Brent B Tinnin Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Ellington, Missouri.
- Location
- 220 Euel Polk Drive, Ellington, Missouri 63638
- CMS Provider Number
- 265472
- Inspections on file
- 14
- Latest survey
- March 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Brent B Tinnin Manor during CMS and state inspections, most recent first.
The facility did not implement a QAPI Plan as required by their policy, which mandates a data-driven program to improve care outcomes and residents' quality of life. The Administrator, new to the role, confirmed that the program was not operational despite having the necessary policy and procedures in place.
The facility did not implement its QAA/QAPI program, failing to develop and document a plan of action to address quality deficiencies. The Administrator admitted the program was not operational, and the DON was unaware of PIPs documentation. This affected all 40 residents.
The facility did not conduct the required quarterly QAA/QAPI meetings with the necessary members. The policy outlined the need for a data-driven QAPI program, but it lacked details on required committee members. The Administrator, who began in January 2025, confirmed that the program was not yet operational, resulting in no committee meetings being held.
The facility failed to maintain a surety bond sufficient to cover residents' personal funds, as required by policy. The bond amount was $51,000, while the average monthly balance of residents' funds required a bond of at least $57,000. The Administrator noted that previous misappropriation of funds led to incorrect accounts, contributing to this deficiency.
The facility failed to document and obtain signatures for Medicare Non-Coverage Notices for three residents discharged from skilled services. The residents were not properly informed of potential non-coverage and financial liability, as required by facility policy.
The facility failed to conduct Criminal Background Checks (CBC) and Employee Disqualification List (EDL) checks prior to hiring four employees, contrary to their policies. Interviews confirmed that these checks should be completed before employment, but records showed they were either done late or not documented.
The facility failed to provide written notices of transfer or discharge to residents and/or their responsible parties, as required by policy. This deficiency was identified for five residents who were transferred to the hospital without documented notifications. The Administrator acknowledged the expectation for such notices to be given.
The facility failed to provide written information about the bed hold policy to residents or their representatives during hospital transfers. This issue affected six residents, with no documentation of the required notifications in their medical records, despite multiple hospital transfers.
A facility failed to complete a significant change MDS assessment within 14 days for a resident admitted to hospice services. Despite acknowledgment from the Administrator and MDS Coordinator that such assessments should be completed within 14 days of a significant change, the facility lacked a policy to ensure this was done, resulting in the deficiency.
A facility failed to provide a coordinated hospice care plan and necessary care for a resident, including turning, repositioning, and wound care. Another resident on valproic acid for epilepsy lacked monitoring of medication levels, with no recent lab results to ensure therapeutic levels. Facility policies on hospice care and lab monitoring were not followed.
A facility failed to obtain a physician's order for a CPAP machine and did not follow the continuous oxygen order for a resident with heart failure and malnutrition. Observations showed inconsistent oxygen use, and interviews with staff confirmed expectations for following physician's orders. The deficiency was identified through observations, interviews, and record reviews.
The facility failed to ensure that four NAs completed their training and certification within four months of hire, as required. Despite completing the training program, the NAs had not yet tested, and the facility's policy did not specify a timeframe for training completion. The Administrator acknowledged the lapse, attributing it to a lack of prioritization by the previous administration.
The facility failed to maintain proper infection control practices during catheter, wound, and incontinent care, with staff not adhering to hand hygiene protocols, failing to use enhanced barrier precautions, and sharing supplies between residents. Additionally, the facility did not correctly screen residents for tuberculosis as required by state regulations.
A facility failed to maintain an effective IPCP, including an antibiotic stewardship program, by not documenting appropriate indications for antibiotic use for a resident. The resident was prescribed doxycycline for a wound infection and Flagyl for diarrhea without necessary lab reports or findings. The DON confirmed the lack of a stool culture for Flagyl, and the Administrator acknowledged the failure to follow standard procedures.
The facility failed to document education and consent for influenza and pneumococcal vaccines for several residents. One resident received a pneumococcal vaccine despite refusing it, and others lacked documentation of education or consent for both vaccines. The facility's policies require documented education and consent, which were not followed.
The facility failed to document COVID-19 vaccination education and administration for three residents, despite their various medical conditions. The facility's policy required offering the vaccine and providing education on its benefits and risks, but there was no record of this being done for these residents. The DON stated that vaccinations were offered on admission, annually, or when available, with education and consent forms provided.
