Carriage Square Rehab And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Joseph, Missouri.
- Location
- 4009 Gene Field Road, Saint Joseph, Missouri 64506
- CMS Provider Number
- 265336
- Inspections on file
- 25
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Carriage Square Rehab And Healthcare Center during CMS and state inspections, most recent first.
Surveyors were unable to timely review necessary records due to the facility’s failure to promptly provide access to the EMR, resident roster, and resident matrix after these items were requested from the Administrator and DON. The Administrator initially supplied only a staff list and withheld EMR access and resident information pending authorization from regional corporate staff, in accordance with the company’s stated protocol that documentation be reviewed by regional team members before release. As a result, surveyors did not receive EMR access and the resident matrix until several hours after the initial request, and no policy addressing timely access to medical records was provided.
Two residents with indwelling urinary catheters did not receive proper catheter care, as staff failed to keep catheter bags off the floor and used improper cleaning techniques, such as reusing soiled wipes and not changing gloves. Staff interviews revealed gaps in knowledge of infection control protocols, contributing to the risk of catheter-associated urinary tract infections.
Staff failed to consistently use enhanced barrier precautions and proper infection control measures during high-contact care for residents with wounds and indwelling devices. Observations included staff not performing hand hygiene, not wearing gowns, not changing gloves after contamination, and allowing catheter bags to touch the floor. These lapses occurred during wound care and catheter care for several residents, despite staff awareness of required protocols.
Staff failed to follow the facility's policy for handling medical record requests, with some staff printing and distributing records without formal written requests. Additionally, a resident's representative experienced significant delays in receiving requested medical records, as the required procedures and documentation were not followed and records were not provided within the required timeframe.
Staff failed to follow proper perineal care and infection control procedures for three residents who were incontinent, including reusing soiled wipes on multiple areas and not changing gloves after care. These residents, who required assistance with hygiene and had histories of incontinence and UTIs, did not receive care in accordance with facility policy, as confirmed by staff interviews and direct observation.
A resident with a history of pneumonia and UTI experienced a significant change in condition, including low blood pressure and confusion, but the facility failed to notify the physician promptly. An ordered antibiotic was not administered due to lack of access, and a urinalysis was delayed, leading to the resident's hospitalization for sepsis. Interviews revealed communication failures and non-compliance with the facility's change of condition policy.
A resident with spinal stenosis and inflammatory spondylopathy experienced severe pain due to the facility's failure to order oxycodone in a timely manner, resulting in five missed doses. The resident reported extreme pain and withdrawal-like symptoms, and interviews revealed that the medication was ordered late and sent to the wrong physician. The DON acknowledged the error and emphasized the need for timely reordering of medications.
The facility's Arbitration Agreement failed to include a clause stating that signing was not a condition for admission or continued care, affecting all residents who signed it. Staff interviews confirmed the omission, with the Admission Coordinator, Regional Director, and Administrator unaware of the missing clause.
The facility failed to designate a qualified Infection Preventionist (IP) with specialized training to manage the Infection Prevention and Control Program (IPCP). The Minimum Data Set Coordinator (MDSC) was acting as the IP without formal training or certification, and the facility had been without a qualified IP since October 2024. The Assistant Director of Nursing (ADON) was being trained for the role, but the MDSC continued to perform IP duties. This deficiency placed all 93 residents at risk for infections.
The facility failed to maintain an effective training program, missing cultural competency training and lacking a system to track staff attendance for required in-services. This deficiency potentially allowed staff to work without necessary skills, risking negative outcomes for residents.
The facility did not maintain an effective training program, failing to provide required annual training on effective communication for direct care staff. The Performance Improvement Plan revealed that the necessary 12 hours of training were not consistently scheduled or completed. The Administrator admitted the lack of a tracking system and a staff educator, leading to incomplete training.
