Brunswick Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brunswick, Missouri.
- Location
- 721 West Harrison St, Brunswick, Missouri 65236
- CMS Provider Number
- 265598
- Inspections on file
- 20
- Latest survey
- July 31, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Brunswick Health Care Center during CMS and state inspections, most recent first.
The facility did not provide a registered nurse (RN) on duty for at least eight consecutive hours per day, seven days a week, and lacked a full-time Director of Nursing (DON). Nursing staff schedules showed multiple days without RN coverage, and the interim DON, who was also covering another facility, was only onsite part-time. The facility relied on an LPN for coverage when unable to secure an RN, resulting in noncompliance with regulatory requirements.
A resident with a history of inappropriate sexual behaviors entered another resident's room without permission and committed sexual abuse, despite prior grievances and documented incidents of sexually inappropriate conduct toward staff and residents. The facility failed to implement adequate supervision or interventions to prevent the abuse, resulting in harm to the victim.
The facility admitted multiple residents with complex mental health diagnoses without ensuring that staff, including CNAs, LPNs, the Activity Director, Social Service Director, ADON, DON, and Administrator, had received formal training or demonstrated competency in behavioral health care. The rapid admission process led to missed diagnoses and inadequate preparation for managing residents' psychiatric and behavioral needs, resulting in staff being unprepared to provide appropriate care.
Two residents with mental disorders did not receive individualized behavioral health services, resulting in repeated incidents of verbal aggression, inappropriate sexual behavior, property damage, and inadequate supervision. Despite documented mental health diagnoses and ongoing behavioral issues, the facility failed to implement meaningful non-pharmacological interventions, timely psychiatric services, or increased monitoring, relying mainly on education and redirection. Staff interviews revealed a lack of mental health training and uncertainty in managing these residents.
The facility failed to schedule CPR-certified staff 24/7, leaving shifts without certified personnel despite having residents with full code status. The ADON and Administrator were unaware of expired certifications and incomplete documentation, leading to non-compliance with facility policy.
The facility failed to maintain RN coverage for at least eight consecutive hours daily and lacked a full-time DON. Despite policy requirements, the facility's assessment showed no active DON, and the staffing schedule revealed no RN or DON coverage for several days. Interviews confirmed the absence of a full-time DON and RN coverage since the interim DON's resignation.
The facility failed to maintain RN coverage for at least eight hours daily and lacked a full-time DON, as required by regulations. Staffing schedules showed multiple days without RN coverage and no DON coverage in August. The DON position was vacant for two months, with the ADON, an LPN, acting as interim DON. The facility used staffing agencies for coverage but still had days without scheduled RNs.
The facility failed to control a fly infestation, affecting multiple residents, including one with an open cancerous wound infested with maggots. Despite having a pest control policy, the measures were insufficient, with fly strips filled and residents swatting flies during meals. The maintenance director and DON were aware but did not implement effective solutions.
The facility failed to provide the services of an RN for at least eight consecutive hours a day, seven days a week, as required. Record reviews and interviews revealed multiple dates over several months where RN hours were either absent or insufficient, affecting all residents.
The facility failed to maintain clean dietary equipment and properly seal food items in storage. Observations showed unsealed food and significant dust and debris buildup on kitchen fixtures. Additionally, the ice machine drain lacked a proper air gap, which was confirmed by the Maintenance Director and registered dietician.
The facility failed to follow proper infection control procedures for hand hygiene and glove use during personal care, did not ensure respiratory equipment remained free of contaminants, and lacked a Legionella Prevention Program. Staff did not consistently wash hands or change gloves, and key personnel were unaware of necessary Legionella monitoring and control measures.
The facility failed to respect and facilitate resident self-determination and choice regarding wake-up times. Four residents with severe cognitive impairments were routinely woken and dressed early in the morning without consideration of their preferences, primarily for staff convenience. Staff interviews revealed a lack of awareness and adherence to residents' preferences, leading to a deficiency in promoting resident self-determination.
The facility failed to maintain a clean and comfortable environment, with observations of unclean shower rooms and ceiling vents in disrepair. The DON and maintenance director acknowledged lapses in cleaning and maintenance responsibilities.
The facility failed to complete required pre-employment screenings for five of eight sampled employees, including criminal background checks, Employee Disqualification List (EDL) checks, and Nurse Aide (NA) registry checks. The Administrator confirmed the lack of a corporate policy and adherence to state guidelines, with an expectation that checks should be completed at least two days prior to the employees' start date.
The facility failed to develop comprehensive care plans for several residents, omitting critical information such as pain management, fall risk, activity preferences, and specific medical conditions. This lack of detailed care planning was evident despite clear indications of these needs in residents' medical records and observations.
The facility failed to update the care plans of three residents to reflect their current safety and care needs, resulting in unaddressed falls, outdated interventions, and missing documentation of prescribed medications and dietary requirements.
The facility failed to provide necessary ADL assistance for four residents, including inadequate perineal care, missed scheduled baths, and lack of feeding assistance, leading to deficiencies in hygiene and nutrition.
The facility failed to evaluate the root cause of falls and update care plans for a resident with severe cognitive impairment, leading to multiple falls. Additionally, staff did not properly use gait belts during transfers for two other residents, causing discomfort and potential injury.
The facility failed to assess residents for bed rail use, obtain informed consent, and perform entrapment risk assessments for six residents. Despite various conditions requiring substantial assistance, the facility did not follow necessary procedures, leading to potential risks for the residents.
The facility failed to provide sufficient nursing staff, resulting in inadequate care for residents, including missed baths and delayed call light responses. Two residents did not receive scheduled showers, and three residents experienced significant delays in call light responses, causing frustration and potential harm.
The facility failed to ensure that four nurse aides completed their training program within four months of employment. The ADON confirmed the start dates and acknowledged that some NAs had not passed their certification classes. The DON stated that NAs not certified within four months should be terminated, and the Administrator was unaware that the certification waiver had expired.
The facility failed to ensure GDRs were attempted or that the physician documented the rationale for not attempting a GDR on psychotropic medications for three residents. One resident with major depressive disorder and traumatic hemorrhage of the cerebrum, another with schizophrenia, and a third with vascular dementia and major depressive disorder were all on psychotropic medications without any GDR attempts or proper documentation of contraindications.
The facility failed to ensure a medication cart was secured when unattended. RN T left the cart unlocked and out of sight multiple times while providing resident care, including leaving a medication unsupervised in a resident's room. Both RN T and the DON acknowledged the importance of securing medication carts and not leaving medications unsupervised.