A resident's funds were misappropriated by the former Administrator (FADM) who used the resident's debit card for personal use, resulting in over $12,000 being misappropriated. The resident, who had cognitive impairments, was unaware of the unauthorized transactions. The FADM claimed the withdrawals were to prevent Medicaid from using the funds for the resident's bill, but no records supported this claim. The facility's policies were violated, and the police were notified, with the Prosecuting Attorney planning to prosecute the FADM.
A facility failed to investigate a resident-to-resident abuse allegation when an LPN did not report a physical altercation to the Administrator. A resident with cognitive impairment was hit by another resident after an argument, but the incident was only reported as a verbal altercation. The facility's policy requires reporting and investigating abuse, but the LPN's incomplete report led to a lack of proper investigation.
Failure to Implement QAPI Plan
Penalty
Summary
The facility failed to implement a Quality Assurance and Performance Improvement (QAPI) Plan, which is essential for maintaining and improving care and services. The facility's policy, dated February 2020, mandates the development, implementation, and maintenance of a data-driven QAPI program focused on care outcomes and residents' quality of life. The policy also states that the facility's owner or governing board is responsible for the QAPI program, and the plan should be presented annually during the recertification survey. However, the facility did not have an implemented QAPI plan that outlined how they would identify and correct quality deficiencies, track and measure performance, and establish goals and thresholds for performance measurements. During an interview, the Administrator, who started in January 2025, acknowledged that although the facility had the QAPI program shell and policy in place, the program was not yet operational.
Failure to Implement QAPI Program
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. The facility's policy, dated February 2020, required the development, implementation, and maintenance of an ongoing, facility-wide, data-driven QAPI program focused on care outcomes and residents' quality of life. However, the facility did not maintain the minimum required documentation for a QAPI plan or Performance Improvement Plans (PIPs). During interviews, the Administrator acknowledged that the QAA/QAPI program was not operational, and the Director of Nursing was unaware of the location of any PIPs documentation. This deficiency had the potential to affect all 40 residents in the facility.
Failure to Conduct Required QAA/QAPI Meetings
Penalty
Summary
The facility failed to maintain quarterly Quality Assessment and Assurance (QAA) and Quality Assurance and Improvement Program (QAPI) committee meetings with the required members. The facility's policy, dated February 2020, outlined the development and maintenance of a data-driven QAPI program focused on care outcomes and quality of life for residents. The policy stated that the QAPI committee should meet monthly to review reports and monitor activities, but it did not specify the required committee members. Upon review, there was no documentation of the facility holding the minimum required quarterly QAA/QAPI meetings with the necessary members. During an interview, the Administrator, who started in January 2025, acknowledged that the QAA/QAPI program was not yet operational, and therefore, no committee meetings had been conducted.
Failure to Maintain Adequate Surety Bond for Residents' Funds
Penalty
Summary
The facility failed to maintain a surety bond for at least one and one-half times the average monthly balance of the residents' personal funds for the last 12 consecutive months. The facility's policy on surety bonds, dated March 2021, outlines that a surety bond is an agreement to compensate residents for any loss of funds managed by the facility. However, the policy did not specify how the bond amount should be calculated. The facility's approved bond amount was $51,000, while the average monthly balance of residents' personal funds was $38,481.13. This average, when rounded to the nearest thousand and multiplied by one and one-half, indicated a required bond amount of at least $57,000, which the facility did not meet. During an interview, the Administrator acknowledged that the bond should be sufficient to cover the residents' funds. It was revealed that the previous administration had misappropriated money, leading to incorrect and unreconciled accounts. This mismanagement contributed to the facility's failure to maintain the appropriate surety bond amount, thereby not ensuring the security of residents' personal funds as required.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to properly document notification and obtain signatures for three residents regarding the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms. This deficiency was identified for three residents who were discharged from skilled services but remained in the facility or were discharged from the facility. The facility's policy requires that these forms be issued to residents or their representatives to inform them of potential non-coverage by Medicare and their financial liability, but this was not done. Resident #2 and Resident #36 were discharged from skilled services with remaining days in their benefit period and stayed in the facility, yet there was no documentation of the NOMNC and SNF ABN forms being issued. Resident #51 was discharged from skilled services and the facility, but the facility failed to notify the resident or their representative of the change in skilled services, and there was no documentation of the NOMNC form. Interviews with the Administrator and Social Service Designee confirmed the expectation that these forms should be provided with proper notifications and signatures in a timely manner, which did not occur in these cases.
