Carmel Hills Wellness & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Independence, Missouri.
- Location
- 810 East Walnut, Independence, Missouri 64050
- CMS Provider Number
- 265727
- Inspections on file
- 28
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Carmel Hills Wellness & Rehabilitation during CMS and state inspections, most recent first.
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.
Surveyors identified several food safety and sanitation deficiencies, including unclean sprinkler heads and kitchen surfaces, unrefrigerated food items, improper hand hygiene, failure to wash fresh fruit, and hot foods held below required temperatures. These issues potentially affected all 143 residents receiving meals from the kitchen.
Hot foods were not consistently served at or near the required temperature, with test trays showing temperatures below policy standards. Several cognitively intact residents reported receiving cold meals frequently, and insufficient staffing for tray delivery was noted as a contributing factor.
A resident with Alzheimer's disease and other conditions passed away while on hospice care, but the facility failed to notify the legal guardian as required. Staff believed hospice would handle notification, but hospice only notifies the legal guardian if no family is present. The business office was also not informed, resulting in a check from the legal guardian being processed after the resident's death. The legal guardian's office only learned of the death during a routine visit, with no prior communication from the facility.
Two residents with significant cognitive and physical impairments did not consistently receive the required two baths or showers per week as outlined in their care plans and facility policy. Documentation and staff interviews confirmed that, due to staffing shortages and inconsistent assignment of bathing duties, these residents often received only one bath per week or missed scheduled baths entirely, with no evidence that they declined care.
A resident who required supervision while smoking was not adequately monitored, resulting in a burn injury that went unreported for two days. Additionally, another resident was found using and storing an e-cigarette in their room, contrary to facility policy. Staff interviews and observations confirmed that smoking materials, including e-cigarettes, were not consistently secured or supervised as required.
A resident with multiple medical conditions did not receive food that accommodated their documented preferences and requests, including repeated failures to provide a requested chef salad. Despite the facility's policy to offer suitable substitutes and honor preferences, the resident was given inappropriate alternatives or no substitute at all, leading to dissatisfaction and the need to supplement meals with personal food.
The facility did not consistently provide scheduled snacks between meals, resulting in two residents—both with significant medical conditions—relying on personal snacks and experiencing inconsistent access to facility-provided nourishment. Staff interviews confirmed that snacks were sometimes missed, not distributed to all residents, and often left at the nursing station, leading to shortages and unequal access.
The facility failed to properly screen new employees for TB, with missing documentation of TST readings for five employees. Additionally, an LPN did not follow hand hygiene protocols during medication administration for two residents, and the facility did not implement Enhanced Barrier Precautions for residents with tracheostomies or feeding tubes. Staff were not fully trained on EBP protocols, leading to lapses in infection control measures.
The facility failed to properly store and maintain respiratory equipment for several residents, leading to potential cross-contamination. Observations showed uncovered suction and oxygen equipment, including face masks and BiPAP tubing, for residents with respiratory conditions. Additionally, oxygen concentrators were dirty, and tracheostomy care was not consistently documented. Staff interviews revealed inconsistencies in following storage and maintenance protocols.
The facility failed to ensure proper storage and labeling of medications and medical supplies, with observations of expired items and improper storage practices. Medications like Fluticasone and Lidocaine were improperly stored, and expired items were found in medication carts and storage rooms. Staff interviews revealed inconsistencies in checking procedures, contributing to the deficiency.
The facility failed to serve food at safe and appetizing temperatures, as evidenced by three residents who reported receiving cold meals, leading to meal refusals. Observations showed food temperatures below the required 135 degrees Fahrenheit. Staff acknowledged complaints but were unaware of the facility's food temperature policy, and monitoring was inconsistent.
A resident who was legally blind and required supervision while smoking experienced a compromise in dignity when a Hospitality Aide (HA) tapped the back of their head to get their attention, instead of calling their name or tapping their shoulder. The resident felt embarrassed and like a child, although no injury occurred. The HA admitted the action was inappropriate, and staff acknowledged the incident compromised the resident's dignity.
A facility failed to obtain a physician's order and assess a resident's ability to self-administer medication. The resident, with COPD and Pulmonary Fibrosis, had an albuterol inhaler at bedside without proper assessment or documentation. Staff interviews confirmed the lack of a self-administration assessment and physician's order, contrary to facility policy.
The facility failed to notify two residents and/or their representatives of a hospital transfer, including the reasons for the transfer in writing. The facility's policy requires such notices to be documented in the resident's medical record, but this was not done for the two residents. Staff interviews revealed a lack of awareness and adherence to the process for ensuring transfer notices were completed and documented.
The facility failed to provide bed hold notifications to two residents upon their transfer to a hospital, as required by the facility's policy. Despite the policy mandating written notification to residents or their representatives, no documentation was found in the electronic medical records for these residents. Interviews with staff revealed a lack of awareness and process to ensure completion and documentation of bed hold notices.
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies in documenting dental issues, BiPAP usage, and falls. One resident's dental issues and another's BiPAP usage were not reflected in their MDS, while a third resident's falls were not documented. Staff interviews revealed a lack of awareness and failure to update the MDS, resulting in incomplete assessments.
The facility failed to develop comprehensive care plans for residents, resulting in unaddressed dental care needs, lack of BiPAP utilization for a resident with chronic respiratory conditions, and unrecorded falls for another resident. Staff interviews revealed a lack of awareness and documentation, leading to deficiencies in care planning and risk management.
A facility failed to update the care plan for a resident on an anticoagulant medication. The resident, admitted with Peripheral Vascular Disease, had a physician's order for Rivaroxaban, but the care plan did not reflect this. Interviews with staff, including LPNs, MDS coordinators, and the DON, revealed an expectation for the care plan to address the medication, highlighting a lapse in updating the care plan as required.
A facility failed to document discharge planning and complete a discharge summary for a resident with complex medical and behavioral needs. Despite attempts to find alternative placement, the social worker did not document efforts or inform the resident's DPOA about potential placements. The resident's family decided to take the resident home without a clear post-discharge plan, and the facility did not arrange for aftercare services.
