Buffalo Prairie Center For Rehab And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Buffalo, Missouri.
- Location
- 631 West Main Street, Buffalo, Missouri 65622
- CMS Provider Number
- 265471
- Inspections on file
- 29
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 17 (1 serious)
Citation history
Health deficiencies cited at Buffalo Prairie Center For Rehab And Healthcare during CMS and state inspections, most recent first.
Staff failed to honor a full-code resident’s wishes for CPR when an LPN discontinued resuscitation efforts before EMS arrived. The resident, who had COPD, prior intracerebral hemorrhage, and kidney cancer, was documented as full code on the face sheet, care plan, and physician orders. When the resident was found unresponsive with fluid from the nose and mouth and no pulse, the LPN verified full-code status, directed staff to call 911, and began chest compressions. As fluid and vomit were observed, the LPN rolled the resident to the side, then stopped CPR, stating the resident had aspirated and could not be resuscitated, and did not proceed with suction. Other staff and later-arriving EMS and the coroner confirmed that CPR had been stopped prior to EMS arrival, despite facility expectations that CPR for a full-code resident be continued until EMS assumes care.
Staff failed to ensure accurate administration and documentation of an antibiotic and steroid regimen for a resident with COPD and pneumonia. The physician ordered cefdinir for a defined seven-day course and a tapering prednisone schedule, but the MAR showed cefdinir documented for ten days while a medication card still contained unused doses, and progress notes indicated the drug was unavailable on some of the days it was charted as given. Prednisone doses for two ordered periods were not documented as administered, and an unopened prednisone card was found despite active orders. Multiple CMTs, LPNs, the DON, and the Medical Director acknowledged that medications should be given and documented as ordered, that blanks on the MAR indicate doses were not given, and that unavailability should be recorded, yet there were unexplained discrepancies between orders, MAR entries, and actual medication availability.
A resident with a history of spina bifida, UTIs, pyelonephritis, sepsis, urostomy, and a brain shunt was not care planned for shunt monitoring, and no shunt-related orders or staff training were documented. The resident experienced frequent headaches and neck/shoulder pain, with repeated PRN Tramadol and Acetaminophen use and several episodes of unrelieved pain, yet progress notes often lacked pain characteristics and there was no consistent evidence of MD notification when pain persisted. The resident’s WBCs were elevated, but follow-up CBC orders and timely MD notification were not documented, and urine output records were inconsistent despite reports from CNAs of decreasing output and dark, tea-colored urine. Staff interviews described the resident’s worsening pain, confusion, hallucinations, low BP, puffy face, distended abdomen, and dark urine, while management initially discussed treating in-house before the resident was eventually sent to the hospital, where hydrocephalus requiring shunt replacement and urosepsis with septic shock were diagnosed.
A resident with paralysis and high risk for skin breakdown developed extensive pressure-related wounds to the coccyx, sacrum, and bilateral buttocks after staff failed to consistently assess, document, and obtain MD orders for a new coccyx wound, did not update the care plan, and did not ensure use of pressure-reducing devices despite MDS-identified need. Initial documentation lacked wound measurements, detailed descriptions, and timely MD notification, and subsequent worsening with open, weeping, foul-smelling areas was reported by staff as resembling “hamburger meat” with odor and blackened areas. Wound orders were inconsistently entered on the POS, weekly skin and wound assessments were missed or incompletely documented, and staff interviews revealed confusion about responsibility and frequency for wound monitoring and documentation after the ADON who previously managed wound assessments was no longer in that role.
Surveyors identified a failure to maintain a sanitary, orderly, and comfortable environment, with multiple halls and rooms containing dried stains, accumulated debris, overflowing trashcans, strong urine and bowel odors, and trash and food crumbs on floors and under beds. A resident reported routinely cleaning their own room and having soiled bedding left on the floor for days, while another resident noted delays in trash removal and better cleanliness on weekdays when housekeeping was present. Staff, including CNAs, a COTA, and a housekeeper, described the building as dirty at the start of shifts, especially after weekends, with trash left by night and weekend staff, shower rooms cluttered with linens and clothing, frequent overflowing trashcans, and uncertainty about housekeeping coverage and leadership, despite existing policies requiring routine and cycle cleaning of all resident-use areas.
A resident with neuromuscular bladder dysfunction and an indwelling catheter did not have catheter care addressed in the care plan or physician orders, despite facility policy requiring catheter care every shift. During observed care, CNAs used a single washcloth on the inner thighs, did not change gloves or perform hand hygiene between perineal and bowel care tasks, failed to retract the foreskin, and cleansed the catheter tubing from the distal end toward the meatus instead of away from the body. Staff interviews, including with the CNA, another CNA, the DON, and the Administrator, confirmed that catheter tubing was expected to be cleansed away from the body to prevent infections, which was not followed in this instance.
Surveyors identified that staff failed to follow the facility’s infection control policies during peri-care for a resident with an indwelling catheter and during wound care for a resident with lower extremity ulcers. During catheter and peri-care, CNAs moved from cleaning bowel incontinence to handling clean briefs, the catheter, the drainage bag, the toilet, and the sink without changing gloves or performing hand hygiene, and did not disinfect surfaces touched with soiled gloves. In a separate wound treatment, an LPN began care without hand hygiene, placed soiled scissors on a clean barrier next to sterile supplies, repeatedly reached into bulk gauze and handled clean supplies with contaminated gloves, then later used those previously contaminated supplies to dress the wound and returned contaminated bulk items to the treatment cart. Interviews with CNAs, the DON, and the Administrator confirmed that these actions were inconsistent with facility expectations for hand hygiene, glove changes, and cleaning of reusable items.
The facility failed to maintain an effective pest control program when multiple flies were repeatedly observed on and around several residents and in their rooms, despite an existing pest control policy and contracted services. One cognitively impaired resident was seen in bed with numerous flies crawling on their hands, legs, body, and linens, while other cognitively intact residents reported that flies were always present, were bothersome, and required them or family to swat and kill multiple flies during visits. Staff, including an RN, reported that flies had recently become widespread after warmer weather, that the issue had been reported to the Administrator and DON, and that flies posed infection control concerns, while the DON, Maintenance Supervisor, and Administrator each described expectations that staff report fly problems to maintenance and rely on pest control monitoring and bug lights.
A resident with severe cognitive impairment and behavioral symptoms was slapped by a staff member during care, and the incident was not reported to facility management or the state agency within the required two-hour timeframe. Staff interviews confirmed knowledge of immediate reporting requirements, but the delay in reporting resulted in noncompliance with abuse prevention and reporting policies.
A facility failed to conduct a timely and thorough investigation into an allegation of physical abuse involving a resident with severe cognitive impairment and behavioral symptoms. The investigation relied only on statements from the two nurse aides involved, without interviewing other staff or residents, and lacked documentation of immediate protective measures for all residents during the investigation.
Staff failed to consistently document and administer physician-ordered medications for multiple residents, resulting in numerous undocumented doses of critical medications such as insulin, antipsychotics, pain relievers, and antibiotics. Residents with complex medical needs reported missed or late medications, and staff interviews revealed that documentation was often incomplete due to workload. Leadership was unaware of the extent of these lapses, and required documentation and notification procedures were not followed.
Three cognitively intact residents with chronic conditions, including diabetes and GERD, consistently received meals that were not served at appropriate temperatures, with food items measured below the required 135°F. Staff and dietary personnel acknowledged receiving complaints about cold food, and a test tray confirmed substandard temperatures. There was inconsistent understanding and application of the facility's food temperature policy among staff.
Facility staff did not complete an admission MDS assessment within the required timeframe for a resident with multiple complex diagnoses, and there was no documented policy on MDS assessments. Interviews with staff confirmed the assessment was not completed as required.