Failure to Conduct Timely Background Checks
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the completion of Criminal Background Checks (CBC) and Employee Disqualification List (EDL) checks for new hires. Specifically, the facility did not conduct CBCs and EDL checks prior to the hire dates for Employees A and B, and failed to complete CBCs prior to the hire dates for Employees C and D. The facility's policy mandates that these checks be initiated within two days of an employment offer and completed before employment begins. However, the records show that these checks were either completed after the hire date or not documented at all. Interviews with the Human Resources staff and the Administrator confirmed that the CBC and EDL checks should be completed before employment and that EDL checks should be conducted quarterly thereafter. The HR staff, who was new to the position, acknowledged the oversight and was in the process of organizing the necessary documentation. The facility's failure to perform these checks as required by their policies represents a deficiency in their hiring and screening processes, potentially compromising resident safety.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide a written copy of the notice of transfer or discharge to residents and/or their responsible parties for five residents. This deficiency was identified through interviews and record reviews. The facility's policy on transfer or discharge, dated October 2022, outlines that a notice should be given as soon as practicable before the transfer or discharge, especially in cases where the health and safety of individuals in the facility are endangered or when an immediate transfer is required due to urgent medical needs. However, the facility did not adhere to this policy for the sampled residents. Specifically, the medical records of five residents showed multiple instances of transfers to the hospital without documented written notifications provided to the residents or their responsible parties. These residents were transferred on various dates, and in each case, there was no documentation of the written notification with the reason for the hospital transfer. During an interview, the Administrator acknowledged the expectation that residents and/or their representatives should receive a written copy of the notice of transfer or discharge, indicating a lapse in the facility's adherence to its own policy and regulatory requirements.
Failure to Provide Written Bed Hold Policy Information
Penalty
Summary
The facility failed to provide written information to residents and/or their representatives regarding the facility's bed hold policy at the time of transfer to a hospital. This deficiency was identified for six residents out of a sample of six, indicating a systemic issue. The facility's policy, dated October 2022, requires that all residents or their representatives receive written information about the bed hold policy at least twice: once in the admission packet and again at the time of transfer, or within 24 hours if the transfer is an emergency. For each of the six residents, there was no documentation in their medical records that they or their representatives were informed in writing of the bed hold policy at the time of their hospital transfers. These residents experienced multiple transfers to the hospital, yet the facility consistently failed to provide the required written notification. During an interview, the Administrator acknowledged the expectation that residents and/or their representatives should be informed in writing of the bed hold policy before a transfer occurs.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days for a resident who was admitted to hospice services. The resident was admitted to hospice on 02/28/25, but there was no significant change MDS dated on or after this date. During interviews, both the Administrator and the MDS Coordinator acknowledged that a significant change MDS should be completed within 14 days of a significant change, such as admission to hospice. However, the facility did not provide a policy regarding the completion of significant change MDS assessments, leading to this deficiency.
Deficiencies in Hospice and Medication Management
Penalty
Summary
The facility failed to ensure that a resident receiving hospice care had a completed coordinated plan of care and received necessary care and services according to professional standards. The resident, who was admitted with diagnoses including protein calorie malnutrition and was at risk for pressure ulcers, had specific orders for turning and repositioning every two hours and daily wound care. However, observations revealed that the resident was left in the same position for extended periods, and wound dressings were not changed daily as ordered. Additionally, the hospice coordinated plan of care did not address the resident's wounds or Foley catheter care. Another resident, who had a diagnosis of epilepsy and was on valproic acid, did not have an order for monitoring valproic acid levels, which is crucial for maintaining therapeutic levels and preventing toxicity. The last documented valproic acid level was from over a year ago, and there was no follow-up to ensure that the levels were checked regularly. The resident's care plan included a focus on maintaining lab values within the therapeutic range, but this was not adhered to, as evidenced by the lack of recent lab results. The facility's policies on hospice care, lab and diagnostic test results, and prevention of pressure ulcers were not followed. The hospice care plan was not updated to reflect the resident's current needs, and there was a failure to monitor and document lab results for medication management. The facility also did not provide a policy regarding ordering labs for medication monitoring, which contributed to the oversight in managing the resident's valproic acid levels.