The facility did not maintain an effective training program for staff on the Quality Assurance and Performance Improvement (QAPI) program. The required annual 12 hours of training were not consistently scheduled or completed. The 2024 in-service calendar lacked QAPI as a training topic, and no such training was provided. The Administrator admitted to the absence of a tracking system for training attendance and the lack of a staff educator, with the former DON unable to cover all educational needs.
The facility failed to provide annual training on compliance and ethics for all staff, as required. The Performance Improvement Plan identified that the necessary 12 hours of training were not consistently scheduled or completed. There was no evidence of compliance training being provided in 2024, and the facility lacked a tracking system to identify staff who missed the training. The absence of a staff educator contributed to this deficiency.
The facility failed to provide the required 12 hours of annual in-service training for CNAs, as mandated by regulation. The absence of a consistent training schedule and tracking system led to CNAs potentially working without necessary skills. The facility's assessment outlined essential training topics, but the 2024 in-service calendar did not include all required trainings, and attendance was not tracked. The Administrator acknowledged the lack of a staff educator and tracking system, which could impact the care provided to the facility's 93 residents.
The facility failed to maintain respiratory care equipment and follow physician orders for three residents. A resident's oxygen concentrator filter was found dirty, contrary to policy. Another resident's oxygen was set at four LPM instead of the ordered two LPM, risking hypoxia or over-oxygenation. A third resident's oxygen was set at 2.5 liters instead of the ordered three liters. These failures risked respiratory complications.
The facility failed to maintain kitchen cleanliness and proper food storage, risking foodborne illnesses for residents. Observations included wet-stacked pans, dirty containers, and unlabeled food items in storage. The ADM confirmed these issues, indicating a lack of knowledge about use-by dates.
The facility failed to maintain an effective infection prevention and control program, with lapses in infection surveillance, water management, and glucometer disinfection. The MDSC did not update infection records due to the absence of an IP, and the Maintenance Director neglected to test the water fountain's pH levels. An LPN failed to clean a glucometer between residents, contrary to protocol.
The facility failed to develop comprehensive care plans for two residents, one receiving hospice services and another with diabetes mellitus. The hospice care plan for a resident was not completed, and another resident's care plan lacked focus on diabetes management, despite physician orders for regular blood sugar checks. These omissions risked unmet care needs.
A medication error occurred when a CMT, distracted while preparing medications, administered another resident's medications to a resident with multiple diagnoses, including a femur fracture and anemia. The error was discovered after the resident questioned the number of medications received, leading to an immediate assessment by an RN, which found no adverse reactions. The CMT failed to follow proper medication administration protocols, such as verifying the resident's identity.
A facility failed to maintain an effective antibiotic stewardship program when a resident with a UTI did not receive an infection screening evaluation to ensure the correct antibiotic was prescribed. The facility also lacked documentation of antibiotic usage tracking and infection occurrences. The MDSC had not completed necessary evaluations since January and was not fully trained, while the administrator and regional nurse consultant cited staffing challenges.
The facility did not provide necessary staff education following allegations of inappropriate conduct by staff towards two residents, one with moderate cognitive impairment and physical limitations, and another who was cognitively intact but physically dependent. Despite these incidents, no additional training on abuse and neglect was conducted, violating the facility's policy.
The facility failed to report allegations of sexual abuse involving two residents to law enforcement and the Department of Health and Senior Services within the required timeframe. In one case, a Physical Therapist Assistant was observed with their hand inside a resident's brief, but the Administrator did not contact law enforcement. In another case, a resident reported inappropriate touching, but the Administrator did not report it due to the resident's history of delusions. The facility did not follow its policy requiring immediate reporting of such incidents.
The facility failed to properly investigate allegations of inappropriate conduct by PTAs with residents. In one case, a CNA reported seeing a PTA with their hand inside a resident's brief, but the facility did not notify the physician or law enforcement. In another case, a resident alleged inappropriate touching by a PTA, but the facility dismissed the claim due to the resident's history of delusions. Both incidents show a failure to follow the facility's abuse prevention policy.