The facility failed to serve food at safe and appetizing temperatures, as observed during a survey. Multiple residents reported that their meals were not served hot. Observations showed that food items were not maintained at the required temperatures during meal service. The dietary manager admitted that the stovetop and griddle were turned off during meal service, leading to the food cooling down before it was served.
The facility failed to adhere to its antibiotic stewardship program, resulting in inadequate monitoring and documentation of antibiotic use. The Infection Preventionist did not keep up to date on antibiotic tracking, and the Director of Nursing confirmed that the IP was responsible for this task. The review showed incomplete tracking of antibiotic use, lacking details such as culture and sensitivity for UTIs and type of infection for wound infections.
The facility failed to provide pneumococcal vaccinations as per CDC guidelines for five residents, resulting in them not being up-to-date on their vaccinations. The infection preventionist admitted to not having time to review all residents' vaccinations, and the Medical Director expected adherence to CDC guidelines, which was not met.
The facility failed to inspect bed frames, mattresses, and bed rails for six residents, leading to potential entrapment risks. Observations showed residents using bed rails for mobility and positioning, but no documented inspections or entrapment zone assessments were found. The DON confirmed that no assessments had been completed prior to the survey.
A resident with moderate cognitive impairment reported multiple instances of being treated rudely by a Nurse Assistant (NA), including being told to 'do it yourself' during a toileting transfer. The resident felt like a burden and teared up when discussing the interactions. The Director of Nursing was aware of the complaints but the NA's behavior continued to make the resident feel disrespected.
A resident with severe cognitive impairment experienced an unwitnessed fall resulting in a minor injury. The facility failed to notify the physician and responsible party, with staff citing miscommunication and workload issues. Both the DON and Medical Director expected such notifications to be made.
The facility failed to report a resident-to-resident abuse incident to the state agency within the required two-hour timeframe. The incident involved a resident hitting another with a fly swatter. Staff did not follow proper reporting procedures, leading to a delay in notifying the state agency.
The facility failed to complete Significant Change in Status Assessments (SCSA) for two residents despite significant changes in their conditions, including declines in ADLs, new medications, and significant weight gain. Interviews revealed a lack of formal training and communication issues among staff responsible for MDS assessments.
The facility failed to ensure that two residents had a preadmission screening for mental disorders and intellectual disabilities (PASRR) completed prior to admission. Both residents' medical records and quarterly MDS lacked documentation of Level I or Level II PASRR screenings.
A facility failed to provide a comprehensive discharge summary for a resident discharged to home, who had multiple medical conditions and required various levels of assistance. The facility lacked a policy on discharge recapitulation, and the resident's medical record did not include a detailed summary of the nursing home stay.
The facility failed to ensure that two residents with complicated feeding problems were assisted with feeding by qualified staff. A Hospitality Aide, who was a paid feeding assistant and not a certified nurse aide, fed the residents without the supervision of an RN or LPN. Both residents had severe cognitive impairment and were on mechanically altered diets, yet were fed by the aide without any licensed staff present.
The facility failed to post required nurse staffing information, including total hours worked by licensed and unlicensed staff per shift. Reviews and observations on multiple dates showed missing or incomplete staffing data. Interviews revealed that charge nurses were responsible for updating the staffing sheets, but this was not consistently done.
The facility failed to provide appropriate CMS SNF Advance Beneficiary Notice (ABN) and CMS Notice of Medicare Non-Coverage (NOMNC) in writing to three residents when initiating discharge from Medicare Part A services, despite benefit days not being exhausted. The Administrator admitted to not having a policy and being unaware of the requirements for providing these notices.
The facility failed to accurately code the MDS for three residents, leading to discrepancies in their assessments. One resident was incorrectly coded as comatose, another's hospice status was not documented, and a third's cognitive status and swallowing disorder were not accurately reflected. Limited training and oversight of MDS Coordinators contributed to these errors.
Failure to Provide Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide a registered nurse (RN) on duty for at least eight consecutive hours per day, seven days a week, as required by their policy and federal regulations. Review of the nursing staff schedules for the entire month showed multiple days with no documentation of RN coverage, including extended periods where no RN was present at all. Additionally, there was no documentation of hours worked by the Director of Nursing (DON) for the entire month. The interim DON, a corporate regional nurse, was only onsite two days per week and sometimes only one day, and was also responsible for another facility. The facility was unable to borrow an RN from another location and instead used an LPN for coverage, which did not meet the regulatory requirement for RN presence. Interviews with the administrator and the interim DON confirmed the lack of consistent RN coverage and the absence of a full-time DON. The interim DON acknowledged the facility was out of compliance and described her limited onsite activities, which included monitoring medication orders, administration, documentation, and wound care instructions. There was no indication that any other RNs were available to meet the required coverage, and the interim DON did not keep a record of her hours worked at the facility.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident with a known history of inappropriate sexual behaviors. One resident, who was cognitively intact but physically dependent and diagnosed with multiple neurological and psychiatric conditions, reported that another resident entered their room without permission and engaged in non-consensual sexual contact. Prior to this incident, the victim had filed a grievance indicating discomfort and fear due to the perpetrator's repeated unwanted physical contact and advances, including being asked on a date and having to ask the perpetrator to stay out of their room. The perpetrator had a documented history of making sexually inappropriate comments and advances toward both staff and other residents. Multiple grievances and progress notes detailed incidents where the perpetrator made explicit sexual remarks to staff, expressed intentions to date or be physically intimate with others, and intruded into other residents' rooms. Despite these documented behaviors, interventions were limited to education and medication for sexual disinhibition, and there was no evidence of increased supervision or environmental modifications to prevent further incidents. On the day of the incident, facility camera footage confirmed that the perpetrator entered the victim's room and remained there unsupervised for approximately 30 minutes. The victim later reported the assault, describing non-consensual sexual contact that resulted in physical injury. Staff interviews and documentation revealed that the facility was aware of the perpetrator's ongoing inappropriate behaviors but did not implement sufficient measures to prevent resident-to-resident abuse, ultimately resulting in a serious incident of sexual abuse.