Failure to Obtain CPAP Order and Follow Oxygen Orders
Penalty
Summary
The facility failed to obtain a physician's order for the use of a CPAP machine and did not follow the physician's order for continuous oxygen for a resident. The resident, who was admitted with diagnoses of protein calorie malnutrition and heart failure, had an order for oxygen at 2 liters per minute via nasal cannula continuously. However, there was no order for a CPAP machine, and the resident's care plan did not address the use of a CPAP machine or its settings. Observations showed that the resident was not consistently wearing the oxygen as ordered, and the CPAP machine was used without a physician's order. Interviews with staff, including an LPN and the DON, revealed that they expected physician's orders to be followed, including continuous oxygen use and having an order for CPAP use with specified settings. The resident's oxygen saturation was found to be low at one point, and oxygen was then administered, which improved the saturation level. The facility's policy required a physician's order for oxygen administration, but there was no policy provided regarding CPAP use. The deficiency was identified through observations, interviews, and record reviews, indicating a failure to adhere to physician's orders and facility policies.
Failure to Ensure Timely Certification of Nurse Aides
Penalty
Summary
The facility failed to ensure that four nurse aides (NAs) completed a nurse aide training program within four months of their employment. The facility's policy required newly hired NAs to attend an orientation program within the first five days of employment, but it did not specify a timeframe for completing the nurse aide training. NA B, NA D, NA F, and NA G were all found to have completed the nurse aide program but had not yet tested, exceeding the four-month requirement from their respective hire dates. Interviews with the NAs and the Director of Nursing revealed that the NAs were working in their positions without having completed the necessary certification within the required timeframe. The Administrator acknowledged the expectation for NAs to be certified within four months of hire and noted that the previous administration did not prioritize this requirement, resulting in the current situation where NAs were ready to test but had not yet done so.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices during catheter care, wound care, and incontinent care for several residents. Observations revealed that staff did not adhere to hand hygiene protocols, failed to use enhanced barrier precautions (EBP), and shared supplies between residents. For instance, a Certified Nursing Assistant (CNA) did not perform hand hygiene before and after providing catheter care to a resident, and shared wipes between residents without changing gloves or sanitizing hands. Similarly, a Licensed Practical Nurse (LPN) and another CNA did not follow proper hand hygiene and EBP protocols during wound care and incontinent care, leading to potential cross-contamination. The facility also failed to have dedicated disposable supply items for residents on EBP, as observed during care for residents with catheters and wounds. Supplies such as wound cleansers and tape were placed on unsanitized surfaces without a clean barrier and were not cleansed before being returned to the treatment cart. This practice was observed during wound care treatments for multiple residents, where shared supplies were used without proper sanitation, increasing the risk of infection. Additionally, the facility did not correctly screen residents for tuberculosis (TB) as required by state regulations. Medical records showed missing documentation of TB screenings for several residents, including the absence of admission TSTs and annual screenings. Interviews with staff, including the Director of Nursing (DON) and the Administrator, confirmed that the expected infection control practices were not followed, and supplies should not be shared between residents, especially those on EBP.
Failure in Antibiotic Stewardship and Infection Control
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program, which is essential for monitoring antibiotic use and ensuring appropriate indications for their use. The deficiency was identified when the facility did not document an appropriate indication for the use of antibiotics for a resident who was being treated with doxycycline for a wound infection and Flagyl for diarrhea. The facility's policy on antibiotic stewardship, revised in December 2016, required antibiotics to be prescribed and administered under the guidance of the program, but the documentation was incomplete and lacked necessary lab reports or findings. Resident #19 was prescribed doxycycline for a wound infection and Flagyl for diarrhea, but there was no stool culture to justify the use of Flagyl. The resident had been taking Senna, a stool softener, which was stopped after diarrhea developed, and the diarrhea subsequently ceased. The Director of Nursing confirmed that the Flagyl order was given by the medical director without a stool culture, and the hospital records for the wound infection were not obtained. The Administrator acknowledged that the facility should have followed policy and procedures for the IPCP, including obtaining cultures and labs as expected with standard practice.