A resident with multiple complex diagnoses was moved to a locked memory care unit after several behavioral incidents involving theft of food and beverages. Staff did not complete a significant change MDS assessment following the transfer, and the care plan was not updated to address the behaviors that led to the move. Facility staff confirmed the required assessment was not completed.
A resident was transferred to the hospital after experiencing chest tightness, tachycardia, and fever, but staff did not complete the required discharge with return anticipated MDS or the readmission MDS within the mandated timeframe. Interviews revealed that the MDS Coordinator was new to the role and the facility lacked a policy for MDS assessments, resulting in the deficiency.
Staff did not complete a baseline care plan within 48 hours for a newly admitted resident with multiple complex diagnoses, contrary to facility policy. Documentation was missing, and staff interviews revealed confusion about the required timeframe for baseline care plan completion.
Staff failed to complete a comprehensive care plan for a resident with multiple complex diagnoses after admission, and did not update another resident's care plan to address repeated behavioral incidents and a subsequent move to a locked unit. Interviews with the SSD, MDS Coordinator, Administrator, and DON confirmed that care plans were not completed or updated as required by facility policy.
The facility did not pay overdue invoices for a portable generator, leading to the removal of the generator after repeated warnings from the service provider. Observations confirmed the absence of an operational generator on site, and interviews revealed that facility leadership was unaware of the outstanding debt due to invoices being sent directly to ownership. The facility lacked a policy on timely payments to service providers.
Two nurse aides provided direct care without completing required CNA training and certification within the mandated 120-day period. Personnel files lacked documentation of certification, and facility leadership acknowledged lapses in oversight and compliance with CNA training requirements.
A resident with Alzheimer's disease, chronic kidney disease, and BPH was left in a Broda chair for over two hours with visible urine incontinence, despite staff passing by and facility policy requiring checks every two hours and as needed. The resident was not checked or changed until prompted by a surveyor, resulting in saturated clothing and chair. Staff interviews revealed uncertainty about care routines and acknowledged the resident should have been attended to sooner.
The facility was cited for ineffective and inefficient use of resources, as identified in a survey. The citation pertains to the overall management and resource utilization practices, without specific details on actions or individuals involved.
The facility failed to maintain adequate RN and DON staffing, leading to the DON working as a charge nurse or CNA, which hindered her ability to perform essential duties. This resulted in a lack of effective antibiotic stewardship and significant medication errors, including missed warfarin doses and unavailable medications.
The facility failed to employ a qualified dietary manager for its food and nutrition services department. The current dietary manager lacked necessary certifications and training, such as being a certified dietary manager or having an associate's degree in food service management. The administrator was unaware of these requirements, leading to a deficiency in staffing qualifications.
The facility failed to maintain an effective infection control program, particularly in preventing Legionella growth and ensuring proper hand hygiene. The facility lacked a Legionella risk assessment and did not monitor water conditions. Staff, including the DON and CMTs, were observed not performing hand hygiene during medication passes, despite being aware of its importance.
The facility failed to maintain an effective antibiotic stewardship program, lacking a current and ongoing log for residents with active infections. Despite having a policy in place, the facility only provided a printout of antibiotic prescriptions for September, with no further tracking documentation. Interviews with the DON revealed no residents on antibiotics, no documented tracking measures, and no outcome surveillance related to antibiotic use. The Administrator expected adherence to guidelines, but the deficiency indicates a lack of proper implementation.
A LTC facility failed to maintain a medication error rate below 5%, resulting in a 12.82% error rate. Errors included administering incorrect medication forms and dosages, and improper techniques for g-tube medication administration. A resident received a tablet instead of liquid medication, another received incorrect dosages, and a third had medications improperly combined for g-tube administration.
The facility failed to store controlled substances securely and left medication carts unlocked and unattended. Controlled substances for two residents were not stored under two locks, and medication carts containing narcotics were left unlocked in areas accessible to residents. Staff interviews confirmed the expectation for secure storage, but observations showed non-compliance with these protocols.
A resident with chronic conditions was found without accessible water on multiple occasions, despite care plan requirements for thickened liquids. Observations showed the resident was visibly thirsty, and staff interviews revealed confusion about hydration protocols. The facility failed to ensure water was accessible during regular rounds.
A facility failed to conduct the required PASARR Level 1 screening for a resident with mental disorders before admission. The resident, diagnosed with major depressive disorder, bipolar disorder, and psychosis, exhibited symptoms such as delusions and socially inappropriate behavior. Despite these indicators, the PASARR was not completed, as confirmed by the Central Office Medical Review Unit. The Social Services Designee was responsible for the PASARR but only completed it if the hospital had not done so.
The facility failed to provide adequate pressure ulcer care and documentation for two residents, leading to deficiencies in wound management. Staff did not consistently assess and document pressure ulcers, and treatment orders were not entered into the system. Interviews revealed that the former wound nurse did not enter treatment orders, resulting in a lack of documented care.
The facility failed to manage oxygen equipment per standards for two residents with COPD, resulting in undated or outdated nasal cannulas and tubing. Despite orders for weekly changes, observations showed equipment unchanged since mid-month. Staff interviews revealed confusion over responsibilities, contributing to the deficiency.
Two residents experienced inadequate pain management due to the facility's failure to administer prescribed medications and document substitute orders. One resident with multiple fractures did not receive morphine or Percocet due to pharmacy delays, while another resident with COPD and cancer faced similar issues with Tylenol and oxycodone. Staff interviews revealed systemic problems with medication procurement and documentation, leading to prolonged pain for the residents.
A resident with schizophrenia and major depressive disorder did not receive their prescribed escitalopram oxalate on multiple occasions due to the medication's unavailability. Despite facility policies requiring timely reordering and follow-up with the pharmacy, staff failed to ensure the medication was available, leading to missed doses. The DON and other staff were not consistently aware of the medication's status, and the facility's tracking system was not reviewed daily, contributing to the deficiency.
A resident with thrombophilia missed three doses of warfarin sodium due to unavailability, as documented by a CMT. The medication was on hold but should have been restarted, and staff failed to notify the DON or physician about the missed doses. The facility's policy required immediate reporting of such discrepancies, which was not followed, resulting in a significant medication error.
The facility failed to maintain complete medical records for two residents transferred to the hospital and later returned. Documentation lacked details such as the reason for transfer, time, and physician notifications. Interviews with staff revealed expectations for obtaining physician orders and documenting all relevant details, which were not followed.
CPR Discontinued Early for Full-Code Resident Prior to EMS Arrival
Penalty
Summary
Facility staff failed to ensure a full-code resident’s wishes regarding cardiopulmonary resuscitation (CPR) were honored when CPR was discontinued prior to EMS arrival. The resident had diagnoses including COPD with acute exacerbation, nontraumatic intracerebral hemorrhage, and malignant neoplasm of the kidney, and was documented as a full code on the face sheet, care plan, and physician orders. The care plan and facility CPR policy required that staff provide basic life support, including CPR, in accordance with the resident’s advance directives and continue CPR prior to EMS arrival if the resident did not show obvious signs of clinical death. On the morning of the incident, an LPN entered the resident’s room and observed the resident sitting on the side of the bed with a cup in hand, appearing as if preparing to get a drink. After tending to the roommate and returning, the LPN noted the resident was unresponsive, with fluid coming from the nose and mouth, and no palpable pulse. The LPN asked another staff member to verify the resident’s code status, was informed the resident was full code, and directed staff to call 911. The LPN initiated chest compressions, during which fluid continued to come from the resident’s mouth and nose. The LPN rolled the resident to the side to allow more fluid to drain, observed vomit on the bedding, and then rolled the resident back and continued compressions. The LPN reported the resident felt room temperature and that the chest felt soft and mushy during compressions. According to written statements and interviews, the LPN stopped CPR after determining the resident had aspirated and believing resuscitation was not possible, despite the resident’s full-code status and without EMS on scene. CNA and CMT staff present confirmed that CPR was started and then discontinued, and that the LPN declined to continue compressions or use suction, stating the resident had aspirated too much and that nothing more could be done. EMS personnel and the county coroner later arrived and found the resident with dependent back lividity and no CPR in progress; both stated that CPR should have been continued until EMS arrival. Multiple staff interviews, including CNAs, CMTs, LPNs, the DON, the Administrator, and the Medical Director, consistently described that facility practice and expectations were to initiate CPR for full-code residents and continue until EMS arrival or a physician pronouncement, indicating that in this case staff actions did not follow the resident’s documented wishes or the facility’s stated process.