Failure to Ensure Staff Competency for Behavioral Health Needs
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to meet the behavioral health needs of residents, particularly after admitting several individuals with complex mental health diagnoses. Despite having a policy requiring all staff, including contracted staff and volunteers, to receive education and training based on resident needs, interviews revealed that no formal training on mental health care had been provided to staff members, including CNAs, LPNs, the Activity Director, the Social Service Director, the ADON/Admission Coordinator, the DON, and the Administrator. Staff consistently reported a lack of preparation and training to care for residents with mental health conditions, and several expressed concerns about their ability to provide appropriate care. The facility's admission process required rapid review and decision-making, with corporate expectations for referral reviews and admission decisions to be made within 15 minutes for medical referrals and within two hours for behavioral referrals. This rushed process led to critical information about residents' mental health diagnoses being overlooked, as seen in the case of a recently admitted resident with bipolar disorder and adjustment disorder. Staff were unaware of the resident's mental health conditions at the time of admission, and the lack of prescribed medications for symptom management was not identified. The Social Service Director and DON both acknowledged that the resident's behaviors, such as stealing, inappropriate use of facilities, and manipulation, were not adequately managed due to insufficient training and screening. Multiple residents with significant psychiatric and behavioral health diagnoses, including schizophrenia, bipolar disorder, psychosis, and anxiety disorders, were admitted without the facility ensuring staff were equipped to address their needs. The facility's own assessment indicated that when unfamiliar conditions arose, the interdisciplinary team was supposed to initiate immediate training and competency checks, but this was not implemented in practice. Staff interviews confirmed that no such training or competencies were completed, and the facility's leadership, including the Administrator and DON, admitted to missing key information during the admission process and lacking the necessary training to support residents with behavioral health needs.
Failure to Provide Individualized Behavioral Health Services for Residents with Mental Disorders
Penalty
Summary
The facility failed to provide individualized treatment and services to two residents with mental disorders, resulting in repeated incidents of verbal, manipulative, and aggressive behaviors. For one resident, there were multiple documented episodes of inappropriate conduct, including smoking in prohibited areas, taking items from other residents, making sexually inappropriate comments and advances toward both staff and other residents, and causing property damage such as flooding a room by tampering with plumbing. Despite these behaviors and a documented history of mental health diagnoses including bipolar disorder, adjustment disorder, and anxiety, the facility did not implement meaningful non-pharmacological interventions, alternate strategies, or timely psychiatric services. The care plan primarily focused on education and redirection, with little evidence of increased supervision or specialized behavioral health interventions, even after repeated grievances and incidents involving other residents and staff. Another resident with a history of paranoid delusional disorder, substance-induced mood disorder, and recent incarceration for psychiatric reasons also exhibited challenging behaviors, including verbal abuse, hallucinations, wandering, and repeated requests for cigarettes. The resident's PASARR Level II evaluation indicated a need for ongoing psychiatric and mental health follow-up, close supervision, and a structured environment to address active psychosis and elopement risk. However, the facility's documentation showed a lack of consistent behavioral health services, monitoring, or trauma-informed interventions tailored to the resident's needs. Behavioral symptoms were noted, but the care plan did not reflect the level of psychiatric oversight or crisis intervention recommended in the evaluation. Interviews with staff revealed a lack of formal mental health training and uncertainty about how to manage residents with complex behavioral health needs. The Social Service Designee admitted to not having received mental health training and being unsure of appropriate interventions. The facility's approach to managing these residents relied heavily on education and redirection, without escalation to specialized services or increased supervision, even after significant incidents and grievances. There was no evidence of psychiatric services being provided or additional monitoring being implemented, despite ongoing behavioral issues and risks to other residents and staff.
Failure to Ensure CPR-Certified Staff on Duty
Penalty
Summary
The facility failed to ensure that CPR-certified staff were scheduled 24/7, which is crucial for residents with full code status who require resuscitation efforts in the event of cardiac arrest. The facility's policy, dated February 2023, mandates that CPR-certified staff be available at all times. However, a review of staffing sheets revealed multiple shifts without a CPR-certified staff member present. Specifically, several evening and day shifts were identified where no CPR-certified personnel were scheduled, despite the facility having seven residents with full code status. Interviews with the Assistant Director of Nursing (ADON) and the Administrator highlighted a lack of awareness and oversight regarding CPR certification status among staff. The ADON admitted to not knowing which staff members had current or expired CPR certifications and acknowledged that new staff members lacked current certification. The Administrator expected all staff to have up-to-date CPR certifications and was unaware of the expired certifications and incomplete documentation. This oversight resulted in shifts being staffed without CPR-certified personnel, contrary to the facility's policy and regulatory expectations.
Deficiency in RN and DON Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and did not have a full-time Director of Nursing (DON) as required. The facility's policy, dated August 2022, mandates sufficient nursing staff to meet resident care plans and requires an RN to be present for at least eight consecutive hours every 24 hours. However, the facility's assessment, last updated in April 2024, indicated the absence of an active DON. The staffing schedule for November 2024 showed no RN or DON coverage from November 1 to November 6. Interviews with the facility's Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) and the Administrator confirmed the lack of a full-time DON and RN coverage since the interim DON resigned on October 31, 2024.
Deficiency in RN and DON Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and did not have a full-time Director of Nursing (DON) as required by regulations. The facility's staffing schedules for July and August 2024 showed multiple days without RN coverage and a complete lack of DON coverage throughout August. The facility census was 22, and the DON position had been vacant for two months. During this period, the facility relied on two Licensed Practical Nurses (LPNs) as nurse managers, but they resigned after a few months, leaving the Assistant Director of Nursing (ADON), an LPN, to act as the interim DON. Interviews with the facility's Administrator and ADON revealed that the facility did not have a policy for RN coverage and was using staffing agencies to fill nursing positions. The Administrator, who had been in the role for three weeks, was unaware of how long the facility had been without a DON. The facility requested either RNs or LPNs from staffing agencies, accepting whichever was available to ensure a licensed nurse was present. Despite these efforts, there were still days when no RN was scheduled, leading to the deficiency.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to implement effective pest control measures, resulting in a significant infestation of flies throughout the facility, including in resident rooms and common areas. This deficiency affected multiple residents, including a resident with an open cancerous wound that became infested with maggots. The resident's condition was exacerbated by the presence of flies, which were observed landing on the resident's body and wound dressing. Despite the facility's pest control policy, which included monthly observations and spraying, the measures in place were insufficient to control the fly population. Observations revealed that fly strips in the resident's room were filled with flies, and the resident was seen swatting at flies that landed on their body. The resident's wound was noted to have a foul smell and was infested with maggots, requiring medical treatment with antibiotics and deworming medication. The presence of flies was also noted in the dining room, where residents were observed using fly swatters to deter flies during meal times. Staff interviews confirmed the ongoing issue with flies, and it was noted that fly strips and ultraviolet plug lights were used as part of the pest control efforts. The facility's maintenance director and Director of Nursing were aware of the fly problem but had not implemented sufficient measures to address it. The maintenance director mentioned installing fly strips and fans to keep flies out, while the Director of Nursing was unaware of the extent of the fly infestation in the resident's room. The facility's pest control log indicated that glue traps and fly strips were changed, but these actions were not effective in controlling the fly population, leading to the deficiency.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulatory guidance. This deficiency was identified through interviews and record reviews, which revealed multiple dates over several months where the facility did not have any documented RN hours. The facility census was 31, indicating that this failure had the potential to affect all residents. The Administrator confirmed that the facility did not have a policy for RN coverage and admitted to days without RN coverage. The Payroll Based Journal (PBJ) report and facility payroll and agency staffing records showed numerous dates from October 2023 to April 2024 where RN hours were either completely absent or insufficient. Specific dates were listed where no RN hours were documented, and on some days, the RN hours recorded were significantly less than the required eight hours. Interviews with the Director of Nursing and the Administrator further confirmed the lack of full RN coverage on a daily basis, highlighting a systemic issue in meeting the regulatory requirements for RN staffing.