A resident with a history of falls and dementia sustained a head laceration requiring staples after a fall. The facility failed to obtain physician orders for monitoring and care of the laceration, including staple removal. Staff interviews revealed an expectation for such orders, but they were not documented, leading to inadequate care.
A resident with diabetic neuropathy suffered a burn on their finger while smoking, despite wearing a smoking apron. The facility failed to document or report the incident, and staff interviews revealed a lack of awareness and communication regarding the event. The required process for handling such incidents was not followed, resulting in a deficiency.
A facility failed to obtain comprehensive physician orders for a resident's suprapubic catheter, including type, size, and care requirements. The resident's care plan was not updated to reflect the new catheter care, and staff provided care without specific orders. Interviews with staff highlighted expectations for detailed orders and care plans, which were not met.
A facility failed to document a resident's refusal of enteral feeding via a Gastrostomy Tube. The resident, who was cognitively intact and at risk for malnutrition, experienced diarrhea and refused feedings, which were not consistently recorded. Interviews with staff confirmed that 14 out of 84 feeding opportunities in October and 21 out of 68 in November were left undocumented, indicating non-compliance with physician orders and resident care documentation.
The facility failed to consistently assess dialysis shunts and ensure proper communication for two residents requiring dialysis. A resident with end-stage renal failure had inconsistent shunt site checks and incomplete dialysis communication documentation. Another resident had no completed dialysis communication forms for scheduled appointments. These deficiencies in monitoring and documentation posed risks to the continuity of care.
A facility failed to ensure a physician documented a rationale for not following a pharmacist's recommendation for a Gradual Dose Reduction (GDR) of a psychotropic medication for a resident with bipolar disorder. The resident had been on Aripiprazole without a GDR since admission. Staff interviews revealed a lack of awareness and responsibility regarding the GDR process, with the DON responsible for ensuring GDRs were completed and documented, which was not done.
A LTC facility reported an eight percent medication error rate. One resident with COPD did not receive their prescribed Symbicort inhaler, as a CMT documented administration without observing or assisting the resident. Another resident with Diabetes Mellitus received the wrong type of insulin due to an RN's failure to verify the medication against the physician's order. The errors were confirmed through staff interviews.
A resident with Type II Diabetes Mellitus was administered the incorrect insulin by an RN who failed to verify the physician's order or ensure the vial was marked with the resident's name. The RN administered Insulin Lispro instead of the prescribed Fiasp, without immediate access to the resident's medical record, and the error was not documented or followed up in the medical record.
The facility failed to provide necessary dental services to two residents, resulting in a deficiency. One resident had broken and carious teeth but had not seen a dentist since admission, while another resident required full mouth extraction but lacked timely follow-up. Staff interviews revealed a lack of awareness and communication regarding the residents' dental needs.
The facility failed to ensure pneumococcal and influenza vaccines were offered, administered, or documented for two residents. One resident, with risk factors for respiratory infections, showed no evidence of receiving the pneumococcal vaccine, while another resident's report lacked documentation of influenza vaccination. Staff interviews confirmed that vaccines should have been offered and documented.
The facility failed to provide COVID-19 vaccine education and obtain consent for three residents, leading to incomplete vaccination documentation. A resident received only one dose of the Moderna vaccine without further doses or evidence of being offered additional vaccination. Another resident also received a single dose with no further doses or documentation of consent or education. A third resident had no vaccination history or evidence of being offered the vaccine. The IP and DON acknowledged the responsibility for ensuring vaccination completion and documentation, but these actions were not fulfilled.
A resident's Oxycodone medication went missing in an LTC facility, with 47 pills unaccounted for. The medication was last seen during a shift change count, but the count sheets were missing. An LPN had access to the cart, and empty medication cards were found in a shred box. The DON and ADON were responsible for monitoring narcotic logs, but the missing medication was only discovered when the resident requested it for pain relief.
A resident with a history of drug abuse and no prior negative behaviors was discharged from an LTC facility after an altercation and threats towards a roommate. Despite being cleared by the hospital, the facility refused re-admission, citing safety concerns. The discharge process lacked proper notification and planning, leading to a deficiency.
The facility failed to ensure resident safety and proper transportation, resulting in significant harm to two residents. One resident was improperly transferred without a Hoyer lift, leading to multiple fractures and delayed medical attention. Another resident was left in a hospital lobby overnight after a dialysis appointment due to a lack of transportation coordination, missing evening medications and supper.
The facility failed to ensure timely assistance in obtaining a hearing device for a resident with a cognitive communication deficit. The resident's hearing aids were lost and broken during a hospital visit, and despite contact with the family and attempts to retrieve or repair the hearing aids, the resident went without them for an extended period, significantly impacting their ability to communicate effectively.
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.
Multiple Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food service operations, including a buildup of grease and dust on sprinkler heads and ceiling tiles above food preparation and serving areas, grime accumulation on metal fixtures and walls under the dishwasher, and the presence of discarded dishes under the dishwasher. Two oven mittens used in the kitchen were found to be ripped, and items requiring refrigeration, such as lemon juice and beef base, were left unrefrigerated on counters and tables. Additionally, a handwashing sink was obstructed by a black speaker, impeding proper hand hygiene. During meal preparation, staff failed to wash fresh grapes before adding them to a fruit salad, and a dietary aide handled French Toast with bare hands instead of using tongs or gloves. Temperature checks revealed that hot foods, including pureed and regular French Toast, were held below the required 135°F at the steam table. Interviews with dietary staff indicated a lack of training regarding proper fruit washing and infrequent cleaning of the area under the dishwasher. These deficiencies potentially affected all 143 residents who received food from the kitchen.
Failure to Serve Hot Foods at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that hot foods were served at or near the required temperature of 120°F, as evidenced by observations and resident interviews. On two separate occasions, vegetables and French toast served on test trays were measured at 111.4°F and 106.3°F, respectively, which is below the facility's policy for proper food service temperatures. The facility's policy requires that food temperatures be checked before serving, using a sanitized thermometer, and that food be served at safe and appetizing temperatures. However, the dietary manager confirmed that test trays are only checked 2-3 times per week and typically on the last tray of the hall, with staff being encouraged but not consistently monitored to check food temperatures on the steam table. Multiple cognitively intact residents reported receiving cold food frequently, with some stating that their meals, including entrees and side items, were cold almost daily regardless of the meal time. Residents also noted that there were often not enough staff to deliver trays promptly, which may have contributed to the food being served at suboptimal temperatures. These issues potentially affected at least four residents out of the 19 sampled, in a facility with a census of 143 residents.