Failure to Accurately Administer and Document Antibiotic and Steroid Therapy
Penalty
Summary
Facility staff failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for one resident with COPD, nontraumatic intracerebral hemorrhage, and kidney cancer. The resident had moderate cognitive impairment, shortness of breath with exertion, at rest, and when lying flat, and was receiving oxygen therapy. On one occasion, the resident was found with an oxygen saturation of 78% on six liters via nasal cannula, with bilateral wheezing and rhonchi and diminished lung sounds at the bases. Staff documented that the resident was on prednisone until a specified date and had completed a course of cefdinir for pneumonia, and the physician was notified for further recommendations. Subsequent physician documentation showed that, due to non-resolving pneumonia, the resident was to continue cefdinir 300 mg PO BID for seven days and start prednisone 40 mg PO daily for five days, then decrease by 5 mg every five days until discontinued. The February Physician Order Sheet reflected an order for cefdinir 300 mg PO BID for seven days, and prednisone 40 mg PO daily for five days followed by prednisone 35 mg PO daily for five days. However, the February MAR showed cefdinir documented as administered twice daily for ten days, three days longer than ordered, and staff progress notes later documented that cefdinir was not available on two of those days. The MAR also showed no documentation of prednisone administration for the ordered periods, with only a single prednisone dose documented on a later date. Observation of the medication storage revealed an unopened package of prednisone 35 mg, ordered once daily for five days, and a cefdinir medication card dated earlier in the month with three of fourteen capsules remaining, despite MAR documentation indicating administration beyond the seven-day order. Interviews with the Medical Director confirmed that all medications should be administered and documented as prescribed, and that he would presume medications were not given if not documented. Multiple CMTs and LPNs stated that medications should be administered as ordered, that blanks on the MAR indicate medications were not administered, and that unavailability or refusals should be documented on the MAR and in progress notes. Staff also reported issues with medication availability related to a pharmacy change. The DON and Administrator both stated that medications should be administered as prescribed, that there should be no blanks on the MAR, and that medications should not remain on the MAR past the stop date, but they were unaware of why cefdinir was documented past the stop date, why doses remained, or why prednisone doses were not documented or administered as ordered.
Failure to Monitor Brain Shunt, Manage Pain, and Respond to UTI/Sepsis Signs
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, resident preferences, and goals for a resident with complex medical needs, including a brain shunt, urostomy, history of UTIs, acute pyelonephritis, and sepsis. The resident’s face sheet and care plan did not include a diagnosis of a brain shunt, and there were no physician orders or care plan interventions for monitoring the shunt. Staff were not documented as being trained or informed about shunt care, and there was no systematic monitoring of head, neck, or shunt-related symptoms despite frequent complaints of headaches and pain. The facility’s pain management policy required evaluation of pain upon admission and with changes in condition, use of appropriate pain assessment tools, and development and revision of interventions, but documentation repeatedly lacked characteristics of the pain, including location and quality, and did not reflect consistent reassessment or escalation when pain was not relieved. The facility also failed to effectively address increasing pain in the resident’s head, neck, and shoulder areas and did not consistently notify the physician of unrelieved or escalating pain. MAR and progress note reviews showed numerous PRN administrations of Tramadol and Acetaminophen for pain scores ranging from 3 to 9 out of 10, including generalized body aching, back pain, and neck and shoulder pain, with multiple instances where pain remained at 5–7 out of 10 after medication. Progress notes frequently omitted the characteristics or location of the pain, and when pain was not relieved, there was no documentation that the physician was notified. Interviews with CNAs indicated the resident complained of daily headaches, described the head as "blowing up or exploding," cried from pain, and reported pain at the shunt site, yet these complaints were only reported verbally to nurses and not reflected in detailed clinical documentation or care plan revisions. A roommate reported the resident’s head appeared swollen and that the resident became confused several days before hospital transfer. In addition, the facility failed to timely recognize and respond to signs of possible UTI and sepsis, and did not complete or follow up on ordered labs for elevated WBCs. The resident had a history of UTIs, kidney infections, and sepsis, and a WBC of 14.4 was documented in December, followed by a WBC of 16.8 on 01/06/26. There was no prompt physician notification documented for the increasing WBC, and although a physician note later referenced leukocytosis with a plan to recheck the CBC, no new lab orders appeared on the POS and no follow-up lab documentation was found. The care plan required monitoring and reporting of signs of kidney infection and sepsis, including no output, deepening urine color, and other symptoms, but MARs showed inconsistent urine output documentation, with multiple days lacking any recorded output. CNAs reported decreasing urine output from several bag drainings per shift to sometimes once per day, and described dark, tea-colored, and burnt orange urine, as well as the resident’s decreased eating, confusion, hallucinations, low blood pressure, puffy face, and distended abdomen. Although these findings were eventually reported to nursing staff, there was a delay in sending the resident to the hospital, and management initially discussed treating the resident in-house and attributing confusion to new medication. The resident was ultimately transferred to the hospital, where documentation showed diagnoses of hydrocephalus requiring shunt removal/replacement and urosepsis with septic shock, with the resident intubated and sedated in the ICU and a WBC of 43.7.
Failure to Assess, Treat, and Document Pressure Ulcers and Prevent Worsening Wounds
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer treatment and preventive services consistent with professional standards for a resident who was at risk for skin breakdown and later developed extensive pressure-related wounds. The resident had spina bifida with paralysis, neuromuscular bladder dysfunction, a history of UTIs and sepsis, and required substantial to maximum assistance with ADLs and mobility. The resident’s MDS indicated intact cognition, no existing pressure ulcers, risk for pressure ulcers, and a need for pressure-reducing devices for bed and chair. The care plan directed staff to assess, record, and monitor wound healing as ordered, measure wounds, document wound bed and perimeter, report changes to the MD, and follow facility policies for prevention and treatment of skin breakdown. On a weekly skin assessment dated early in the month, staff documented no open areas and no pressure-reducing devices in use, with only skin discoloration on the left buttock. A few days later, the DON documented being called to the resident’s room for an open coccyx area and applied a foam dressing, but there was no documented full wound description, no measurements, and no documentation of MD notification or treatment orders for this new area. The POS for that month did not contain orders for pressure-reducing devices or for treatment of the new coccyx wound, and no new skin assessment was completed after the earlier weekly assessment. The care plan was not updated to reflect the new coccyx wound, and progress notes for the following week contained no wound assessments or documentation related to the open area. Later in the month, a nurse documented that the resident’s coccyx, sacrum, and bilateral buttocks were open, red, irritated, and weeping serous drainage, and that the MD was notified and wound care orders were received and applied. However, this note still lacked wound measurements and a detailed wound description, and the new wound orders were not entered on the POS. A physician progress note documented ulcerations to the coccyx, sacrum, and bilateral buttocks and the need for a wheelchair cushion for pressure reduction, but no order for a pressure-reducing cushion was documented on the POS. A subsequent wound assessment recorded multiple open areas on both buttocks with specific measurements and daily dressing changes, but again without detailed descriptive characteristics. Shortly thereafter, the resident was hospitalized, and a surgery consult described excoriated sacral skin, necrotic-appearing tissue near the anus, and foul-smelling purulent drainage. Interviews with CNAs, nurses, and other staff showed inconsistent understanding and implementation of wound assessment and documentation practices. CNAs and other staff described the buttock wounds as looking like “hamburger meat,” oozing, bleeding, with odor and blackened areas, while RNs and LPNs acknowledged that nurses were responsible for wound care, assessments, and documentation. Staff reported that an ADON had previously completed weekly wound assessments and that after the ADON’s departure, expectations for who would perform and document weekly wound measurements were unclear. One LPN who completed a weekly wound assessment stated that measurements were documented on paper and should have been entered into the EMR but was unsure how regularly wounds should be monitored or documented. The DON stated she expected weekly skin and wound assessments with measurements, MD notification for new open areas, and documentation of assessments, but indicated she did not become aware of the wounds opening until around the middle of the month. The Administrator stated an expectation that wounds and skin be assessed, monitored, measured, documented, and that care plans be individualized, which did not occur in this case.