Dietary Equipment and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure dietary equipment was free of an accumulation of grease, oil, dust, and debris, and did not properly seal food items in the freezer and dry storage room. Observations revealed unsealed plastic bags of frozen biscuits and natural cocoa powder, as well as a significant buildup of dust and debris on various kitchen fixtures, including ceiling vents, rotary fans, fluorescent light fixtures, and kitchen hood suppression nozzles and piping manifold. The dietary manager, administrator, and registered dietician all confirmed that they expected these areas to be clean and free of contaminants, and that food items should be properly sealed. Additionally, the facility did not maintain a proper air gap for the ice machine drain. The ice machine's drain pipe extended into the sump pump floor well without an appropriate air gap, which was confirmed by the Maintenance Director and the registered dietician. Both acknowledged that they were unaware of the requirement for the ice machine drain pipe to be above the top edge of the sump pump well.
Infection Control Deficiencies and Lack of Legionella Prevention Program
Penalty
Summary
The facility failed to use appropriate infection control procedures for hand hygiene and changing gloves during personal care for four residents. Observations showed that staff did not wash their hands before donning gloves, did not change gloves after touching contaminated items, and used the same gloves to handle clean items and perform personal care tasks. This was observed in multiple instances, including handling soiled linens, performing perineal care, and touching clean clothing and equipment without changing gloves. Interviews with staff confirmed that they were aware of the hand hygiene policies but did not follow them consistently during care activities. The facility also failed to ensure respiratory equipment remained free of contaminants. An observation showed a CNA dragging a nasal cannula tubing on the floor and then placing it on a resident's table before the resident used it. This practice exposed the resident to potential contaminants from the floor. Interviews with staff indicated a lack of awareness regarding the proper handling of respiratory equipment to prevent contamination. Additionally, the facility did not develop and implement a Legionella Prevention Program as required. The facility's water management team did not conduct annual risk assessments, monitor water sources for sediment or biofilm, or check chlorine levels. Key staff members, including the Infection Preventionist and Maintenance Director, were not educated on Legionella prevention and were unaware of the necessary monitoring and control measures. The facility lacked documentation of water management team meetings and activities, indicating a significant gap in their infection control program.
Failure to Respect Resident Wake-Up Preferences
Penalty
Summary
The facility failed to respect and facilitate resident self-determination and choice, particularly regarding the time residents preferred to wake up in the morning. This deficiency was observed in four residents with severe cognitive impairments and dependencies on staff for activities of daily living. Staff routinely woke and dressed these residents early in the morning without considering their preferences, primarily for staff convenience. This practice was observed during early morning hours when residents were still asleep, and despite their verbal objections, staff proceeded to get them up and dressed for the day. Resident #15, who had severe cognitive impairment and multiple diagnoses including hemiplegia and Parkinson's, was woken up at 5:30 A.M. and dressed without being given a choice. Similarly, Resident #36, with severe cognitive impairment and dementia, was woken up at 6:00 A.M. and expressed a desire to stay in bed but was dressed and then allowed to lie back down. Resident #30, diagnosed with Alzheimer's and severe cognitive impairment, was also woken up at 6:15 A.M. and dressed despite expressing a desire to stay in bed. Resident #27, who had Alzheimer's and severe cognitive impairment, was noted to be resistant to being woken up, and staff reported that this resident often tried to hit them when they attempted to get him/her up. Interviews with staff revealed that there was no list of residents' preferences for wake-up times, and night shift aides were expected to get all residents up before their shift ended at 6:00 A.M. The Director of Nursing and the Administrator were unaware of this practice, and the Director of Nursing stated that if a resident did not want to get up, staff should try later. However, the observed practice showed that residents' preferences were not being honored, leading to a failure in promoting and facilitating resident self-determination and choice.
Failure to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to provide a clean and comfortable environment by not ensuring the cleanliness and proper maintenance of the shower room and ceiling vents. Observations revealed black marks on the floor near the shower stall, a large crack in the shower basin, blackened grout, and brown stains by the drain. The Director of Nursing indicated that staff were responsible for notifying maintenance of needed repairs and cleaning the shower room if it was left messy, but these actions were not adequately carried out. Additionally, multiple ceiling vents in the west hall shower room and several occupied resident rooms had significant accumulations of lint, dust, and debris. The maintenance director admitted that he was responsible for cleaning the vents approximately every 45 days or when notified by staff or residents, but he had overlooked the vents in the west hall shower room. This oversight contributed to the unclean and uncomfortable environment observed during the survey.