Failure to Provide Timely Access to EMR and Resident Matrix for Surveyors
Penalty
Summary
The facility failed to provide timely access to resident electronic medical records (EMR), a staff list, and a resident matrix needed by surveyors to conduct a survey and review care provided to residents. On 1/27/2026 at 9:50 A.M., the Administrator and DON were given a list of required items, including the resident matrix and EMR access, to conduct an abbreviated survey process. By 11:19 A.M., the Administrator had only provided a staff list and stated he would not provide EMR access, the resident roster, or the resident matrix until he received authorization from regional team members. Surveyors did not receive EMR access and the resident matrix until 12:42 P.M., delaying their ability to review necessary records. The Administrator later stated that the company protocol required documentation to be reviewed by regional corporate team members before being provided to surveyors, and no facility policy regarding timely access to medical records was provided.
Deficient Catheter Care and Infection Control Practices
Penalty
Summary
The facility failed to provide appropriate catheter care management for two residents with indwelling urinary catheters, resulting in deficiencies related to the prevention of urinary tract infections (UTIs). One resident with a suprapubic catheter and limited mobility was observed with their catheter bag touching the floor while seated in a wheelchair, and staff did not secure the bag off the floor during care. Additionally, catheter care was performed improperly, with a CNA using the same soiled wipe in a back-and-forth motion on the catheter tubing and not changing gloves after touching other items. This resident had a recent history of urinary retention and was diagnosed with a UTI associated with the indwelling catheter, requiring antibiotic treatment and catheter replacement. Another resident, also dependent on staff for catheter and incontinence care, was observed receiving catheter care in which the tubing was scrubbed in a back-and-forth motion, contrary to facility policy. Interviews with staff revealed a lack of knowledge regarding proper catheter care techniques, such as using a new wipe for each swipe and ensuring catheter bags and tubing do not touch the floor. Staff acknowledged difficulties in keeping catheter bags off the floor and inconsistencies in following infection control protocols, including hand hygiene and glove changes.
Failure to Implement Infection Prevention and Control Measures During High-Contact Care
Penalty
Summary
Facility staff failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in the use of enhanced barrier precautions (EBP) and personal protective equipment (PPE) during high-contact care for residents with wounds and indwelling devices. Observations revealed that staff did not consistently perform hand hygiene, wear gowns, or change gloves appropriately when providing wound care and catheter care. For example, a registered nurse and a licensed practical nurse did not wear protective gowns or perform hand hygiene between glove changes while changing dressings on a resident with chronic leg wounds and a catheter. The same staff touched their faces, handled contaminated items, and continued care without changing gloves or sanitizing hands, despite the resident's recent hospitalizations for wound infections and cellulitis. Another incident involved the facility's infection preventionist, who placed a resident's dirty sock on top of clean wound dressing supplies during a dressing change for a pressure ulcer. The infection preventionist continued the procedure without changing gloves or obtaining new supplies after contamination occurred. The director of nursing confirmed that staff were expected to change gloves and retrieve new supplies if contamination happened, but this protocol was not followed during the observed care. Additionally, staff failed to follow proper catheter care protocols for residents with indwelling urinary catheters. Observations showed that catheter bags were allowed to touch the floor, and staff did not wear isolation gowns or change gloves after handling potentially contaminated items such as trash cans before providing catheter care. Interviews with staff and the director of nursing confirmed awareness of the correct procedures, but these were not implemented during the observed care. These failures were noted for multiple residents who were dependent on staff for wound and catheter care.
Failure to Follow Medical Record Request Policy and Timely Release of Records
Penalty
Summary
The facility failed to follow its own policy regarding the handling of medical record requests and the safeguarding of resident-identifiable information. Staff members reported printing and providing copies of electronic medical records to residents and their representatives without obtaining a formal written request, as required by facility policy. The policy specified that all requests for access to protected health information (PHI) must be in writing and directed to the HIPAA Privacy Officer, with a specific form to be completed. However, interviews revealed that LPNs would print and hand over records directly to residents or their representatives, bypassing the required process. The Medical Records Director was unaware that nursing staff were distributing records in this manner and confirmed this was not the correct procedure. Additionally, the facility failed to provide requested medical records in a timely manner for a previous resident. The resident's representative made multiple written and verbal requests for records over several months, but the records were not provided within the state-specified time period. The Medical Records Director acknowledged delays in receiving and processing requests, citing that some requests were found at nurses' stations months after submission and that approval from the corporate office was required before releasing records. There was no documentation of the required request form being completed for the resident in question, and the records had still not been sent at the time of the surveyor's review.