Failure to Maintain Sanitary and Clean Resident Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior environment in resident-use areas, despite written policies requiring routine and cycle cleaning. Surveyors observed multiple instances of unclean conditions throughout several halls and rooms. On Buffalo Blvd. Hall, there was a large dried splatter stain with a white crust on the floor, a large pile of dried leaves accumulated at an exit door, and a resident room with a pillow on the floor amid food crumbs, napkins, tissues, a clear cup, and an empty food box. Between two rooms, an orange medication cart cap and a single blue plastic glove were on the floor. On Memory Lane Hall/Unit, surveyors noted a strong urine odor upon entering. The dining room trash can at the end of the serving counter was overflowing, with trash and napkins on the surrounding floor. In the TV/visiting area, a resident was reclined in a chair next to a wheeled side-table cart heaped with trash, including soda cans, rolled tissues, and wrappers, with food crumbs, tissues, and an elastic hair band on the floor under the recliner. Multiple rooms on this unit had tissue and food crumbs on the floor, large stained discolorations on the floor, popcorn and wadded trash items on the floor, overflowing trashcans, splatter-like stains across the floors, and various discarded items such as straws, wrappers, tissues, Q-tip wrappers, and bottle caps under beds. On a later observation date, one room had a strong urine odor, wadded trash under the bed, and dried, hardened wads of paper splattered onto the floor. On Prairie Lane Hall, a wadded-up piece of paper was observed on the floor outside a room and appeared to remain in the same location several days later. A cognitively intact resident reported usually cleaning the room independently because it took too long for staff to do it, stating that housekeeping staff were good but too few, and that other staff did not help with cleaning. This resident’s room had a strong bowel odor, and the resident pointed out a pile of soiled bedding under the sink counter that had been removed from the bed two days earlier and not picked up, causing embarrassment. Another cognitively intact resident stated that staff would empty trash but took a long time to do so, and that weekdays were better because housekeeping came to help clean rooms. Staff interviews further described ongoing cleanliness issues. A COTA reported noticing the facility in disarray at times and personally cleaning gum wrappers from under a resident’s bed because they had been there so long. A CNA stated the facility was dirty at the start of shifts, that night shift staff were the worst about throwing trash around, and that there was no current housekeeping department head after the prior Maintenance Director left. This CNA also reported that some residents were incontinent and that urine-containing items in trash contributed to odors, and that plumbing issues caused sewer smells, especially after showers. Another CNA reported the facility was filthy on Monday mornings and after weekends, with weekend staff leaving trash in rooms instead of disposing of it. A housekeeper stated it was normal to arrive each day to find trash all over floors, shower rooms with clothes, bedding, and towels scattered, and overflowing trashcans. Another CNA said housekeeping tasks completed depended on who was working, that housekeepers were supposed to clean every room daily and deep clean monthly, and that they always carried trash bags because someone’s room was always dirty. The DON reported there were three or four housekeeping staff, was unsure if housekeeping worked weekends, and stated housekeeping should empty trash, sweep, and wipe surfaces daily, with aides also able to perform these tasks. The Administrator stated an expectation that all staff pick up after any mess they make and that staff try to clean when they notice cleanliness or odor issues.
Failure to Provide Proper Catheter Care and Care Planning for Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate catheter care and related services for a resident with an indwelling urinary catheter, as required by facility policy and the resident’s needs. The resident was cognitively intact, dependent on staff for toileting, and had a diagnosis of neuromuscular dysfunction of the bladder with an indwelling catheter in use. The resident’s care plan addressed monitoring intake and output, catheter tubing kinks, pain or discomfort related to the catheter, and signs and symptoms of urinary tract infections, but did not include any interventions for catheter care. Review of the physician orders for the month showed there were no orders related to catheter care, despite the facility’s written policy requiring catheter care every shift and as needed. During an observed catheter care episode, two CNAs entered the resident’s room, performed hand hygiene, and donned PPE. One CNA removed the resident’s brief while the other cleansed the resident’s inner thighs with a single wet washcloth, folding it over between swipes but not obtaining a new washcloth. The CNA did not remove soiled gloves, perform hand hygiene, or apply new gloves before proceeding. The CNA did not retract the foreskin and cleansed the catheter tubing from the distal end toward the proximal end at the meatus, contrary to the facility policy that required cleansing from the meatus outward. The CNA then provided care to the resident’s backside after bowel incontinence without changing gloves or performing hand hygiene before placing a clean brief under the resident, adjusted the catheter, and hung the catheter bag on the bed. Interviews with the CNA, another CNA, the DON, and the Administrator confirmed that catheter tubing was expected to be cleansed away from the body to prevent infections, which did not occur during the observed care, and that catheter care was not ordered or care-planned for this resident.
Failure to Follow Hand Hygiene and Aseptic Technique During Peri-Care and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its infection prevention and control program, specifically related to hand hygiene, glove use, and prevention of cross-contamination during resident care. For one resident with multiple sclerosis, neuromuscular bladder dysfunction, quadriplegia, and an indwelling catheter, two CNAs entered the room to perform catheter and peri-care. Both CNAs initially performed hand hygiene and donned PPE. One CNA removed the resident’s brief while the other provided catheter care and then cleaned the resident’s backside after bowel incontinence. After providing this care, the CNA obtained a clean brief and placed it under the resident without performing hand hygiene or changing gloves. The same CNA then adjusted the resident’s urinary catheter and hung the catheter bag on the side of the bed, again without performing hand hygiene or changing gloves. The CNA obtained a graduate, drained the catheter bag, emptied the graduate into the toilet, flushed the toilet, touched the resident’s sink, and turned on the water to rinse the graduate, all while wearing the same soiled gloves. Only after these tasks did the CNA remove gloves and perform hand hygiene. The CNA did not sanitize any of the room surfaces that had been touched with soiled gloves. Staff interviews, including with CNAs, the DON, and the Administrator, confirmed that the facility’s expectation was that staff perform hand hygiene and change gloves when moving from dirty to clean surfaces to prevent cross-contamination. A second deficiency occurred during wound care for another resident with cellulitis of the left lower limb, non-pressure chronic ulcers of both lower legs, and open foot lesions. An LPN entered the room to perform wound care on a left leg wound that had an odor, visible brownish-yellow drainage through the gauze wrap, and drainage on a bed pad under the leg. The LPN placed clean dressing supplies on a clean barrier, then applied gloves without hand hygiene, removed the resident’s shoe and sock, used scissors from a pocket to cut off the soiled dressing, and then placed the soiled scissors on the clean barrier next to clean supplies. The LPN removed gloves, did not perform hand hygiene, donned new gloves, and began cleansing the wounds, repeatedly reaching into a bulk bag of gauze and handling clean supplies without changing gloves or performing hand hygiene. The LPN placed the used wound cleanser bottle and clean gauze roll back on the designated clean barrier after touching them with contaminated gloves, briefly acknowledged not remembering all the steps, then removed gloves, performed hand hygiene, donned new gloves, and used the previously contaminated gauze roll to wrap the wound. The LPN then handled the resident’s sock and shoe, placed the leg back on the soiled bed pad, exited the room, removed gloves, used hand sanitizer, and left the contaminated bulk gauze bag, scissors, and wound cleanser on top of the treatment cart. Interviews with CNAs, the DON, and the Administrator confirmed expectations that reusable items used for multiple residents be sanitized before and after use and that soiled hands not be placed into bulk supplies.