Failure to Complete Pre-Employment Screenings
Penalty
Summary
The facility failed to complete required pre-employment screenings for five of eight sampled employees hired since the previous survey. Specifically, the facility did not request a criminal background check for four employees, did not complete an Employee Disqualification List (EDL) check for four employees, and did not complete a Nurse Aide (NA) registry check for two employees prior to hire. The facility census was 31 at the time of the survey. For example, the Activity Aide's criminal background check was requested 66 days after the hire date, and the EDL check was completed 36 days after the hire date. Similarly, the Director of Nursing's criminal background check and EDL check were both completed 25 days after the hire date. The Speech Therapist had no criminal background check or EDL check on file, and the NA registry check had no date provided. The Administrator's checks were completed within a few days of hire, while the LPN's criminal background check was requested before the hire date but had no record of being received. Interviews with the Administrator confirmed the lack of a corporate policy and adherence to state guidelines, with an expectation that checks should be completed at least two days prior to the employees' start date. The Administrator acknowledged that she was responsible for completing the criminal background checks, EDL, and NA registry checks. The failure to complete these checks in a timely manner or at all for several employees indicates a significant lapse in the facility's hiring practices. This deficiency could potentially compromise the safety and well-being of the residents, as the necessary screenings are designed to prevent abuse, neglect, and theft by ensuring that only qualified and vetted individuals are employed. The report highlights the need for stricter adherence to pre-employment screening protocols to maintain a safe environment for residents and staff alike.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan specific to the needs of several residents. For Resident #2, the care plan did not include critical information such as the use of a bariatric bed, bed pan, supplemental oxygen therapy, pain management, pressure ulcer prevention devices, skin wounds, Alzheimer's disease, type II diabetes mellitus, or Parkinson's disease. Despite multiple observations and nurse's notes indicating these needs, the care plan remained incomplete and not updated to reflect the resident's current condition and requirements for care. Resident #12's care plan lacked focus areas related to activities, despite the resident being cognitively intact and having specific activity preferences documented in the Minimum Data Set (MDS). The resident expressed a preference for various activities, but these were not addressed in the care plan. The resident spent most of their time in their room, indicating a potential gap in meeting their psychosocial and activity needs. Resident #16's care plan did not include critical information such as the resident's high risk for falls, a recent fall with intervention, antibiotic prescriptions for pneumonia, smoking habits, or the need to monitor for bleeding related to anticoagulant use. Similarly, Resident #15's care plan did not address pain management despite the resident showing clear signs of pain and having a diagnosis of pain. Lastly, Resident #37's care plan did not include details about lower extremity limitations, mobility status, transfer status, or the assistance needed for transfers, even though the resident was dependent on staff for these activities. The facility's MDS Coordinator admitted to not having formal training for MDS assessments and care plans, which likely contributed to these deficiencies.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to update interventions in the care plans of three residents to reflect their current safety and care needs. Resident #1, who had severe cognitive impairment and a history of falls, experienced multiple falls that were not addressed in the care plan. Despite several incidents, including falls resulting in injuries and increased behavioral issues, the care plan was not updated to include new interventions or changes in the resident's condition, such as the need for supervision with toileting hygiene and the use of a wheelchair for mobility. Additionally, the care plan did not reflect the resident's prescribed medications or dietary requirements. Resident #19, who had moderately impaired cognition and a history of falls, also had an outdated care plan. The care plan did not include the resident's need for supervision with various activities of daily living, such as oral hygiene, toileting hygiene, and upper body dressing. Furthermore, the care plan did not document the resident's falls or the need to keep the wheelchair away from the bed while the resident was in bed. Despite the resident's repeated falls and the implementation of new safety measures, these updates were not reflected in the care plan. Resident #16, who was admitted with diagnoses including alcohol abuse and chronic obstructive pulmonary disease, experienced a fall that was not documented in the care plan. The care plan also failed to include monitoring for alcohol withdrawal symptoms and treatment for pneumonia. Despite the resident's fall and the need for specific interventions, the care plan remained unchanged. Interviews with staff revealed that the responsibility for updating care plans was shared among various team members, but there was a lack of formal training and consistent follow-through in updating the care plans as required.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for four residents, leading to deficiencies in care. Resident #15 and Resident #30 were not provided with appropriate perineal care. Observations showed that staff did not cleanse all areas where urine or feces touched the residents' skin, which is contrary to the facility's policy. Resident #15 was found with a wet pad from incontinence, and the staff did not clean the genital area. Similarly, Resident #30 was found with a saturated pad and was not cleaned properly, leaving areas in contact with urine unaddressed. Resident #27 and Resident #30 were not offered bathing as scheduled. The facility's records showed significant gaps in the documentation of baths offered or refused. Resident #27 received only one bath out of eight scheduled in February and two out of eight in March. The resident's family member reported finding the resident in an unkempt state with a urine smell and feces under the fingernails. Similarly, Resident #30 received only four baths out of nine scheduled in March and two out of five in April. Observations confirmed the resident's unkempt appearance and urine smell, indicating a lack of proper hygiene care. Resident #25 was not provided with feeding assistance when needed. The resident, who had diagnoses including dementia and required moderate assistance with eating, was observed sitting with an untouched plate during a meal. Despite needing help, no staff assisted the resident, leading to significant weight loss over a period of 75 days. Interviews with staff confirmed that the resident needed help to eat, but due to staff shortages and call-ins, the necessary assistance was not provided. The Director of Nursing acknowledged that the facility was often short-staffed, making it difficult to complete all required cares, including feeding assistance and bathing.
Failure to Evaluate Falls and Improper Use of Gait Belts
Penalty
Summary
The facility failed to consistently evaluate the root cause for falls and implement and modify interventions as necessary following falls for one resident. The resident experienced multiple falls over several months, and the facility did not document attempts to identify the root cause or re-evaluate current interventions after each fall. The resident had severe cognitive impairment, fluctuating behaviors, and was occasionally incontinent of bladder and frequently incontinent of bowel. Despite these conditions, the facility did not consistently update the care plan with new interventions to prevent future falls after each incident. Additionally, the facility failed to use or properly use a gait belt during transfers and assistance with walking for two other residents. One resident was assisted by a nurse aide without the use of a gait belt, and the aide admitted to forgetting to use one. Another resident was lifted to a sitting position by the shoulder and neck, causing discomfort and a facial grimace. The nurse aide involved acknowledged that this method was inappropriate and could cause injury. The Director of Nursing (DON) confirmed that staff were expected to use gait belts for unsteady residents during transfers and ambulation. The DON also stated that new interventions were supposed to be implemented after each fall, but the care plans were not consistently updated. The facility's failure to follow proper procedures for fall prevention and safe transfers led to multiple deficiencies in resident care.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess residents for the use of bed rails/assist bars prior to installation, to have a system in place to obtain informed consent and educate residents and their responsible parties about the risks of bed rail use prior to use, assess residents for entrapment risk, and failed to assess for continued safe use of bed rails for six residents. The facility's undated policy required staff to complete a form to determine whether a side rail was appropriate for a particular resident, but this was not followed. The FDA guidelines also emphasize the need for careful assessment and ongoing monitoring to prevent risks associated with bed rails, such as strangling, suffocating, and bodily injury, but these guidelines were not adhered to by the facility. For Resident #12, the facility did not conduct a side rail assessment, obtain a physician order, document interventions attempted prior to installation, or perform a bed rail entrapment assessment. The resident was observed using the side rails for bed mobility, but there was no informed consent documented. Similarly, Resident #23 had severe cognitive impairment and used side rails for bed mobility, but there was no documentation of side rail assessments, physician orders, or informed consent. The resident's bed rail assessment form was only completed after the survey began. Other residents, including Resident #15, Resident #30, Resident #2, and Resident #31, also had bed rails installed without proper assessments, physician orders, or informed consent. These residents had various conditions such as severe cognitive impairment, hemiplegia, Parkinson's disease, and Alzheimer's disease, which required substantial assistance from staff for bed mobility and transfers. Despite their conditions, the facility did not follow the necessary procedures to ensure the safe use of bed rails, leading to potential risks for the residents.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, resulting in inadequate care for several individuals. Specifically, two residents did not receive regular baths or showers as scheduled, and three residents experienced significant delays in response to their call lights. The facility's staffing levels were consistently below the required ratios outlined in their Facility Assessment, leading to these deficiencies. For example, Resident #12, who is cognitively intact and dependent on staff for bathing, did not receive six of the 19 scheduled showers or bed baths, with no documentation of refusal. Similarly, Resident #27, who has severe cognitive impairment and is dependent on staff for bathing, missed eight of the 19 scheduled showers or bed baths, again with no documentation of refusal. Both residents and their family members expressed frustration and concern over the lack of adequate care and hygiene. The facility also failed to respond to resident call lights in a timely manner, causing frustration and potential harm to the residents. Resident #2, who is cognitively intact and dependent on staff for various activities of daily living, experienced multiple instances where call lights were not answered promptly, with wait times ranging from 17 to 30 minutes. Resident #19, who has moderately impaired cognition and requires minimal assistance with transfers and dressing, also reported long wait times for call light responses, with documented delays of up to 32 minutes. Resident #5, who has moderate cognitive impairment, expressed feelings of being a burden and reported instances of incontinence due to delayed responses to call lights, with wait times ranging from 12 to 40 minutes. Interviews with staff and the Director of Nursing (DON) revealed that the facility often operated with insufficient staff due to frequent call-ins, making it challenging to provide all necessary care, including showers and timely responses to call lights. The DON acknowledged that the facility was short-staffed and that it was difficult to complete all required tasks with the limited number of aides available. The Administrator also confirmed that call light response times exceeding 10 minutes were unacceptable, and many delays occurred during meal times. The facility's inability to maintain adequate staffing levels directly contributed to the deficiencies in resident care and hygiene.