Improper Perineal Care and Infection Control Practices
Penalty
Summary
Facility staff failed to provide appropriate perineal care to residents who were incontinent of bowel and/or bladder, as observed in three sampled residents. The facility's policy required perineal care to be performed at least daily and as needed, using clean soapy washcloths or wipes, moving from front to back, and using a clean area of the washcloth or a new wipe for each stroke. However, observations revealed that staff repeatedly used the same soiled wipe to clean multiple areas of the perineal region, rather than discarding wipes after a single use. In some cases, staff also failed to change gloves after providing perineal care and before applying a new incontinent brief, contrary to facility policy and standard infection control practices. The residents involved were dependent on staff for personal care and hygiene, with medical histories including frequent or occasional incontinence, cognitive impairment, and recent or ongoing treatment for urinary tract infections. Staff interviews confirmed improper perineal care techniques, such as reusing wipes and not changing gloves, while other staff and the Director of Nursing stated that wipes should be used once and gloves changed after care. These actions and inactions resulted in a failure to provide appropriate care and services to prevent urinary tract infections and to restore continence to the extent possible.
Failure to Notify Physician and Administer Treatment Leads to Resident Hospitalization
Penalty
Summary
The facility failed to notify the physician in a timely manner when a resident experienced a change in condition, failed to start an antibiotic that was ordered by the resident's physician, and failed to obtain a physician-ordered urinalysis (UA) in a timely manner. These failures involved a resident who was admitted with diagnoses including pneumonia, urinary tract infection (UTI), and retention of urine. The resident was emergently discharged to the hospital due to sepsis related to a UTI. The resident's vital signs showed a significant drop in blood pressure over several days, indicating a change in condition. Despite these changes, the attending physician was not notified promptly. The resident's family requested an antibiotic, which was ordered but not administered because the staff did not have access to the medication. Additionally, a urinalysis was ordered but not collected until over 24 hours later, delaying the diagnosis and treatment of the UTI. Interviews with staff revealed a lack of communication and failure to follow the facility's policy on change of condition notification. The Director of Nursing stated that a drastic change in blood pressure or mental status should have prompted notification of the physician. The Advanced Practice Registered Nurse and Medical Doctor confirmed they were not informed of the resident's low blood pressure or the delay in obtaining the urinalysis, which would have led to immediate hospital transfer to rule out sepsis.
Failure to Manage Pain Effectively for a Resident
Penalty
Summary
The facility failed to effectively manage pain for a resident, identified as R71, who was prescribed oxycodone for pain management. The resident was admitted with conditions including spinal stenosis and unspecified inflammatory spondylopathy of the lumbar region, and was assessed to have a Brief Interview for Mental Status (BIMS) score indicating cognitive intactness. The resident's pain was frequently rated at a 7 on a numeric scale of 0-10, and he was prescribed oxycodone 10mg/325mg every 6 hours. However, the facility did not order the medication in a timely manner, resulting in the resident missing five doses over two days. This led to the resident experiencing severe pain, inability to sleep, and symptoms resembling withdrawal. Interviews revealed that the Certified Medication Technician (CMT) had informed the Assistant Director of Nursing (ADON) about the medication running out, but the issue was not resolved promptly. The Director of Nursing (DON) acknowledged that the medication was ordered late and sent to the wrong physician, and emphasized that the medication should have been reordered five to six days before the last dose. The resident expressed significant distress due to the missed medication, reporting a pain level of 10 out of 10 and continued severe pain affecting his entire body.