Failure to Notify Legal Guardian of Resident's Death
Penalty
Summary
The facility failed to notify the legal guardian of a resident's death in a timely manner, as required by facility policy. The resident, who had diagnoses including Alzheimer's disease with late onset, unsteadiness, and hyperlipidemia, was admitted with the Public Administrator's Office listed as the legal guardian and primary contact. On the day of the resident's death, progress notes documented the resident was actively dying, received comfort medications, and passed away with a relative and hospice nurse present. However, there was no documentation that the legal guardian was notified at any point during or after the resident's passing. Interviews revealed that staff believed hospice was responsible for notifying the legal guardian, especially since a relative was present at the bedside. Hospice staff stated they only notify the legal guardian if no family is present, and in this case, did not make the notification. The facility's charge nurse and other staff did not contact the legal guardian, and the Director of Nursing and Assistant Director of Nursing also believed hospice had handled the notification. The Social Service Director claimed to have reached out to the legal guardian but later it was determined that no contact was made. As a result of the lack of notification, the business office was also not informed of the resident's death in a timely manner. The Business Office Manager, who was on vacation, processed a check from the legal guardian's office two weeks after the resident's death, unaware of the passing. The legal guardian's office only learned of the resident's death during a routine monthly visit, and no paperwork or direct communication from the facility was received regarding the death.
Failure to Provide Required Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who required assistance with activities of daily living, specifically bathing, received care in accordance with facility policy and their care plans. Two residents with significant cognitive and physical impairments, including conditions such as diabetes, heart disease, stroke, amputation, and incontinence, were dependent on staff for personal care and bathing. Documentation and interviews revealed that these residents were not consistently provided with the required two baths or showers per week as outlined in their care plans and the facility's bathing policy. Review of bathing records showed that one resident received only one bath per week over several weeks, with no documentation indicating that the resident declined bathing. Another resident received five showers out of nine scheduled opportunities in a one-month period, with some weeks showing only one or no baths provided. Staff interviews confirmed that, due to staffing shortages and the absence of bath aides on certain days, residents often did not receive the scheduled number of baths. Staff also indicated that when bath aides were unavailable, CNAs were expected to provide baths, but this was not consistently done due to time constraints and workload. The facility's policy required that residents be scheduled for two baths or showers per week, with adjustments only if requested by the resident. However, both documentation and staff interviews confirmed that this standard was not met for at least two residents, and there was no evidence that the residents refused care. The deficiency was identified through observation, record review, and staff interviews, which consistently indicated a failure to provide the required level of personal hygiene care.
Failure to Supervise Smoking and Safely Store Smoking Materials
Penalty
Summary
The facility failed to ensure that a resident who required supervision while smoking was adequately monitored, resulting in a burn injury. On a windy day, the resident was outside in the designated smoking area, but was not in the direct line of sight of the assigned hospitality aide. While attempting to light a cigarette, ashes blew into the resident's hair, igniting it and causing a burn to the left ear. The hospitality aide did not immediately report the incident to nursing staff, as requested by the resident, which led to a delay in the assessment and treatment of the burn. The incident was only reported two days later when the resident experienced pain and a blister was noticed by another staff member. Additionally, the facility failed to ensure that electronic smoking materials were safely stored and not used inside the facility. Another resident was observed with an e-cigarette in bed and on the bedside table, and admitted to using the device in the room. Multiple staff members confirmed that residents kept and used e-cigarettes in their rooms, despite facility policy prohibiting the storage and use of smoking materials, including e-cigarettes, inside the facility. There was no documentation in the resident's care plan or smoking assessment regarding the use or storage of e-cigarettes, and staff were not consistently aware of or enforcing the policy. Both deficiencies were identified through observation, interviews, and record review. The facility's policies required supervision during smoking, secure storage of all smoking materials, and immediate reporting of incidents. However, these protocols were not followed, resulting in a resident sustaining a burn injury without prompt medical attention and another resident having unsupervised access to and use of an e-cigarette in their room.
Failure to Honor Resident Food Preferences and Provide Suitable Substitutes
Penalty
Summary
A deficiency occurred when the facility failed to provide food that accommodated a resident's preferences and requests, as required by facility policy. The resident, who had a history of congestive heart failure, diabetes mellitus, and anxiety disorder, was on a regular diet with a fluid restriction and expressed a preference for a heart-healthy diet, fresh fruit, and salads. Despite these documented preferences and care plan instructions to monitor diet acceptance and concerns, the resident reported that the facility sometimes ran out of food, did not offer alternatives, and failed to provide requested items such as a chef salad. On multiple occasions, the resident either did not receive the requested salad or received an inappropriate substitute, such as mashed potatoes and gravy, which did not align with their dietary needs or preferences. Observations and interviews confirmed that the resident's requests for a chef salad were not honored, even when the meal ticket indicated the item, and the resident had to make their own salad from personal supplies. The Dietary Manager acknowledged the availability of lettuce and was unaware that the resident did not receive the requested salad. The Administrator stated that alternative food choices should be offered and was not aware of the specific incident. The facility's failure to provide suitable substitutes and honor the resident's food preferences, as outlined in their own policy, led to the deficiency.