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. NA J had been employed for approximately seven months and three weeks, NA L for one year, NA K for two years and eight months, and NA F for approximately eight months. During interviews, the Assistant Director of Nursing (ADON) confirmed the start dates and acknowledged that some NAs had not passed their certification classes. The Director of Nursing (DON) stated that NAs not certified within four months should be terminated, and the ADON oversees the certification process. The Administrator was under the impression that a waiver for NA certification was still in effect, not realizing it had expired.
Failure to Attempt Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure gradual dose reductions (GDRs) were attempted or that the physician documented the rationale for not attempting a GDR on psychotropic medications for three residents. Resident #1, diagnosed with major depressive disorder and traumatic hemorrhage of the cerebrum, was on sertraline and mirtazapine without any GDR attempts or documentation of contraindications. The resident's pharmacist did not recommend GDRs in multiple reviews, and the care plan did not reflect any GDR attempts or discussions with the physician and family about the ongoing need for the medications. Resident #13, diagnosed with schizophrenia, was on Florentine and Invega. The pharmacist recommended a GDR for Florentine on two separate occasions, but there was no documentation that these recommendations were addressed. The resident's care plan and quarterly MDS did not show any GDR attempts or documentation of clinical contraindications. The social services director confirmed that the pharmacy recommendation was not included in the paperwork for the resident's psychiatry appointment. Resident #22, diagnosed with vascular dementia with agitation and major depressive disorder, was on escitalopram. The pharmacist recommended a GDR, but the physician disagreed without providing a rationale. The resident's care plan and MDS did not reflect any GDR attempts or documentation of clinical contraindications. The Director of Nursing and Medical Director both stated that they expected GDRs to be addressed in a timely manner, but this was not done for the residents in question.
Unsecured Medication Cart
Penalty
Summary
The facility failed to ensure a medication cart was secured when unattended, as observed on multiple occasions. RN T was seen leaving the medication cart unlocked and unattended several times while providing resident care. Specifically, RN T left the cart unsecured and out of sight for approximately three to four minutes on multiple occasions, including when entering residents' rooms, getting ice, and seeking assistance from other staff members. During one instance, a resident walked past the unattended cart, and on another occasion, RN T left a medication on a resident's counter unsupervised while the cart remained unlocked and out of sight. During an interview, RN T acknowledged that the medication cart should always be locked and secured when unattended and that medications should not be left unsupervised in a resident's room. The Director of Nursing also confirmed that the expectation is for medication carts to be securely locked anytime a staff member is not in direct line of sight and that medications should not be left at a resident's bedside. The facility's policy on medication storage emphasizes the importance of securing medication carts and ensuring medications are only accessible to authorized personnel.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food items at a safe and appetizing temperature, as observed during a survey. Multiple residents reported that their meals were not served hot. Specifically, one resident mentioned that their food was not hot, and another resident noted that their breakfast was not warm and that their lunch was inconsistently warm. The facility's Food Storage Guideline and Procedure Manual requires potentially hazardous foods to be kept out of the temperature danger zone (41 degrees Fahrenheit to 135 degrees Fahrenheit). However, observations showed that the food items were not maintained at the required temperatures during meal service. For instance, the Salisbury steak, cheesy noodles, and stewed tomatoes were all served at temperatures significantly below the required 135 degrees Fahrenheit, and the banana pudding was served at a temperature above the required 41 degrees Fahrenheit. The dietary manager and registered dietician both stated that they expected hot foods to be served hot and cold foods to be served cold. The dietary manager admitted that the stovetop and griddle were turned off during meal service because staff felt hot while serving the trays. This practice led to the food cooling down before it was served to the residents. The dietary manager also mentioned that staff sometimes checked the temperature of the food during the meal but did not record these temperatures. Despite these issues, the dietary manager claimed not to have received any recent complaints from residents regarding the temperature of the food. The administrator also confirmed the expectation that hot foods should be served hot and cold foods cold.
Failure to Follow Antibiotic Stewardship Program
Penalty
Summary
The facility failed to follow an antibiotic stewardship program as part of their infection prevention and control program. The facility's policy outlined detailed protocols for antibiotic use and monitoring, including appropriate prescribing, administration, and management practices to reduce inappropriate use. However, the facility did not adhere to these protocols. The review of the facility's antibiotic tracking system showed that for the months of February, March, and April 2024, the tracking only included a list of residents taking antibiotics and the reasons for the prescriptions. There was no indication of culture and sensitivity for UTIs, type of infection for wound infections, or post-antibiotic use tracking. Additionally, there was no evidence of using an antibiotic assessment tool like McGeer's tracking, and no current residents with infections were included in the tracking. During an interview, the Infection Preventionist (IP) admitted to not keeping up to date on antibiotic tracking, believing she was doing too much and that the Director of Nursing (DON) was assisting with the antibiotic stewardship. The IP was unaware that more was required beyond listing the antibiotics being used, their purposes, and infection surveillance. The DON confirmed that the IP was responsible for tracking antibiotic use for the antibiotic stewardship program. The facility's failure to follow its antibiotic stewardship program resulted in inadequate monitoring and documentation of antibiotic use, which is essential for ensuring appropriate treatment and preventing adverse effects. The lack of comprehensive tracking and assessment of antibiotic use indicates a significant deficiency in the facility's infection prevention and control program.