Failure to Maintain Effective Pest Control for Fly Infestation in Resident Areas
Penalty
Summary
The facility failed to maintain an effective pest control program to control a significant fly population in resident care areas, despite having a written Pest Control Program policy and contracted pest control services. Pest control inspection documentation showed fly activity on an interior bug light in early December, with no detailed findings documented on a subsequent December visit. On the day of survey, multiple observations revealed numerous flies in and around several residents and their rooms. One cognitively impaired resident was observed in bed with flies buzzing around and crawling on the resident’s hand, legs, body, and bed linens, including five to six flies on the resident’s legs and body during an observation with the DON. Another resident with intact cognition was observed in bed with flies on the forehead and neck, several flies buzzing around the resident, and approximately six flies on the floor beside the bed; later the same day, additional flies were observed around the bed and on the floor in that room. A third cognitively intact resident, seated in a wheelchair in their room, had a fly land on their head and reported that flies were always present in the room and were bothersome, keeping a fly swatter at the end of the bed and keeping the door closed to try to keep flies out. A fourth resident, also in a wheelchair in their room, reported that flies had been bad and had bothered them the previous night while in bed, and a family member present stated they had killed about eight flies during that visit while swatting at flies on the floor. Staff interviews showed that housekeeping expected staff to report flies to a supervisor, and an RN reported that flies had been “everywhere and bad” after a recent warm spell, that they had informed the Administrator and DON about the fly problem, and that flies put residents at risk for skin infections and contamination of food. The DON stated that pest control monitored flies, that staff should report flies to maintenance, that she had not heard recent complaints, and that flies caused infection control issues and a non-homelike environment. The Maintenance Supervisor acknowledged ongoing issues with flies, reliance on bug lights and pest control guidance, and the expectation that staff report flies to him, while the Administrator stated that pest control visited monthly, staff were expected to report flies to maintenance, and staff were expected to kill flies as needed.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all allegations of possible abuse were reported immediately to facility management and within two hours to the state licensing agency, as required by both facility policy and federal regulations. Specifically, a nurse aide (NA C) witnessed another aide (NA D) slap a resident during care after the resident, who has severe cognitive impairment and behavioral symptoms related to dementia, became physically aggressive. Instead of reporting the incident immediately, NA C waited until the following day to inform management, citing discomfort with reporting while still on shift with the involved staff member. The resident involved had a history of vascular dementia, polyneuropathy, and required assistance with personal care, exhibiting frequent behavioral challenges such as yelling, physical aggression, and refusal of care. The care plan for this resident included specific interventions for managing behavioral symptoms, but during the incident, the staff response escalated to physical abuse. The delay in reporting meant that the incident was not brought to the attention of the Administrator until the afternoon of the following day, and the state agency was not notified within the required two-hour window. Interviews with multiple staff members, including CNAs, RNs, the Social Services Director, the DON, and the Administrator, confirmed that facility policy and their training require immediate reporting of abuse allegations to management and notification to the state agency within two hours. Despite this, the actual practice in this case did not align with policy, resulting in a failure to protect the resident and comply with regulatory requirements for timely reporting of abuse.
Failure to Conduct Timely and Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into an allegation of possible physical abuse involving a resident with severe cognitive impairment and behavioral symptoms related to dementia. The incident occurred when two nurse aides entered the resident's room to provide care, and the resident began hitting one of the aides. In response, the aide allegedly slapped the resident. The incident was not reported immediately; instead, it was reported the following day by the other aide present during the event. Upon review, it was found that the facility's investigation was insufficient. The investigation relied solely on written statements from the two nurse aides involved and did not include interviews with other staff or residents who might have had relevant information. The facility's own policy requires a comprehensive investigation, including interviews with multiple staff and residents, but this was not followed. Additionally, the investigation summary was undated and lacked documentation of immediate protective measures for all residents during the investigation period. The resident involved had a history of severe cognitive impairment, required assistance with activities of daily living, and exhibited behavioral symptoms such as physical aggression toward staff. Despite these vulnerabilities, the facility did not document a full assessment or protective interventions immediately following the allegation. The failure to follow established abuse prevention and investigation protocols resulted in a deficiency related to the facility's response to alleged abuse.
Failure to Document and Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring accurate administration and documentation of physician-ordered medications for six residents. Staff did not consistently document medication administration in the Medication Administration Record (MAR) as required by facility policy, resulting in multiple undocumented doses across a range of medications, including insulin, antipsychotics, pain medications, antibiotics, and medications for chronic conditions such as hypertension, COPD, and diabetes. The facility's policy required staff to document all administered medications, note refusals, and provide reasons for any missed doses, but these procedures were not followed. Residents affected had complex medical histories, including diagnoses such as chronic obstructive pulmonary disease, schizophrenia, diabetes, hypertension, depression, and recent acute medical events like peptic ulcer with hemorrhage and perforation. For example, one resident with diabetes and chronic pain did not have documentation for several doses of insulin, pain medication, and other prescribed drugs. Another resident with hypertension, COPD, and a history of fractures had multiple undocumented doses of blood pressure medication, pain medication, and antibiotics. In several cases, there was no documentation in the nurses' progress notes to explain the missed or undocumented doses. Interviews with residents revealed that some experienced increased pain, missed doses, and inconsistent medication administration, which affected their comfort and ability to sleep. Staff interviews confirmed that documentation was sometimes omitted due to being busy, and blank areas on the MAR were not in accordance with policy. The Director of Nursing and Administrator were unaware of the extent of the documentation lapses and missing doses, despite policies requiring staff to notify them if medications were unavailable or not administered.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and appetizing temperatures for three residents who frequently ate in their rooms. Observations and interviews revealed that these residents consistently received meals that were cold or not warm enough, with one resident stating that food was always served cold and another noting that breakfast was usually cold. Although staff offered to reheat or replace meals when complaints were made, residents often declined these offers. A test tray taken from an uninsulated food cart at the end of meal service showed food temperatures below the facility's policy requirements, with all items measuring between 124.3°F and 126°F, which is below the required minimum of 135°F for hot foods. Staff interviews confirmed that complaints about cold food were received, particularly on one hall, and that dietary staff were notified of these issues. The dietary manager and staff demonstrated inconsistent knowledge of the facility's food temperature policy, with some believing that food should be above 120°F or 125°F, rather than the policy-stated 135°F. The administrator stated that staff should not reheat served meals in the microwave but should replace them with fresh meals, though this practice was not consistently followed. The affected residents had diagnoses including diabetes, hyperlipidemia, and GERD, and were cognitively intact, able to report their dissatisfaction with food temperatures.
Failure to Complete Timely Admission MDS Assessment
Penalty
Summary
Facility staff failed to complete an admission Minimum Data Set (MDS) assessment in a timely manner for one resident. The resident was admitted with multiple diagnoses, including vascular dementia, type II diabetes mellitus, major depressive disorder, Alzheimer's disease, cerebral atherosclerosis, and a history of mini stroke. Documentation showed the resident arrived at the facility, but there was no record of an admission MDS being completed. Interviews with the Social Services Director, MDS Coordinator, and Administrator confirmed that the admission MDS should be completed within 14 days of admission, and acknowledged that it was not done for this resident. Additionally, the facility did not provide a policy related to MDS assessments.