Inconsistent Snack Delivery Between Meals
Penalty
Summary
The facility failed to consistently provide snacks between meals as required by its own schedule, which called for snacks to be offered at 10:00 A.M., 2:00 P.M., and 7:00 P.M. daily. Observations and interviews revealed that snacks were not always delivered to the long-term care unit, particularly in the mornings and evenings. Staff and residents reported that snacks were sometimes missed entirely, and when they were delivered, they were placed at the nursing station rather than being distributed to residents. This led to situations where some residents, especially those unable to go to the nursing station, did not receive snacks, and others took multiple snacks, resulting in shortages. Two residents were specifically identified as being affected by this deficiency. One resident, with diagnoses including diabetes, high cholesterol, high blood pressure, and cancer, reported relying on personal snacks and noted that facility-provided snacks were inconsistently available, especially in the evenings. Another resident, with heart failure, high cholesterol, diabetes, and malnutrition, also kept personal snacks and stated that facility snacks were left at the nursing station and not distributed by staff. Both residents were alert, oriented, and able to eat independently, but the inconsistent snack delivery impacted their access to facility-provided nourishment between meals. Interviews with various staff members, including CNAs, dietary aides, and nursing staff, confirmed that snack delivery was inconsistent and sometimes missed due to staff changes and lack of communication. Dietary staff were not always aware when snacks were not delivered, and there was confusion about responsibilities for distributing snacks to residents who could not retrieve them themselves. The dietary manager and assistant director of nursing acknowledged that snacks were supposed to be offered three times daily but were not always provided as scheduled.
Infection Control Deficiencies in TB Screening and Hand Hygiene
Penalty
Summary
The facility failed to properly screen new employees for Tuberculosis (TB), a communicable disease, as required by state regulations. Five out of ten sampled new employees did not have the date of their TB skin tests (TST) read documented, which is a critical step in the screening process. The Assistant Director of Nursing (ADON) responsible for administering and reading the TSTs admitted to not documenting the date the tests were read due to the absence of a prompt on the TB form. This oversight in documentation could potentially affect all residents, employees, and visitors to the facility. The facility also failed to ensure proper hand hygiene and glove usage during medication administration, blood glucose testing, and insulin administration for two residents. An LPN was observed not sanitizing hands before and after glove use, not using a barrier for placing supplies during procedures, and wearing gloves inappropriately during medication administration. The LPN admitted to not performing hand hygiene as expected, which was confirmed by interviews with other staff members who acknowledged the lapses in protocol. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with conditions that increased the risk of carrying resistant organisms. Several residents with tracheostomies, wounds, or feeding tubes did not have EBP signage or PPE carts outside their rooms, and staff were observed not using gowns and gloves as required. Interviews revealed that staff were not fully trained on EBP protocols, and the facility had only recently started training on these precautions, indicating a lack of adherence to infection control measures.
Improper Storage and Maintenance of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage and maintenance of respiratory equipment for several residents, leading to potential cross-contamination and non-compliance with physician orders. Observations revealed that suction and oxygen equipment, including face masks, nasal cannulas, and BiPAP tubing, were left uncovered and not stored in plastic bags when not in use. This was noted for multiple residents with respiratory conditions such as tracheostomy, COPD, and respiratory failure. Additionally, oxygen concentrators were found with dirt and debris, and their external filters had a buildup of dust, indicating a lack of regular cleaning and maintenance. For Resident #95, who had a tracheostomy, the facility did not cover the nebulizer face mask, humidifier machine, and suction machine tubing, leaving them exposed. Similarly, Resident #126's oxygen and BiPAP equipment were uncovered, and the resident was unaware of the need for protective storage. Resident #19, who had COPD, also had uncovered oxygen and nebulizer equipment, with no care plan for oxygen use documented. Resident #14's oxygen concentrator was dirty, and the nasal cannula was not bagged when not in use. Furthermore, the facility failed to follow physician orders for tracheostomy care for Resident #116, with several instances of missed care opportunities documented in the Treatment Administration Record. Interviews with staff, including the Infection Control Preventionist, Certified Medication Technicians, and the Director of Nursing, highlighted inconsistencies in the implementation of policies regarding the storage and maintenance of respiratory equipment. The lack of adherence to these protocols contributed to the deficiencies observed during the survey.
Deficiency in Medication and Supply Management
Penalty
Summary
The facility failed to ensure the proper storage and labeling of medications and medical supplies, which was observed during a survey. Medications such as Fluticasone Propionate Nasal Spray and Fluticasone Propionate and Salmeterol were stored in the same box, contrary to the facility's policy that requires each medication to be stored in its own container. Additionally, a vial of Lidocaine 1% was found half-used, outside of its original container, with a ripped-off label, and a bottle of Dakin's solution was found expired. These observations indicate a lack of adherence to the facility's medication storage policy. Further observations revealed expired medical supplies and medications in the medication storage rooms and carts. Items such as liquid skin preparation, Dermaview II transparent film wound dressings, Curad oil emulsion dressings, and thickened liquids were found expired. The Tuberculin PPD solution was stored outside of its original container with an unreadable open date, and an IV administration set and needleless connectors were also expired. These findings suggest a systemic issue with monitoring and managing the expiration dates of medications and supplies. Interviews with staff, including CMTs, RNs, ADONs, and the DON, highlighted inconsistencies in the frequency and responsibility for checking medication carts and storage rooms for expired items. While some staff believed checks were done weekly, others indicated they were done three times a week or daily. The staff acknowledged that expired medications and supplies should be removed and disposed of appropriately, yet the survey findings showed this was not consistently practiced. The lack of clear accountability and adherence to the facility's policies contributed to the deficiency in medication and supply management.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was at a safe and appetizing temperature, as evidenced by observations and interviews with three residents. These residents, who were cognitively intact, consistently reported receiving cold food, which led to them refusing meals. The facility's policy required food to be served at temperatures above or equal to 135 degrees Fahrenheit, but observations showed that food temperatures were significantly below this standard, with items such as ham, baked potatoes, and steamed carrots being served at temperatures ranging from 100 to 120 degrees Fahrenheit. Interviews with staff, including CNAs, RNs, and the ADON, revealed that there were frequent complaints from residents about the temperature of the food. Staff members acknowledged these complaints and reported them to the appropriate personnel, such as the Director of Nursing and the kitchen staff. However, there was no evidence that food temperatures were being monitored consistently, and some staff members were unaware of the facility's food temperature policy. The Dietary Manager claimed to monitor room tray temperatures daily and ensure timely delivery of trays, but observations contradicted this, showing room trays being passed from a rolling cart without temperature checks. The Director of Nursing was unaware of the facility's policy for room tray temperatures and who was responsible for monitoring them. This lack of awareness and adherence to the policy contributed to the ongoing issue of serving food at inappropriate temperatures, leading to resident dissatisfaction and meal refusals.
