and misappropriation of narcotics involving three residents. Resident #2 reported being slapped on the hand by a staff member, which was corroborated by a Certified Nurse Assistant (CNA) who reported the incident to the Director of Nursing (DON). Despite the resident being cognitively intact and having a bruise on the hand, the DON did not pursue further investigation, as the resident later stated the bruise was self-inflicted. In another incident, Resident #1, who was also cognitively intact, reported not receiving a prescribed pain medication, which was documented as administered by an LPN. Similarly, Resident #3, with moderate cognitive impairment, reported severe pain and did not receive a scheduled dose of pain medication, although the narcotic count sheet indicated it was removed by the same LPN. The facility's investigation lacked written statements from staff or residents, indicating an incomplete investigation process. The DON admitted to not obtaining necessary documentation or conducting thorough interviews, citing inexperience with such investigations. The facility also failed to report the investigation results to the state agency within the required timeframe. The administrator acknowledged the expectation for a comprehensive investigation, including obtaining written statements, which was not fulfilled.
Pest Control Deficiency in Dining and Kitchen Areas
Penalty
Summary
The facility failed to maintain effective pest control measures, resulting in the presence of mice and roaches in critical areas such as the east dining room and the kitchen. Observations revealed that a resident was eating breakfast in the east dining room where a refrigerator contained eight to ten small insects resembling roaches. A Certified Nurse Assistant confirmed that the dining room had been treated for roaches the previous day, but was unaware of the infestation inside the refrigerator. Residents had also complained about the presence of roaches in the facility. Further observations in the kitchen's dry storage room revealed mouse droppings on the floor under a metal shelving unit, along with brown debris, loose dry pasta, and crackers. A bag of corn bread mix was found on the floor near the droppings. Interviews with dietary staff indicated a lack of awareness regarding the mouse droppings and the cleanliness of the storage area. The facility's pest control company and the Maintenance Director highlighted that food on the floor serves as a food source for pests, and the east dining room was supposed to be closed to residents due to recent roach treatment. The Administrator acknowledged previous issues with mice and the need for dry storage items to be stored in plastic bins, but was unsure why this practice had ceased.
Misappropriation of Narcotics by LPN
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their medications by an LPN. The LPN was found to have signed out narcotics for a resident who was alert and oriented, yet the resident denied receiving the medication. This incident was discovered when the resident, who was cognitively intact, reported not having requested or received the pain medication that was documented as administered by the LPN. The resident's medical records and narcotic count sheets confirmed the discrepancy, as there was no evidence of a pain complaint or request for medication on the day in question. Another resident, who had moderate cognitive impairment, was also affected by the LPN's actions. The LPN removed a narcotic from the count sheet but failed to document its administration on the Medication Administration Record (MAR). This resident later complained of severe pain, suggesting that the scheduled dose of pain medication was not administered. The LPN was on probation for a previous incident involving missing pain medication and was required to have another staff member sign out any PRN narcotics, a protocol that was not followed. The facility's Director of Nursing and other staff members, including a Certified Medication Technician and a House Supervisor, identified these discrepancies during their investigation. The LPN exhibited suspicious behavior, such as excessive sweating, and was sent home on the day of the incident. The LPN was subsequently terminated due to the misappropriation of narcotics and failure to adhere to established protocols, which had been previously addressed with a verbal warning.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to properly document the administration of controlled medications for several residents, leading to discrepancies in medication records. For Resident #13, there were multiple instances where hydrocodone/acetaminophen and lorazepam were removed from the Nexus machine, but the administration was not documented on the Medication Administration Record (MAR). Additionally, there were occasions where medications were signed out by one staff member but administered by another, without proper documentation of the administration or destruction of the medication. Resident #15's records showed similar issues, with Ativan being removed from the Nexus machine but not documented as administered on the MAR. There were also instances where more medication was removed than documented as administered, and some doses were not accounted for in terms of administration or destruction. This pattern of inadequate documentation and medication handling was also observed with Resident #11, where tramadol was removed but not documented as administered. Furthermore, Resident #16 had tramadol removed from the Nexus machine without a physician's order, and there was no documentation of its administration. Interviews with staff revealed that medications were sometimes removed early and left in medication carts, which is against the facility's policy. The Assistant Director of Nursing confirmed that medications should not be left in cups in the cart and must be double-locked if not administered immediately.
Inappropriate Transfer Techniques Lead to Resident Injuries
Penalty
Summary
The facility failed to provide safe transfers and prevent bruising and skin tears for a resident identified as at risk for such injuries. The resident, who had severe cognitive impairment and was dependent on staff for mobility and personal care, was observed being transferred by staff using inappropriate techniques. Staff lifted the resident under the arms with a gait belt, contrary to the facility's policy that manual lifting should be eliminated when feasible and that a mechanical lift should be used for total body lifts. This improper handling led to multiple bruises and skin tears on the resident's fragile skin. The resident's care plan indicated a high risk for skin integrity issues, requiring the use of protective measures such as tubigrip sleeves and sheep's wool padding. Despite these precautions, staff were observed pulling on the resident's arms while dressing and undressing, which contributed to the skin injuries. The resident's medical history included conditions such as arthritis, muscle weakness, and Alzheimer's disease, which necessitated careful handling to prevent further harm. Interviews with staff revealed a lack of adherence to the facility's safe lifting policy. CNAs admitted to lifting the resident under the arms and acknowledged that the resident did not bear weight during transfers, which should have been performed using a mechanical lift. The Assistant Director of Nursing and the Administrator confirmed that lifting under the arms with a gait belt was inappropriate and could cause injuries, yet this practice was observed during the survey.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment and utensils for Resident #9, who was identified as needing these items to assist with eating and drinking. The resident had diagnoses of arthritis, muscle weakness, Alzheimer's disease, and required assistance with personal care. The care plan specified the need for a divided plate, curved utensils, and Kennedy cups at all meals to facilitate eating and drinking. However, during observations, the resident was not provided with these adaptive devices, and the food was not served in the required consistency. During breakfast, the resident was served food on a regular plate with flat silverware, and no Kennedy cup was provided. The resident struggled to eat, using fingers to pick up food and attempting to drink milk with a spoon. The CNA supervising breakfast acknowledged the absence of adaptive utensils and was unaware of their location. At lunch, the resident was again served food without the necessary adaptive equipment, and a family member had to assist in cutting the food. Interviews with staff, including the Dietary Supervisor and the Assistant Director of Nursing, confirmed that adaptive equipment should have been provided according to the dietary cards. The Dietary Supervisor admitted that dietary staff were not consistently following the dietary cards, and the Assistant Director of Nursing emphasized the importance of providing assistive devices to prevent choking and facilitate eating. The Administrator also stated that staff should ensure dietary requirements are followed and adaptive equipment is provided as indicated.
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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