Failure to Complete Significant Change MDS After Resident Transfer to Locked Unit
Penalty
Summary
Facility staff failed to complete a significant change Minimum Data Set (MDS) assessment for a resident who was moved to the memory care (locked) unit following multiple documented behavioral incidents. The resident, who had diagnoses including paranoid schizophrenia, congestive heart failure, major depressive disorder, morbid obesity, type II diabetes, mild intellectual disabilities, impulse disorder, COPD, and hypertension, was involved in several incidents of theft or loss, such as taking and consuming other residents' food and beverages. After these incidents, the resident was moved to the locked unit, and the guardian was notified. Despite the change in the resident's condition and environment, the most recent MDS assessment on record was a quarterly assessment completed prior to the move. Staff did not complete a significant change MDS within the required timeframe following the behavioral incidents and transfer to the locked unit. Additionally, the resident's care plan was not updated to address the behaviors that led to the move, and the facility did not provide a policy related to MDS assessments. Interviews with facility staff confirmed that a significant change MDS should have been completed and that the care plan had not yet been updated for the resident's behaviors.
Failure to Complete Timely Discharge and Readmission MDS Assessments
Penalty
Summary
The facility failed to complete a discharge with return anticipated Minimum Data Set (MDS) and a readmission MDS within seven days for a resident who was transferred to the hospital and subsequently returned. Review of the resident's records showed that after experiencing chest tightness, tachycardia, and elevated temperature, the resident was sent to the hospital. Documentation confirmed the resident's hospital transfer, but staff did not complete the required discharge MDS for this event. When the resident returned from the hospital several days later, there was also no readmission MDS completed as required. Interviews with facility staff revealed that the Social Services Director was responsible for certain MDS sections, while the MDS Coordinator, who was new to the role, was responsible for completing the discharge MDS. The Administrator acknowledged that a discharge with return anticipated MDS should have been started once the resident was out of the building for 24 hours, and both the Administrator and DON confirmed that the required MDS assessments were not completed in a timely manner. The facility was unable to provide a policy related to MDS assessments during the review.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to develop and implement a baseline care plan within 48 hours of admission for one resident, as required by facility policy. The policy specifies that a baseline care plan must be created within 48 hours to address the resident's immediate needs, including initial goals, physician and dietary orders, therapy, and social services. Review of the resident's electronic record showed no documentation of a baseline care plan following the resident's admission. Interviews with facility staff, including the Social Services Director, MDS Coordinator, Administrator, and Director of Nursing, revealed inconsistent understanding of the required timeframe, with some staff stating 72 hours instead of the policy-mandated 48 hours. The resident involved had multiple complex diagnoses, including vascular dementia, type II diabetes mellitus, major depressive disorder, Alzheimer's disease, cerebral atherosclerosis, and a history of mini stroke. The resident was admitted to the facility, and nursing staff documented the arrival, but no baseline care plan was completed or documented within the required timeframe. This omission resulted in the resident's immediate care needs not being formally addressed as outlined in the facility's policy.
Failure to Develop and Update Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and implement accurate, comprehensive care plans for all residents, as evidenced by two specific cases. In the first case, a resident admitted with multiple diagnoses including vascular dementia, type II diabetes mellitus, major depressive disorder, Alzheimer's disease, cerebral atherosclerosis, and a history of mini stroke did not have a comprehensive care plan completed within the required timeframe. The resident's electronic medical record showed no documentation of a completed care plan following admission, despite facility policy and staff interviews confirming that such a plan should have been developed within 21 days. In the second case, another resident with diagnoses including paranoid schizophrenia, congestive heart failure, major depressive disorder, morbid obesity, type II diabetes mellitus, mild intellectual disabilities, impulse disorder, COPD, and high blood pressure exhibited repeated behavioral incidents involving theft of food and beverages from other residents. These behaviors were documented in multiple incident reports and ultimately led to the resident being moved to a locked memory care unit. However, the resident's care plan was not updated to address these behaviors or the move, contrary to facility policy and staff expectations that care plans should be updated promptly when such behaviors occur or when a resident is transferred to a different unit. Interviews with facility staff, including the Social Services Director, MDS Coordinator, Administrator, and DON, confirmed that comprehensive care plans should be completed and updated in a timely manner to reflect residents' needs and changes in condition or behavior. The failure to complete and update care plans as required resulted in deficiencies in meeting the comprehensive care planning requirements for these residents.
Failure to Pay Generator Invoices Resulting in Removal of Emergency Power Source
Penalty
Summary
The facility failed to administer its operations in an effective and efficient manner by not paying invoices for a portable generator in a timely fashion. Observation revealed a disconnected natural gas generator on the facility grounds, with no other operational generator present. Review of invoices showed a significant outstanding balance, with amounts overdue for more than 90 days. The generator company had communicated multiple times regarding the overdue payments and warned that the generator would be removed if the balance was not paid. Ultimately, the generator was removed after the facility failed to resolve the outstanding debt. Interviews with facility staff indicated a lack of awareness and communication regarding the unpaid invoices. The Administrator stated that invoices were sent directly to the owners and not to him, and he was unaware of any outstanding balances or issues with the generator. The Director of Fiscal Services reported ongoing negotiations with the generator company over disputed charges, but the generator was removed during these negotiations. The facility did not provide a policy regarding the timeliness of payments to service providers.
Failure to Ensure Timely CNA Certification for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides who had been employed for more than four months completed a state-approved CNA training program, competency evaluation, and certification test within the required timeframe. Specifically, two nurse aides continued to provide direct care to residents without documentation of CNA certification beyond the 120-day limit. Review of personnel files confirmed the absence of certification for both aides, and interviews with the DON and Administrator revealed that oversight and follow-through on certification requirements were lacking. Additionally, the facility did not provide a policy regarding nurse aide training classes.
Failure to Provide Timely Incontinent Care for Dependent Resident
Penalty
Summary
Staff failed to provide appropriate incontinent care for a resident with Alzheimer's disease, chronic kidney disease, and benign prostatic hyperplasia, who was dependent on staff for activities of daily living. The resident's care plan required frequent checks, assistance with toileting, and peri-care after each incontinent episode. Despite these directives, the resident was observed seated in a Broda chair near the nurses' station for an extended period, during which time a visible puddle of urine formed under the chair and the resident's clothing and chair became saturated with urine. Multiple staff members, including a registered nurse, certified medication tech, and nurse aides, passed by or interacted with the resident but did not check or change the resident or address the incontinence, even after the presence of urine was apparent. The resident remained in the same location for over two hours without being checked or changed, despite the facility's policy and staff statements that residents should be checked every two hours and as needed. It was only after the surveyor intervened and requested the resident be checked that staff provided incontinent care, changed the resident's clothing, and cleaned the chair. Interviews with staff revealed uncertainty about when the resident was last checked or changed, with some staff citing a busy workload and others indicating that the resident had been in the Broda chair since before their shift began. Staff acknowledged that the resident should have been checked and changed sooner, and that the presence of a puddle should have prompted immediate action. The deficiency was due to staff inaction and failure to follow the care plan and facility policy regarding incontinent care.
Ineffective Resource Management
Penalty
Summary
The facility was cited for not administering its resources effectively and efficiently, as noted in event ID NQRP12. The deficiency was identified during a survey with an exit date of January 14, 2025. The report does not provide specific details about the actions or inactions that led to this citation, nor does it mention any particular residents or staff involved. The citation is linked to the facility's overall management and resource utilization practices.