Resident Dignity Compromised by Inappropriate Staff Interaction
Penalty
Summary
The facility failed to ensure the dignity of a resident who was legally blind and cognitively intact. The resident was dependent on tobacco and required supervision while smoking, including wearing a smoking apron for safety. An incident occurred when a Hospitality Aide (HA) observed the resident in the smoking area without the apron and approached the resident by touching the back of the resident's head to get their attention, which the resident perceived as being hit. The resident initially expressed that the HA had struck them, but later clarified that the contact did not cause injury or mental anguish, although it made them feel embarrassed and like a child. The resident felt that the HA should have called their name instead of touching their head. The HA admitted to tapping the resident on the back of the head to get their attention and acknowledged that it was inappropriate, stating they should have tapped the resident's shoulder instead. Interviews with staff and the resident indicated that the interaction was disrespectful and compromised the resident's dignity. The Assistant Director of Nursing and the Administrator both acknowledged that the HA's actions were inappropriate and that the resident's dignity was compromised by the incident.
Failure to Obtain Physician's Order for Self-Administration of Medication
Penalty
Summary
The facility failed to obtain a physician's order for a resident to self-administer medication at bedside and did not evaluate or document the resident's ability to self-administer medication. The resident, who was admitted with diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Pulmonary Fibrosis, was cognitively intact according to the Minimum Data Set. However, the resident's care plan did not address the self-administration of medication, and there was no physician's order for the resident to self-administer any medication, including the prescribed albuterol sulfate inhaler. An observation revealed the inhaler was kept at the resident's bedside, and the resident reported receiving it from an unknown staff member without an assessment of their ability to self-administer. Interviews with facility staff, including a Certified Medication Technician, a Registered Nurse, an Assistant Director of Nursing, and the Director of Nursing, confirmed that no assessment or physician's order was in place for the resident to self-administer the inhaler. Staff were unaware of the inhaler's presence in the resident's room and did not follow the facility's policy requiring an assessment and physician's order for self-administration of medication.
Failure to Notify Residents of Hospital Transfer
Penalty
Summary
The facility failed to notify two residents and/or their representatives of a transfer to a hospital, including the reasons for the transfer in writing. This deficiency was identified for two residents out of a sample of 35, with a facility census of 151 residents. The facility's Transfer and Discharge Policy, revised in June 2020, mandates that residents or their representatives receive advanced notice of transfer or discharge, and that this notice be documented in the resident's medical record. However, for Resident #137 and Resident #109, there was no documentation of such notice in their electronic medical records. Interviews with facility staff revealed a lack of awareness and adherence to the process for ensuring transfer notices were completed and documented. Medical Records Staff confirmed the absence of transfer/discharge notices for the two residents in question. A Registered Nurse indicated that the charge nurse was responsible for completing the notice, but was unaware of the process to ensure its completion. The Director of Nursing acknowledged that if there was no documentation in the electronic medical record, it indicated the notice was not completed. This lack of documentation and communication represents a failure to comply with the facility's policy and regulatory requirements.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide a bed hold notification to two residents and/or their representatives upon transfer or discharge to a hospital. This deficiency was identified during a review of the facility's records and interviews with staff. The facility's Bed Hold Policy, dated June 2020, mandates that residents or their representatives be informed in writing about the bed hold policy upon admission and any time a resident is transferred to a hospital. However, for two sampled residents, there was no documentation of such notifications in their electronic medical records. Resident #137 was discharged to a hospital with an anticipated return, but no bed hold notice was found in the resident's electronic medical record. Similarly, Resident #109 was also discharged to a hospital with an anticipated return, and again, no bed hold notice was documented. Interviews with the medical records staff and nursing staff revealed a lack of awareness and a clear process to ensure bed hold notices were completed and documented. The Director of Nursing confirmed that if there was no documentation in the electronic medical record, it indicated that the bed hold notice was not completed.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for two residents, leading to discrepancies in their assessments. Resident #14 was admitted with a diagnosis requiring assistance with personal care and had dental issues, including missing and broken teeth, which were not accurately reflected in the MDS. Despite observations and interviews confirming these dental issues, the MDS indicated no missing teeth or cavities, and the resident's care plan did not address the need for dental care. Resident #98, who had chronic respiratory conditions and was dependent on supplemental oxygen, also had inaccuracies in their MDS. The resident's MDS failed to document the use of a BiPAP machine, which the resident had been using for approximately seven years. Additionally, the MDS inaccurately reported no dental issues, despite the resident having multiple missing and broken teeth. Interviews with the MDS coordinators revealed a lack of awareness of these issues, and the necessary information was not captured in the MDS. Furthermore, Resident #109 experienced two falls that were not documented in the MDS. Despite the resident's falls being discussed in clinical meetings, the MDS coordinators were unaware of these incidents, and the falls were not coded in the MDS. The facility's staff, including the MDS coordinators and the Director of Nursing, acknowledged the expectation for the MDS to be updated to reflect such incidents, but this was not done, leading to incomplete and inaccurate resident assessments.
Deficiencies in Care Planning for Dental, Respiratory, and Fall Risk Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for several residents, leading to deficiencies in addressing their functional and health status. For Resident #14, the facility did not identify or address dental care needs despite the resident having broken and/or carious teeth, as observed during an interview and physical examination. The resident reported having few teeth and experiencing pain, yet the current care plan did not reflect any dental care needs, and the Quarterly MDS showed no issues with teeth. Resident #98 also experienced a lack of comprehensive care planning. Despite having chronic respiratory conditions and a dependence on supplemental oxygen, there was no order for the utilization of a BiPAP, which the resident had been using for approximately seven years. Additionally, the resident had multiple missing and broken teeth, yet these dental issues were not captured in the MDS or care plan. Interviews with staff revealed a lack of awareness regarding the resident's dental and BiPAP needs, indicating a failure in the assessment and documentation process. Resident #109 experienced two falls outside the facility, resulting in pain and injuries, yet these incidents were not reflected in the resident's care plan or MDS. The facility's policy required fall evaluations and care plan updates following such events, but these were not conducted. Interviews with staff, including CNAs, RNs, and MDS coordinators, revealed a lack of communication and documentation regarding the falls, leading to an absence of fall prevention interventions in the resident's care plan.