Failure to Document Vaccine Education and Consent
Penalty
Summary
The facility failed to document the provision of education regarding the benefits, side effects, or warnings of the influenza and pneumococcal vaccines for several residents. Specifically, four residents did not have documented evidence of receiving pertinent information about the influenza vaccine, and three residents lacked documentation for the pneumococcal vaccine. Additionally, one resident was administered the pneumococcal vaccine despite having refused it. The facility's policies require that residents or their legal representatives receive and acknowledge this information, which was not adhered to in these cases. Resident #2's medical record showed that they were administered the influenza vaccine without documented consent or education, and received the pneumococcal vaccine after refusing it. Resident #4's record lacked documentation of education, consent, or administration for both vaccines. Resident #25's record showed no documentation of education, consent, or administration for both vaccines in 2024 and 2025. Resident #34 was administered the influenza vaccine without documented education or consent, and there was no documentation regarding the pneumococcal vaccine. The Director of Nursing stated that vaccinations were offered with accompanying education and consent forms, but this was not reflected in the records reviewed.
Failure to Document COVID-19 Vaccination Education and Administration
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccination was offered, administered, or refused by three residents out of five sampled residents. The facility's policy required that each resident be offered the COVID-19 vaccine unless medically contraindicated or fully vaccinated, with education provided regarding the benefits, risks, and potential side effects. However, for Residents #2, #4, and #34, there was no documentation in their medical records indicating that COVID-19 vaccination education was provided, nor was there any record of the vaccine being administered or refused. Resident #2 had multiple diagnoses, including metabolic encephalopathy, COPD, schizophrenia, hypertension, major depressive disorder, panic disorder, anxiety disorder, and hearing loss. Resident #4 had diagnoses of hematogenous osteomyelitis, heart failure, and dementia. Resident #34 had Alzheimer's disease, cerebral infarction, atrial fibrillation, and hypertension. Despite these conditions, there was no documentation of COVID-19 vaccination education or administration for these residents. The Director of Nursing stated that vaccinations were offered on admission, annually, or when provided by the facility, with education and consent forms given to residents or their representatives.
Misappropriation of Resident's Funds by Former Administrator
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their property when the former Administrator (FADM) used the resident's bank debit card for personal use, resulting in a misappropriated amount exceeding $12,000. The incident occurred between November and December 2024, and the facility was notified of the missing funds in January 2025. The resident, who had some cognitive loss and diagnoses including Metabolic Encephalopathy, Schizophrenia, and Major Depressive Disorder, was unaware of the unauthorized withdrawals and purchases made using their account. The facility's investigation revealed that the FADM had used the resident's debit card to withdraw cash and make purchases, including medications sent to the FADM's address. The FADM claimed that the withdrawals were made to prevent Medicaid from requiring the funds to be used for the resident's bill, and that the money was given to the former bookkeeper to pay the resident's expenses. However, there were no records of these transactions being applied to the resident's billing or trust account, and the FADM admitted to accidentally using the resident's card for personal purchases. Interviews with the resident and facility staff confirmed that the resident did not give the FADM permission to use the card, and the facility's policies did not allow for such actions. The FADM's actions were not in line with the facility's Abuse Prevention Program and Management of Residents' Personal Funds policy, which emphasize safeguarding residents' funds and obtaining consent for any transactions. The police were notified, and the case was under investigation, with the Prosecuting Attorney intending to prosecute the FADM for the misappropriation.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident abuse involving two residents. A Licensed Practical Nurse (LPN) did not report the physical altercation between the residents to the Administrator for investigation. The facility's policy mandates the reporting and investigation of any abuse allegations, but in this case, the LPN only reported a verbal altercation, despite being informed of the physical nature of the incident by multiple staff members and the residents involved. Resident #1, who has diagnoses of congestive heart failure, anxiety, and schizophrenia, reported being hit by Resident #2 after an argument over the television volume. Resident #1, who is moderately cognitively impaired and requires maximum assistance with personal care, fell out of the wheelchair after being struck. Resident #2, who is cognitively intact and requires minimal assistance with activities of daily living, admitted to hitting Resident #1 and expressed no remorse for the action. Despite these admissions, there was no documentation of an abuse allegation investigation in either resident's medical record. The incident was initially reported as a verbal altercation by the LPN to the Director of Nurses and the Administrator, who was on vacation at the time. The Administrator delegated the investigation to a Registered Nurse (RN), who was informed by the LPN that there were no injuries and only an argument had occurred. As a result, the RN did not conduct a thorough investigation, believing the situation was resolved by relocating Resident #2 to another room. The failure to properly report and investigate the physical altercation represents a deficiency in the facility's adherence to its abuse and neglect policy.
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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