Inadequate RN and DON Staffing Leads to Multiple Deficiencies
Penalty
Summary
The facility failed to ensure consistent and sufficient Registered Nurse (RN) and Director of Nursing (DON) hours, which impacted the DON's ability to fulfill her duties. The DON frequently had to work as a charge nurse or certified nurse aide, which left her behind on essential DON responsibilities such as reviewing physician orders, tracking labs, hiring and terminating staff, and monitoring the infection prevention and antibiotic stewardship programs. The DON reported working multiple shifts on the floor, including every weekend in September, which contributed to the backlog in her administrative duties. Additionally, the facility did not implement an effective antibiotic stewardship program, as there were no measures in place to track residents on antibiotics for various infections. This lack of tracking was confirmed by the DON during interviews. Furthermore, the facility failed to ensure residents were free of significant medication errors, as staff did not administer warfarin sodium per physician's orders. There were also instances where ordered medications were unavailable on-site, preventing administration to residents. The DON acknowledged reviewing a computer dashboard daily for missed or unavailable medications, but these issues persisted.
Deficiency in Employing Qualified Dietary Manager
Penalty
Summary
The facility staff failed to employ a qualified dietary manager for the food and nutrition services department, as required by regulatory guidelines. The dietary manager, who started the position in March 2024, did not possess the necessary qualifications such as being a certified dietary manager (CDM), a certified food services manager, or having an associate's degree or higher in food service management or hospitality. The dietary manager had previous experience as a nutritional assistant and completed a certificate of proper temperature safety through the health department, but these credentials did not meet the requirements for the Director of Food and Nutrition Services (DFNS) in a long-term care setting. During an interview, the dietary manager confirmed the lack of required certifications and training. Additionally, the facility administrator admitted to being unaware of the necessary qualifications for the dietary manager position and indicated plans to send the manager to the required classes. The facility did not provide documentation of certification, training, or experience that met the regulatory requirements for the DFNS, resulting in a deficiency in employing appropriately qualified staff for the food and nutrition services department.
Infection Control Deficiencies in Legionella Prevention and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection control program, particularly in preventing the growth of Legionella bacteria in the water supply. The facility did not conduct a Legionella risk assessment, lacked a diagram of the water system, and did not monitor water temperature or pH levels to prevent Legionella growth. The Maintenance Director was unaware of the necessary water temperature and pH levels and did not know the location of the facility's water system map. The Administrator confirmed that only resident room sinks and toilets were flushed, with no other preventive measures taken. Additionally, the facility did not have a policy or procedure for hand hygiene, leading to multiple instances of non-compliance with hand hygiene standards during medication passes. The Director of Nursing (DON) and Certified Medication Technicians (CMTs) were observed not performing hand hygiene before and after resident contact, after glove removal, and between medication passes. The DON was seen handling medical equipment and administering medications without washing hands, and CMTs were observed preparing and administering medications without performing hand hygiene. Interviews with staff, including CNAs, LPNs, and RNs, revealed that they were aware of the importance of hand hygiene but did not consistently practice it. The DON and Administrator acknowledged the expectation for staff to perform hand hygiene, yet observations showed a lack of adherence to these standards, contributing to the facility's failure to maintain an effective infection control program.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of a current and ongoing antibiotic log for residents with active infections. The facility's policy, dated December 2016, outlined that antibiotics should be prescribed and administered under the guidance of the Antibiotic Stewardship Program, with specific requirements for prescribers to provide detailed information about the antibiotic orders. However, the facility only provided a computer printout of residents prescribed antibiotics for September, with no additional documentation of antibiotic tracking measures. Interviews with the Director of Nursing (DON) revealed that while a monthly report of antibiotic usage is obtained and reviewed with the physician, there were no residents currently on antibiotics, and no other tracking measures or notes from the monthly physician meeting were documented. The DON also mentioned that outcome surveillance related to antibiotic use was not tracked, and although a new urinalysis is obtained upon completion of antibiotics, the results are not logged. The Administrator expected staff to follow guidelines for prescribed antibiotics, but the lack of documentation and tracking measures indicates a deficiency in the facility's antibiotic stewardship program.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a 12.82% error rate with five medication errors out of 39 opportunities. These errors affected three residents. The errors included administering the wrong form of medication, incorrect dosages, and improper administration techniques. For instance, a Certified Medication Technician (CMT) administered a guaifenesin tablet instead of the prescribed liquid form to a resident with diabetes mellitus and congestive heart failure. Another resident, who was cognitively intact and diagnosed with throat cancer, lupus, and diabetes mellitus, received an incorrect dosage of olanzapine and the wrong form of ondansetron. The CMT administered a 10 mg tablet of olanzapine instead of the prescribed 5 mg and an orally dissolving tablet of ondansetron instead of the regular tablet form. These actions were contrary to the physician's orders and the facility's medication administration policy. Additionally, a resident with a feeding tube, diagnosed with nontraumatic intracerebral hemorrhage and respiratory failure, received medications improperly combined and administered through the g-tube. The Director of Nursing (DON) crushed and mixed hydralazine and tramadol tablets without a physician's order to combine them, contrary to the facility's policy and best practices for administering medications via enteral feeding tubes. This improper technique was observed during a medication administration process, highlighting a significant deviation from the prescribed method of administering and flushing medications separately.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that all medications were stored and labeled according to standards of practice, specifically regarding the storage of controlled substances and the security of medication carts. Observations revealed that controlled substances for two residents were not stored under two locks as required. Resident #1, who had diagnoses including human immunodeficiency virus and acute kidney failure, had a prescription for dronabinol capsules stored in an unlocked refrigerator. Similarly, Resident #39, with conditions such as benign intracranial hypertension and cancer, also had dronabinol capsules stored in the same unsecured manner. Additionally, medication carts were observed to be left unlocked and unattended on multiple occasions. One instance involved a nurse medication cart outside the Director of Nursing's office, which contained insulin pens and narcotics, being left unlocked while residents were nearby. Another observation noted the Director of Nursing leaving a cart unlocked near the nurses' station, with several residents in the vicinity. Interviews with staff, including Certified Medication Technicians and Registered Nurses, confirmed that medication carts and storage areas should be locked when not in use. However, the observations indicated a failure to adhere to these protocols, as controlled medications were found unsecured in the refrigerator, and medication carts were left unattended and unlocked. The Director of Nursing and Administrator acknowledged these lapses, emphasizing the expectation for medications to be stored securely and under double lock for narcotics.
Failure to Provide Accessible Hydration for Resident
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident's hydration needs, as observed during a survey. The resident, who had diagnoses including chronic kidney disease, COPD, and heart failure, was found without accessible water on multiple occasions. The resident's care plan required nectar/mildly thick consistency liquids to be provided in a two-handled cup with a lid and spout. Despite this, observations showed that water was either out of reach or not present in the resident's room, and the resident was observed to be visibly thirsty with a dry mouth. Interviews with facility staff, including a CNA, RN, and the Director of Nursing, revealed that there was a misunderstanding about the resident's ability to have water in the room due to the need for thickened liquids. Staff were responsible for ensuring water was accessible during rounds every two hours, but this was not consistently done. The CNA mentioned that they were initially told the resident couldn't have water due to choking risks, but this was later clarified. Despite these instructions, the resident did not have water accessible, leading to the deficiency noted by the surveyors.