Failure to Update Care Plan for Anticoagulant Medication
Penalty
Summary
The facility failed to update the care plan for a resident who was on an anticoagulant medication. The resident, who was admitted with a diagnosis of Peripheral Vascular Disease and was cognitively intact, had an admission Minimum Data Set (MDS) completed, which indicated the use of an anticoagulant. However, the care plan developed on 10/15/24 did not include any mention of the anticoagulant medication, despite the resident having a physician's order for Rivaroxaban 20 mg daily by mouth in the evening, dated 10/19/24. Interviews with facility staff, including Licensed Practical Nurse (LPN) B, MDS coordinators, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), revealed that there was an expectation for the care plan to address the anticoagulant medication. The MDS coordinators acknowledged their responsibility for updating care plans and stated that a care plan for the anticoagulant would have been created during the next assessment when medications were reviewed. The DON emphasized the importance of monitoring physician's orders to ensure care plans are created and updated as needed.
Failure to Document Discharge Planning and Summary
Penalty
Summary
The facility failed to document discharge planning and complete a discharge summary for a resident who was discharged to home. The resident, who had been diagnosed with leukoencephalopathy, schizoaffective disorder, bipolar disorder, depression, and anxiety, was admitted to the facility and was receiving weekly psychotherapy. Despite the resident's complex medical and behavioral needs, there was no documented discharge plan or summary in the resident's medical record. The facility's policy required discharge planning to begin upon admission, but this was not adhered to in the case of this resident. The resident exhibited behaviors that led to hospital evaluations, and there was an attempt to find an alternative placement more suitable for the resident's age and needs. However, the social worker did not document efforts to contact other facilities or inform the resident's DPOA about a potential placement that was found. When the resident's family decided to take the resident home, the social worker did not arrange for aftercare services or document a discharge summary, leaving the resident without a clear post-discharge plan. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's discharge planning. The social worker admitted to not documenting conversations with the resident's DPOA or efforts to find alternative placements. The DON expected thorough documentation of discharge plans, but this was not present in the resident's record. The resident's DPOA expressed concerns about the resident's quality of life and was not informed of any progress in discharge planning, ultimately leading to the resident being taken to the hospital instead of home.
Failure to Obtain Treatment Orders for Head Laceration
Penalty
Summary
The facility failed to obtain treatment and monitoring orders for a head laceration with staples for one resident. The resident, who was admitted with a history of falls and dementia, sustained a 3.8 cm laceration to the back of the head after a fall. The resident was taken to the hospital, where staples were placed in the laceration, and instructions were given to monitor for signs of infection and to contact a doctor if the staples came apart or fell out before seven days. However, upon return to the facility, there were no physician orders documented for the care or monitoring of the laceration, nor for the removal of the staples. Interviews with facility staff, including a CNA, LPN, and the Director of Nursing, revealed that there was an expectation for physician orders to be in place for monitoring and treatment of the laceration, including staple removal. The LPN noted that the resident had been picking at the site, resulting in the loss of a staple, and confirmed the absence of physician orders. The DON also confirmed the expectation for orders to be transcribed and documented by nursing staff, but this was not done, leading to a lack of proper care and monitoring for the resident's head laceration.
Failure to Supervise and Document Smoking-Related Burn Incident
Penalty
Summary
The facility failed to adequately supervise, assess, and investigate a burn incident related to smoking for a resident who was cognitively intact and required supervision for activities of daily living. The resident, who had diabetic neuropathy affecting their fingers, was observed on the smoking patio with a burn on their finger, despite wearing a smoking apron. The facility's policy required incidents such as burns to be reported and documented immediately, but no incident report or documentation was found in the resident's medical record. Interviews with staff revealed a lack of communication and awareness regarding the incident. The Assistant Director of Nursing and the Director of Nursing were unaware of the burn, and the Hospitality Aide did not report the incident despite being aware of it. The Licensed Practical Nurse was also unaware of the burn and did not complete the necessary assessments or notifications. The facility's process for handling such incidents, including completing an incident report and notifying relevant parties, was not followed, leading to a deficiency in the supervision and care of the resident.
Deficiency in Suprapubic Catheter Care Documentation
Penalty
Summary
The facility failed to obtain comprehensive physician orders for a suprapubic (S/P) catheter for a resident, which included the type, size, and care required. The resident, who was readmitted to the facility following hospitalization for blood in urine and had a diagnosis of prostate cancer, had a newly placed S/P catheter. However, the physician's orders did not include specific instructions for the care and monitoring of the S/P catheter and its stoma site. Additionally, the resident's care plan was not updated to reflect the new S/P catheter care requirements. Interviews with facility staff revealed that the CNAs were only responsible for emptying the resident's urine drainage bag, while the nursing staff performed the S/P catheter care without a physician's order. The LPN and DON both expressed expectations for detailed physician orders and an updated care plan, which were not present. This lack of comprehensive documentation and care planning for the S/P catheter represents a deficiency in the facility's adherence to its own policies and procedures regarding physician orders and resident care plans.
Failure to Document Enteral Feeding Refusals
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's refusal of enteral feeding via a Gastrostomy Tube. The resident, who was cognitively intact and at risk for malnutrition, had difficulty swallowing and was dependent on enteral feedings. Despite this, there were multiple instances where the resident's refusal of feedings was not documented in the electronic medical record. Specifically, 14 out of 84 feeding opportunities in October and 21 out of 68 in November were left blank, with only two instances noted as refusals. This lack of documentation was confirmed through interviews with the nursing staff, the resident, and the Director of Nursing. The resident experienced a period of refusing feedings due to diarrhea, which was not consistently documented by the nursing staff. The Registered Nurse and Nurse Practitioner both acknowledged that refusals should have been recorded in the resident's medical record. The Director of Nursing also confirmed that blank entries in the Treatment Administration Record indicated that the physician's orders were not completed. This oversight in documentation led to a deficiency in the facility's compliance with ensuring accurate records of physician orders and resident care.