Failure to Provide Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to provide the pneumococcal vaccine as indicated by the current CDC guidelines for five residents out of a sample of 15. The facility's policy stated that residents would be offered pneumococcal vaccinations per CDC and CMS guidelines, and that residents or their legal representatives would be provided with information and education regarding the benefits and potential side effects of the vaccinations. However, the facility did not adhere to these guidelines, resulting in several residents not being up-to-date on their pneumococcal vaccinations. Resident #2, who had diagnoses including type II diabetes mellitus, heart failure, chronic obstructive pulmonary disease, and asthma, was found to be not up-to-date with the pneumococcal vaccine. The resident's immunization record showed that the last PPSV23 vaccine was administered on 10/6/09, which did not meet the current CDC recommendations. Similarly, Resident #11, who had congestive heart failure and severe cognitive impairment, was also not up-to-date with the pneumococcal vaccine, with the last recorded vaccine being administered on 9/28/15. Other residents, including Resident #22, Resident #23, and Resident #30, were also found to be not up-to-date with their pneumococcal vaccinations according to CDC guidelines. The facility's infection preventionist acknowledged that some residents were behind on their vaccinations and admitted to not having had the time to conduct a full review of all residents' vaccinations due to other responsibilities. The facility's Medical Director expected the facility to follow CDC guidelines and ensure that residents' vaccines were up-to-date, but this expectation was not met in these cases.
Failure to Inspect Bed Frames, Mattresses, and Bed Rails for Entrapment Risks
Penalty
Summary
The facility failed to complete inspections of bed frames, mattresses, and bed rails as part of their regular maintenance program to identify areas of possible entrapment for six residents. This deficiency was identified through observation, interview, and record review. The facility's policy on bed rail safety checks was not adhered to, as there was no evidence of inspections being conducted for the residents' beds, which included bariatric beds and beds with assist bars or side rails. The residents involved had various levels of cognitive and physical impairments, requiring substantial assistance with bed mobility and transfers, and some had physician orders for bed rails to assist with mobility and positioning. Resident #2, who was cognitively intact but required maximal assistance with bed mobility, was observed in a bariatric bed with an assist bar. However, there was no documentation of an inspection of the bed frame, mattress, or assist bars. Similarly, Resident #31, who had impaired ADL functioning and required substantial assistance with bed mobility, was observed with assist bars on both sides of the bed, but no inspection records were found. Resident #12, who had hemiplegia following a stroke and used bilateral 1/2 side rails for bed mobility, also had no documented entrapment zone assessment or physician order for side rails prior to the survey. Other residents, including Resident #23 with severe cognitive impairment and obesity, Resident #15 with hemiplegia and Parkinson's disease, and Resident #30 with severe cognitive impairment and Alzheimer's, were also found to have bed rails without documented inspections. Observations showed these residents using bed rails for mobility and positioning, but there were no records of entrapment zone assessments or measurements. The Director of Nursing confirmed that no entrapment zone assessments or measurements had been completed prior to the annual survey, indicating a systemic failure in the facility's maintenance and safety protocols for bed rails and mattresses.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect. The resident, who had moderate cognitive impairment, reported multiple instances of being treated rudely by a Nurse Assistant (NA). The NA was overheard being impatient and telling the resident to 'do it yourself' during a toileting transfer. The resident expressed feeling like a burden and teared up when discussing the interactions with the NA. The NA admitted to sometimes not laying the resident down when requested and acknowledged that the resident might be upset due to having to sit on a hard toilet longer than desired. The Director of Nursing (DON) was aware of the complaints against the NA and emphasized that residents should be treated respectfully, like guests in their own home. Despite the grievances and the resident's emotional distress, the NA continued to exhibit behavior that made the resident feel disrespected and neglected. The facility's policy on resident rights, which includes treating residents with kindness, respect, and dignity, was not upheld in this case.
Failure to Notify Physician and Family of Resident Fall
Penalty
Summary
The facility failed to notify the physician and/or responsible party when a resident had a fall with a minor injury. The resident, who had severe cognitive impairment and dementia, experienced an unwitnessed fall resulting in a small laceration to the right upper cheek. The nursing progress notes did not document any notification to the resident's physician or next of kin regarding the fall and injury. The responsible party confirmed that they were not informed about the incident and cited a lack of communication and frequent staff changes as ongoing issues. The Registered Nurse on duty at the time of the fall admitted to not notifying the necessary parties immediately, as they were also dealing with another critical situation. The RN assumed that the day shift would handle the notifications but did not explicitly communicate this to the day shift nurse. Both the Director of Nursing and the Medical Director stated that they expected staff to notify family and physicians of any condition changes or falls with injuries, which did not occur in this instance.
Failure to Report Resident-to-Resident Abuse in a Timely Manner
Penalty
Summary
The facility failed to report a resident-to-resident abuse allegation to the state agency within the required two-hour timeframe. The incident involved Resident #19 hitting Resident #11 with a fly swatter after Resident #11 got too close to Resident #19's table. Despite the facility's policy requiring immediate notification to the state agency in cases of serious bodily injury, the incident was not reported as required. The facility's undated policies on Resident-to-Resident Altercations and Reporting of Abuse Allegations were not followed, as the incident was not reported within the stipulated timeframes. Interviews revealed that the staff did not follow proper reporting procedures. LPN C, who was informed of the incident, sent a text message to the Nurse Manager and Administrator but did not receive a response. The Director of Nursing and the Administrator were not notified of the incident in a timely manner, and the state agency was not informed until two days later. The failure to report the incident promptly was attributed to a lack of proper communication and adherence to the facility's policies by the staff involved.
Failure to Complete Significant Change in Status Assessments
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for two residents, despite significant changes in their conditions. Resident #30 experienced a decline in multiple activities of daily living (ADLs), was started on a new antianxiety medication, and was placed on a mechanically altered diet. Observations showed that the resident required substantial assistance from staff for various tasks, including eating and transfers, yet no SCSA was completed to reflect these changes in the resident's care plan. Resident #36 showed both improvements and declines in various ADLs, including becoming independent with eating and bed mobility but requiring more assistance with toileting hygiene and bathing. Additionally, the resident experienced a significant weight gain. Despite these changes, the resident's medical record did not include an SCSA to update the care plan accordingly. Interviews with the facility's MDS Coordinators revealed a lack of formal training and communication issues between the on-site and off-site staff responsible for completing the MDS assessments. The Director of Nursing stated that the MDS should be coded according to the RAI manual, indicating an expectation that was not met in these cases.