Arbitration Agreement Lacks Required Clause
Penalty
Summary
The facility failed to ensure that the Arbitration Agreement presented to residents and their representatives during admission included a clause stating that signing the agreement was not a condition for admission or continued care. This omission affected all residents who had signed the Arbitration Agreement and any future residents who might sign it. The facility's policy on arbitration, dated October 24, 2022, indicated that the agreement should comply with federal and state laws and that signing was not a requirement for admission or continued treatment. However, the actual agreement, revised in July 2022, did not include this critical clause. Interviews with facility staff, including the Admission Coordinator, the Regional Director of Clinical and Reimbursement Services, and the Administrator, confirmed the absence of the necessary clause in the arbitration agreement. The Admission Coordinator acknowledged that the agreement was developed by the corporation and used across all their facilities. Both the Regional Director and the Administrator were unaware of the omission, indicating a lack of oversight in ensuring the agreement's compliance with stated policies and regulations.
Lack of Designated and Trained Infection Preventionist
Penalty
Summary
The facility failed to ensure there was a designated Infection Preventionist (IP) with specialized training in infection prevention and control, which is necessary for the effective management of the Infection Prevention and Control Program (IPCP). The Minimum Data Set Coordinator (MDSC) was identified as the acting IP, but she had not completed any formal infection preventionist training and lacked certification. The MDSC also indicated that she did not have sufficient time to oversee the IPCP while fulfilling her duties as the MDSC. The facility had been without a qualified IP since October 2024, and a nurse hired for the position vacated it within a month. Interviews revealed that the Assistant Director of Nursing (ADON) was being trained for the IP role, but the MDSC was still performing the IP duties. The Regional Nurse Consultant mentioned that a Licensed Practical Nurse (LPN) was overseeing the program and had completed IP training, but the LPN clarified that she was not the current IP and did not oversee the program. This lack of a designated and trained IP placed all residents at risk for acquiring diseases and infections, as the facility census was 93.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for all staff members, as required by their facility assessment. Specifically, the facility did not provide cultural competency training in 2024, despite it being identified as a need. Additionally, while training on abuse and neglect, infection control, and behavioral health was provided, the facility lacked a system to monitor which staff members had completed the training. This deficiency potentially allowed staff to work without the necessary skills to care for the resident population, placing all residents at risk for negative healthcare outcomes. The facility's Performance Improvement Plan (PIP) acknowledged that the required annual 12 hours of training had not been consistently scheduled or completed by all staff. The PIP outlined a plan for Human Resources and the Administrator to schedule the required in-services and track attendance. However, the facility did not have a staff educator, and the former Director of Nursing could not continue to provide all the required education. This lack of a tracking system was evident in several instances, including behavior management training and enhanced barrier precautions training, where there was no record of which staff attended.
Deficiency in Staff Training on Effective Communication
Penalty
Summary
The facility failed to maintain an effective training program for all staff, specifically lacking training on effective communication for direct care staff. The Performance Improvement Plan (PIP) dated 12/13/24 identified that the required annual 12 hours of training had not been consistently scheduled or completed by all staff. The facility's assessment dated 08/06/24 indicated that CNAs were supposed to receive annual education on effective communication, but the in-service calendar for 2024 showed that this training was not provided. During an interview, the Administrator acknowledged the absence of a tracking system to identify staff who missed training and noted that the former Director of Nursing had been unable to provide all the required education due to the lack of a dedicated staff educator.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to maintain an effective training program for all staff, specifically regarding the Quality Assurance and Performance Improvement (QAPI) program. The Performance Improvement Plan (PIP) dated 12/13/24 identified that the required annual 12 hours of training had not been consistently scheduled or completed by all staff. The plan outlined that Human Resources (HR) and the Administrator were responsible for obtaining the list of required in-service trainings and scheduling them, but this was not effectively implemented. The review of the 2024 in-service calendar revealed that QAPI was not included as a training topic, and no such training was provided to the staff. During an interview, the Administrator acknowledged the lack of a tracking system to identify staff who missed training and noted the absence of a staff educator, with the former Director of Nursing (DON) unable to provide all the required education.