Deficiencies in Dialysis Care and Communication
Penalty
Summary
The facility failed to consistently follow physician's orders for assessing dialysis shunts and ensuring proper communication between the nursing staff and dialysis providers for two residents. Resident #7, who had cognitive impairment, diabetes, peripheral vascular disease, high blood pressure, communication deficit, and end-stage renal failure, was scheduled for dialysis three times a week. However, the nursing staff did not consistently check the resident's shunt site for bruising, bleeding, and signs of infection as ordered. Additionally, there were significant gaps in the documentation of dialysis communication sheets, with many instances where monitoring of thrill and bruit was not documented before or after dialysis sessions. Resident #7 also frequently refused dialysis treatments, and there was a lack of documentation regarding the resident's condition and communication with the dialysis center. Despite the resident's refusal, the facility was expected to continue monitoring the shunt site and document findings, which was not consistently done. The resident eventually transitioned to hospice care, but the deficiencies in monitoring and documentation persisted until that point. Similarly, Resident #97, who was cognitively intact and diagnosed with end-stage renal disease, had dialysis communication forms that were not completed for any of the scheduled dialysis appointments in October and November. The charge nurses were responsible for completing these forms and monitoring the resident's condition before and after dialysis, but there was no system in place to ensure the forms were returned and reviewed. This lack of documentation and communication posed a risk to the continuity of care for residents requiring dialysis services.
Failure to Document Rationale for GDR Recommendation
Penalty
Summary
The facility failed to ensure that the resident's physician provided a rationale for not following the pharmacist's recommendation for a Gradual Dose Reduction (GDR) of psychotropic medication for a resident diagnosed with bipolar disorder, depression, and insomnia. The resident had been taking Aripiprazole, an antipsychotic medication, without a GDR since admission. The pharmacist recommended reducing the dose, but the physician declined without documenting a rationale, which is against the facility's Medication Management policy. Interviews with facility staff revealed a lack of awareness and responsibility regarding the GDR process. The Registered Nurse was unaware of the facility's policy and process for medication reviews and GDRs, while the Assistant Director of Nursing indicated that the Director of Nursing was responsible for ensuring GDRs were completed and documented. The Director of Nursing confirmed that the pharmacy sends GDR recommendations, which should be discussed with the physician, and any decision should be documented in the resident's Electronic Medical Record. However, this process was not followed, leading to the deficiency.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate. One incident involved a resident with Chronic Obstructive Pulmonary Disease (COPD) and Pulmonary Fibrosis who did not receive their prescribed Symbicort inhalation medication. A Certified Medication Technician (CMT) documented that the medication was administered without actually observing or assisting the resident in taking it. Interviews with the CMT, a Registered Nurse (RN), the Assistant Director of Nursing (ADON), and the Director of Nursing (DON) confirmed that the CMT did not follow proper procedures for medication administration and documentation. Another incident involved a resident with Diabetes Mellitus who was supposed to receive Fiasp insulin but was instead given Insulin Lispro. The RN responsible for administering the insulin did not verify the medication against the physician's order and used a vial without resident identifiers. The error was not documented or followed up in the resident's medical record. The DON stated that insulin should be administered from a vial marked with the resident's name and verified against the physician's order.
Medication Error: Incorrect Insulin Administered
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors when a registered nurse (RN) administered the incorrect type of insulin to a resident with Type II Diabetes Mellitus. The resident was prescribed Fiasp (Insulin Aspart with Niacinamide) to be administered subcutaneously with meals. However, during an observation, RN A retrieved and administered 17 units of Insulin Lispro from a vial without verifying the accuracy of the order or ensuring the vial was marked with the resident's name. This action was contrary to the facility's Insulin Administration policy, which required verification of the insulin type against the physician's order prior to administration. The incident occurred without RN A having immediate access to the resident's medical record, and there was no documentation or follow-up of the medication error in the resident's medical record. The Director of Nursing (DON) later confirmed that the expectation was for insulin to be administered as ordered and from a vial marked with the resident's name, with staff verifying physician orders from the medical record before administering medication.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide routine and emergency dental services to meet the needs of two residents, leading to a deficiency. Resident #14 was admitted with a diagnosis requiring assistance with personal care and had broken and/or carious teeth. Despite a physician's order for dental treatment, the resident had not seen a dentist since admission. Observations revealed multiple missing teeth, a loose tooth, and a buildup of yellow substance on the remaining teeth. The resident expressed uncertainty about the last dental visit and reported occasional tooth pain, yet the care plan did not address the need for dental care. Resident #98 was admitted with his own teeth, but the initial assessment left the question about broken or carious teeth blank. The resident's dental evaluation later revealed multiple missing teeth and root tips, with a recommendation for full mouth extraction. The resident expressed a desire for teeth extraction and dentures due to occasional pain. However, the facility's records did not reflect timely follow-up or documentation of dental services, and the resident's care plan only mentioned monitoring oral hygiene and notifying the MD of concerns. Interviews with facility staff, including the social worker, MDS coordinators, and nursing directors, revealed a lack of awareness and communication regarding the dental needs of these residents. The social worker was unaware of Resident #14's dental issues and could not locate paperwork for Resident #98's dental visit. The MDS coordinators and ADONs acknowledged the expectation for dental issues to be captured and care planned but were not fully informed of the residents' conditions. The DON expected residents with dental issues to be seen by a dentist within a month, but this was not achieved for the residents in question.
Failure to Document and Administer Vaccines
Penalty
Summary
The facility failed to ensure that pneumococcal and influenza vaccines were offered, administered, or documented for two residents. Resident #95, who was older than the recommended age for pneumococcal vaccination and had risk factors for respiratory infections, showed no evidence of receiving the pneumococcal vaccine. The resident's immunization report lacked documentation of education, consent, refusal, or administration of the vaccine, despite CDC recommendations for vaccination. Similarly, Resident #48's immunization report showed no evidence of influenza vaccination administration, nor documentation of education, consent, or refusal. Interviews with the Infection Preventionist and the Director of Nursing revealed that residents should have been screened for pneumococcal immunizations upon admission and offered the influenza vaccine annually. Both staff members acknowledged that all administered immunizations and any refusals should have been documented in the residents' medical records.