Failure to Complete PASRR Screenings Prior to Admission
Penalty
Summary
The facility failed to ensure that two residents had a preadmission screening for individuals with a mental disorder and individuals with an intellectual disability (PASRR) completed prior to admission. Resident #13, who was admitted with a diagnosis of schizophrenia, had no documentation of a Level I or Level II PASRR in their medical record. The resident's quarterly Minimum Data Set (MDS) also had the PASRR sections left blank. Similarly, Resident #23, who had diagnoses including dementia with behavioral disturbance, depression, and PTSD, also had no documentation of a Level I or Level II PASRR in their medical record. The resident's quarterly MDS had the PASRR sections left blank as well. During an interview, the administrator acknowledged that the facility did not have a specific policy for PASRR screenings but followed state guidelines. The administrator also confirmed that she was aware of the requirement for all residents to have at least a Level I PASRR screening prior to admission. An email from the state agency confirmed that no Level I PASRR screening was found for Resident #23, further highlighting the facility's failure to comply with PASRR requirements.
Failure to Provide Comprehensive Discharge Summary
Penalty
Summary
The facility failed to provide a discharge summary containing a recapitulation of the resident's nursing home stay for Resident #39, who was discharged to his/her home. The resident, who was cognitively intact and had multiple medical conditions including sepsis, high blood pressure, obstructive uropathy, nicotine dependence, polyneuropathy, a Stage 4 sacral region pressure ulcer, and a right below knee amputation, did not receive a comprehensive discharge summary. The resident's care plan indicated various levels of assistance required for daily activities and medical needs, including an indwelling urinary catheter and a pressure ulcer on the coccyx. Despite these needs, the facility did not have a policy regarding discharge recapitulation, as confirmed by an email from the administrator dated 4/16/24. The Director of Nursing (DON) acknowledged that a recapitulation summary should be completed by all departments but was not done in this case. The resident's discharge instructions only included medications, upcoming appointments, and home services, without a detailed summary of the resident's stay in the facility. The resident's medical record showed no documentation of a recapitulation summary, and the DON confirmed that the charge nurse was responsible for completing discharge instructions. The resident was discharged to home on 4/1/24, with the Social Services Director and a transporter assisting with the discharge. The resident's face sheet and wound orders were faxed to two home health companies, both of which denied services due to compliance and refusal of care. The lack of a comprehensive discharge summary represents a failure in the facility's discharge process, as it did not provide the necessary information to the resident and the receiving health care provider.
Failure to Ensure Qualified Staff for Residents with Complicated Feeding Problems
Penalty
Summary
The facility failed to ensure that two residents with complicated feeding problems were assisted with feeding by qualified staff. Hospitality Aide (HA) M, who was a paid feeding assistant and not a certified nurse aide, fed the residents without the supervision of a Registered Nurse (RN) or Licensed Practical Nurse (LPN). Resident #30, who had severe cognitive impairment and was on a mechanical soft diet, was fed by HA M without any licensed staff present. Similarly, Resident #37, who had severe cognitive impairment, a mechanically altered diet, and a history of coughing or choking during meals, was also fed by HA M without supervision from licensed staff. The facility's list of residents eligible for assistance from feeding assistants included both Resident #30 and Resident #37, despite their complicated feeding issues. HA M's employee file showed that he/she had completed feeding assistant training but was not a certified nurse aide. Interviews with HA M, the Director of Nursing, and the Administrator revealed a lack of awareness and understanding regarding the restrictions on feeding assistants and the necessity for supervision by licensed staff when assisting residents with complicated feeding problems.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to post required nurse staffing information, including the total actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift on a daily basis. The facility census was 31. Review of the facility's staffing sheets on multiple dates showed missing information for both day and night shifts, including staff working, total hours worked, and census data for RNs, LPNs, CMTs, CNAs, and NAs. Specific dates with deficiencies included 4/5/24, 4/9/24, 4/12/24, 4/13/24, 4/15/24, 4/16/24, and 4/17/24. Observations confirmed that the staffing postings were incomplete or outdated on these dates, failing to meet regulatory requirements for daily staffing information display. Interviews with staff revealed that the charge nurses on each shift were responsible for posting and updating the staffing sheets. However, this responsibility was not consistently fulfilled. An LPN confirmed that all areas of the staffing sheet were supposed to be completed, while the Director of Nursing stated that charge nurses were expected to adjust the staffing information each shift if there were changes. Despite these expectations, the facility did not ensure that the staffing information was accurately and consistently posted, leading to the identified deficiencies.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide appropriate CMS Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) and the CMS Notice of Medicare Non-Coverage (NOMNC) in writing to three residents when initiating discharge from Medicare Part A services, despite benefit days not being exhausted. Specifically, the facility did not provide written NOMNCs or include the necessary Quality Improvement Organization (QIO) contact information for Residents #1, #33, and #91. Additionally, the facility did not complete or provide ABNs for these residents or their representatives, even though the residents had remaining Medicare Part A days and continued to reside in the facility. During an interview, the Administrator admitted to not having a policy regarding ABN and NOMNC notices and was unaware of the requirements for providing these notices, including the necessity of including QIO contact information and issuing written notices to residents or their representatives. The Administrator also acknowledged that she did not know that ABNs and NOMNCs had to be given to residents who would remain in the facility with Medicare Part A days remaining. This lack of knowledge and policy led to the failure in providing the required notices to the residents and their representatives.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to discrepancies in their assessments. Resident #6 was incorrectly coded as comatose despite being independent in several activities and having no documented diagnosis of coma. The resident's care plan did not address cognition, and the resident was discharged after 12 days without the error being corrected. Resident #17, who was on hospice care, had MDS entries that failed to reflect their hospice status and life expectancy accurately. Despite being on hospice until their death, the MDS did not document this, leading to inconsistencies in the resident's records. Resident #15 had a dysphagia directive and several medical conditions, including Parkinson's disease and hemiplegia. However, the MDS assessments did not accurately reflect the resident's cognitive status or swallowing disorder. The resident's care plan mentioned the risk of impaired nutritional status and the need for monitoring chewing and swallowing difficulties, but these were not properly coded in the MDS. The facility's MDS Coordinators had limited training and did not review each other's work, leading to these inaccuracies. Interviews with the facility staff revealed that the MDS assessments were not conducted according to the Resident Assessment Instrument (RAI) manual. The Director of Nursing expected the MDS to be coded correctly, but the lack of formal training and oversight resulted in significant errors. The facility's failure to ensure accurate and comprehensive assessments compromised the quality of care provided to the residents.
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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