Failure to Complete PASARR Screening for Resident with Mental Disorders
Penalty
Summary
The facility failed to administer the required Preadmission Screening and Resident Review (PASARR) Level 1 screening for a resident with mental disorders prior to their admission. The resident, who was admitted with diagnoses including major depressive disorder, bipolar disorder, and psychosis, did not have a PASARR completed as required. The facility's policy mandates coordination with the Medicaid PASARR program to determine the nursing and medical needs of individuals with mental disorders, and potential residents with such conditions should only be admitted if the state mental health agency has determined the necessity of the level of service provided by the facility. The resident's records indicated cognitive intactness but an inability to complete a mental status interview, along with symptoms such as delusions and the use of antidepressant, antianxiety, and antipsychotic medications. The care plan noted confusion, disorganized thinking, and socially inappropriate behavior. Despite these indicators, a PASARR was not completed, as confirmed by an email from the Central Office Medical Review Unit. Interviews with the Social Services Designee and the Administrator revealed that the responsibility for completing the PASARR fell on the SSD, who admitted to completing it only if the hospital had not done so prior to admission.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and documentation for two residents, leading to deficiencies in wound management. For Resident #152, the staff did not consistently assess and document the resident's pressure ulcers on the right and left buttocks. Despite the presence of stage 2 pressure ulcers, the facility's records frequently omitted documentation of the right buttock ulcer, and there were no documented treatment orders in the system for the wounds. The resident was admitted with pressure ulcers, and the facility's policy required weekly wound assessments and documentation, which were not consistently followed. Resident #6 also experienced inadequate wound care documentation. The resident had a history of type two diabetes, peripheral vascular disease, and heart failure, and was at risk for pressure ulcers. The resident's care plan included orders for wound care, but the documentation was incomplete, with missing records for the left buttock wound and inconsistent weekly wound observations. The resident's wounds were not properly documented in the facility's system, and there was a lack of follow-through on treatment orders. Interviews with staff, including the DON and RN, revealed that the former wound nurse did not enter treatment orders into the computer system, leading to a lack of documented care. The facility's failure to adhere to its wound care policy and ensure proper documentation and treatment of pressure ulcers resulted in deficiencies in the care provided to these residents.
Deficiencies in Oxygen Equipment Management for Residents
Penalty
Summary
The facility failed to provide respiratory care per standards of practice for two residents, resulting in deficiencies related to the management of oxygen equipment. Resident #46, who has diagnoses including chronic obstructive pulmonary disease (COPD), heart disease, and chronic kidney disease, was observed with an oxygen concentrator and portable oxygen tank with undated or illegibly dated nasal cannulas and tubing. Despite physician orders to change the oxygen humidifier and tubing weekly, observations revealed that the equipment was not changed as scheduled, with dates on the equipment indicating it had not been updated since 09/16/24. Similarly, Resident #36, diagnosed with COPD and interstitial pulmonary disease, was also found with undated nasal cannulas and tubing that had not been changed since 09/16/24, contrary to the weekly change orders. Additionally, the resident's care plan did not include documentation of oxygen use, which is a critical component of their care. The September 2024 Medication Administration Record (MAR) lacked documentation for changing the humidifier and oxygen orders, further indicating a lapse in following prescribed care protocols. Interviews with facility staff, including Certified Medication Technicians, Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides, revealed inconsistencies and confusion regarding responsibilities for changing oxygen equipment. Staff members provided conflicting information about who was responsible for changing the tubing and when it should be done. The Director of Nursing confirmed that oxygen tubing should be changed weekly and that both nurses and aides are responsible for this task, yet the deficiency persisted, indicating a lack of adherence to established procedures and communication breakdowns among staff.
Inadequate Pain Management Due to Medication Unavailability and Documentation Failures
Penalty
Summary
The facility failed to provide effective pain management for residents, as evidenced by the failure to administer pain medications as ordered and the lack of documentation for pain medication orders. Resident #252, who was admitted with multiple fractures and high blood pressure, did not receive the prescribed morphine sulfate and Percocet due to delays in pharmacy delivery. Despite the resident's complaints of pain and requests for medication, staff only offered Tylenol, which was ineffective. The resident's pain levels were consistently documented as moderate, yet the ordered medications were not administered, and staff failed to provide alternative pain management solutions. Resident #36, diagnosed with COPD, prostate cancer, and interstitial pulmonary disease, also experienced inadequate pain management. The resident's prescribed Tylenol and oxycodone were not administered on multiple occasions due to unavailability. Upon returning from a leave of absence, the resident requested pain medication, but the facility did not have the prescribed oxycodone in stock. Although a substitute order for hydrocodone was obtained, it was not documented in the physician orders or the MAR, leading to further delays in pain relief. The resident reported severe pain levels, and staff interviews revealed ongoing issues with medication availability and documentation. Interviews with staff, including RNs, LPNs, and the DON, highlighted systemic issues with medication procurement and documentation. The facility struggled with timely medication delivery from the pharmacy, and there were instances where substitute medications were not properly documented. Staff were aware of the residents' pain but were unable to provide the necessary medications due to these logistical challenges. The facility's failure to adhere to its pain management policy resulted in prolonged periods of unrelieved pain for the residents involved.
Medication Unavailability for Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as Resident #15, by not ensuring the availability of prescribed medication, escitalopram oxalate, on multiple occasions. The resident, who had diagnoses including schizophrenia and major depressive disorder, required this medication as part of their treatment plan. Despite having a documented order for the medication, it was not administered on several dates in August and September 2024 due to unavailability. The facility's policies required timely reordering of medications and follow-up with the pharmacy to prevent lapses in administration. However, the documentation showed that the medication was not available on multiple dates, and staff did not consistently follow up with the pharmacy or utilize the emergency kit as per the facility's procedures. Interviews with staff, including Certified Medication Technicians (CMTs) and the Director of Nursing (DON), revealed a lack of communication and follow-up regarding the medication's unavailability. The DON acknowledged that the missed doses coincided with a period when physician orders were being redone for the pharmacy. Despite the facility's system for entering and faxing orders to the pharmacy, the medication was not received in a timely manner. The DON and other staff members were not consistently aware of the medication's unavailability, and the facility's dashboard, which tracks missed or unavailable medications, was not reviewed daily as required. This resulted in multiple missed doses of the resident's essential medication, highlighting a deficiency in the facility's pharmaceutical services.
Failure to Administer Warfarin as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when staff did not administer warfarin sodium as per the physician's order. The resident, who had a diagnosis of thrombophilia and an abnormal coagulation profile, was supposed to receive warfarin sodium, a blood thinner, to prevent blood clots. The medication was on hold from September 6th to September 11th, but after the hold ended, the resident missed three doses on September 11th, 12th, and 13th because the medication was reportedly unavailable. Certified Medication Technician (CMT) B documented that the warfarin sodium was not available on these dates and did not notify the Director of Nursing (DON) or the physician about the missed doses. Interviews revealed that CMT B was unaware that the medication was in a pill bottle until informed by the resident's responsible party. The facility's policy required staff to report any discrepancies in medication administration immediately to the DON and notify the physician and family, which was not done in this case. The DON and other staff members confirmed that the medication should have been available, possibly in the emergency kit, and that the resident should not have gone without warfarin for more than a couple of days due to the risk of blood clots. The facility's computer system was supposed to alert staff to medications not administered, and the DON was expected to review this daily. However, the missed doses were not reported or addressed in a timely manner, leading to a significant medication error.
Incomplete Documentation for Resident Transfers
Penalty
Summary
The facility failed to maintain complete medical records for two residents who were transferred to the hospital and later returned. For Resident #41, the nursing progress notes did not document the reason for the transfer, the time of transfer, or notification to the physician. Additionally, there was no record of the time or date of the resident's return from the hospital or physician notification of the return. The resident had a history of cerebral infarction, atrial fibrillation, and a fracture of the right femur, and was admitted to the ICU with atrial fibrillation, a urinary tract infection, and sepsis. For Resident #46, the nursing progress notes failed to document the notification of the physician regarding the transfer to the hospital. The resident was admitted to the hospital with an intestinal infection due to Clostridiodes difficile and returned to the facility without documentation of the return or physician notification. The resident had chronic obstructive pulmonary disease, heart disease, and chronic kidney disease, and was sent to the emergency room due to diarrhea and vomiting, which posed a risk of dehydration and acute kidney injury. Interviews with facility staff, including a Registered Nurse, a Licensed Practical Nurse, and the Director of Nursing, revealed that there were expectations for obtaining physician orders for transfers and documenting all relevant details in the resident's medical records. However, these procedures were not followed, leading to incomplete documentation for the residents involved.
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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