Failure to Provide COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to provide necessary education and obtain consent for the COVID-19 vaccination for three residents, leading to a deficiency in their vaccination process. Resident #71 received only a single dose of the Moderna COVID-19 vaccine and had no further doses or evidence of being offered additional vaccination. There was no signed consent or refusal documented, nor was there any record of COVID-19 vaccine education provided to the resident or their representative. Similarly, Resident #93 also received only one dose of the vaccine with no further doses or evidence of being offered additional vaccination, and lacked documentation of consent or education. Resident #95 had no COVID-19 vaccination history, no evidence of being offered the vaccine, and no documentation of consent or education. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed that the IP was responsible for ensuring the completion of COVID-19 vaccinations, including reviewing vaccine history upon admission and offering the vaccine to residents. The IP acknowledged that the facility was trying to catch up on offering the vaccine to residents. The DON confirmed that the IP was tasked with ensuring residents received education, signed consents were obtained, and vaccination status was documented. However, these actions were not completed for the sampled residents, resulting in the identified deficiency.
Narcotic Medication Security Breach
Penalty
Summary
The facility failed to ensure the security of a resident's narcotic medication, resulting in the disappearance of 47 Oxycodone pills. The incident involved a resident who was admitted with diagnoses including breast cancer and chronic pain, and had an order for Oxycodone-Acetaminophen to be administered as needed for pain. The medication was received by the facility on two separate occasions, but the narcotic count sheets for these deliveries were missing, and the medication was not found in the narcotic lock box when needed. Interviews with staff revealed that the Oxycodone was last accounted for during a shift change count, but the count sheets were not present in the count book. The Assistant Director of Nursing (ADON) later found empty medication cards in the shred box at the nurse's station. There were also prior complaints from residents about not receiving narcotic pain medications during shifts when a particular LPN was on duty, despite the medications being signed off as administered. The Director of Nursing (DON) was responsible for monitoring narcotic logs and ensuring adherence to policy, while the ADON was tasked with daily checks of the logs. The investigation indicated that the medications went missing after an LPN had access to the cart, and the count sheets for the missing Oxycodone were never located. The facility's policies required that any discrepancies in controlled substance counts be reported immediately and investigated, but the missing medication was not discovered until a resident requested it for pain relief.
Inappropriate Discharge Process for Resident with Behavioral Issues
Penalty
Summary
The facility staff failed to provide an appropriate immediate discharge letter for a resident, leading to a deficiency in the discharge process. The resident, who was cognitively intact and had no history of negative behaviors, was admitted with diagnoses including spinal stenosis, Type II diabetes mellitus, and a history of drug abuse. On a particular day, the resident's behavior escalated, resulting in an altercation with a roommate and subsequent hospitalization for evaluation. The facility issued a discharge notice citing aggressive behavior, medication refusal, and threats, including homicidal threats towards the roommate. Despite the hospital's assessment that the resident was at their cognitive baseline, the facility decided not to re-admit the resident, citing ongoing threats to safety. Interviews revealed that the facility administrator believed they could deny re-admission if the resident posed an active threat to others. However, the facility did not provide appropriate discharge planning or find alternative placement for the resident. The ombudsman noted discrepancies in the emergency discharge documentation, specifically the incorrect disposition to a hospital. The facility's actions were based on the resident's sudden behavioral changes, which they were unprepared to manage, leading to the decision to discharge the resident without proper notification or planning.
Failure to Ensure Resident Safety and Proper Transportation
Penalty
Summary
The facility failed to ensure residents were free from accidents for two sampled residents. On one occasion, a CNA attempted to transfer a resident without using the required Hoyer lift, resulting in the resident being lowered to the floor. The CNAs then lifted the resident back to bed without using a gait belt or mechanical lift. This incident was not reported to the nursing staff, and the resident was not assessed for injuries immediately after the fall. The resident later exhibited increased yelling behavior, was found to be unresponsive, and had significant bruising and pain. The resident was eventually sent to the hospital, where multiple fractures and significant blood loss were discovered, requiring surgical intervention and blood transfusions. The care plan did not identify the need for a Hoyer lift, and the CNAs were unaware of the proper transfer procedures, leading to the resident's injuries and delayed medical attention. In another incident, the facility failed to ensure the safe transportation and location of a resident who was left sitting in a hospital lobby all night after a dialysis appointment. The resident was not picked up by the facility's transportation, and attempts to contact the facility were unsuccessful. The resident eventually returned to the facility the next morning using an alternative transportation method. The resident missed evening medications and supper due to the transportation failure. The facility did not have a transportation policy in place, and there was a lack of communication and coordination between the facility and the dialysis center regarding the resident's return. The facility's policies on transfers and falls were not followed, leading to significant harm to the residents. The staff failed to report and assess the resident's condition after the fall, and there was a lack of proper communication and coordination for the resident's transportation. These deficiencies highlight the need for better adherence to policies and procedures to ensure resident safety and prevent accidents and injuries.
Failure to Provide Timely Assistance in Obtaining Hearing Device
Penalty
Summary
The facility failed to ensure timely assistance in obtaining a hearing device for a resident with a cognitive communication deficit. The resident was admitted with a diagnosis that included a communication problem related to a hearing deficit. The care plan included specific interventions to address the resident's communication needs, such as ensuring hearing aids were placed in both ears and using alternative communication tools as needed. However, the resident's hearing aids were not consistently applied as documented in the Treatment Administration Record, and there were no progress notes explaining the absence of the hearing aids on certain days. The resident's hearing aids were lost and broken during a hospital visit, and despite contact with the family and attempts to retrieve or repair the hearing aids, the resident went without them for an extended period. Interviews with staff and family members revealed that the resident's hearing aids were essential for communication, and the lack of hearing aids significantly impacted the resident's ability to communicate effectively. The family was under the impression that the facility was responsible for getting the hearing aids fixed, but there was a delay in obtaining the repaired or new hearing aids. The resident's family expressed frustration with the facility's handling of the situation, noting that the resident went without hearing aids for at least eight months. The hearing aids only arrived at the facility on the day the resident was discharged to a new facility.
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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