Deficiency in Staff Training on Compliance and Ethics
Penalty
Summary
The facility failed to maintain an effective training program for all staff, specifically regarding the annual training on compliance and ethics program standards, policies, and procedures. This deficiency was identified through interviews, record reviews, and facility policy review. The facility's Performance Improvement Plan (PIP) dated 12/13/24 revealed that the required 12 hours of annual training had not been consistently scheduled or completed by all staff. The PIP outlined a plan for Human Resources and the Administrator to schedule the required in-services, but there was no documented evidence that the compliance training was provided in 2024. The Administrator acknowledged the lack of a tracking system to identify staff who missed the training and noted the absence of a staff educator, with the former Director of Nursing unable to provide all the required education.
Deficiency in CNA Continuing Education Program
Penalty
Summary
The facility failed to maintain an effective continuing education program for Certified Nurse Aides (CNAs), as required by regulation, which mandates 12 hours of in-service training annually. The facility's policy outlined the necessity for CNAs to complete this training to ensure competency in providing care to residents. However, the facility did not consistently schedule or track the required in-service trainings, leading to CNAs potentially working without the necessary education and skills. The facility's Performance Improvement Plan (PIP) acknowledged this issue, noting that the required training topics were not consistently offered, and there was no system in place to track CNA attendance or completion of the training. The facility's assessment indicated that CNAs were to receive annual education on various critical topics, including dementia care, abuse prevention, and infection control, among others. Despite this, the in-service calendar for 2024 did not reflect all necessary trainings, and there was no documentation of the length of the in-services or the CNAs who attended. The Administrator confirmed the lack of a tracking system and the absence of a staff educator, with the former Director of Nursing unable to fulfill all educational requirements. This deficiency in the training program potentially compromised the quality of care provided to the facility's 93 residents.
Failure to Maintain Respiratory Care Equipment and Follow Physician Orders
Penalty
Summary
The facility failed to maintain respiratory care equipment and provide respiratory care per physician orders for three residents. Resident 15's oxygen concentrator was observed with a filter covered in dust, indicating it had not been cleaned as required by the facility's policy. The Licensed Practical Nurse (LPN) confirmed the filter was dirty and should have been cleaned weekly when the oxygen tubing was changed. The Director of Nursing (DON) also stated that the filter should be cleaned every time the oxygen tubing is changed. Resident 53, who was cognitively intact, had a physician's order for oxygen to be administered at two liters per minute (LPM) via nasal cannula. However, observations revealed the oxygen concentrator was set at four LPM on multiple occasions. An LPN verified the incorrect setting and adjusted it to the correct flow rate. The DON stated that nurses are expected to follow physician orders and check the oxygen concentrator's level regularly. The incorrect flow rate could lead to hypoxia or over-oxygenation, especially in residents with COPD. Resident 41, who was also cognitively intact, had a physician's order for oxygen at three liters via nasal cannula. Observations showed the oxygen concentrator's flow rate was set at 2.5 liters on multiple occasions. An LPN and the Regional Nurse Consultant (RNC) confirmed the incorrect setting. The RNC verified the physician's order and acknowledged the discrepancy. These failures in maintaining proper oxygen flow rates and equipment cleanliness placed residents at risk for respiratory complications.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a survey. Several deficiencies were noted, including wet stacking of large metal sheet pans, a dirty plastic container of sugar packets with dried food particles, and a clean industrial stand mixer that was uncovered and had empty boxes stacked on it. Additionally, 13 clean metal pots and pans were stored on a dirty shelf with dried food particles. These observations indicate a lack of adherence to the facility's policy on pot and pan cleaning, which requires air drying without the use of towels. Further deficiencies were observed in the storage of food items. The walk-in refrigerator contained multiple items that were not labeled, dated, or had use-by dates, including rice, cream of wheat, beef broth, ketchup, soup, and cream of chicken soup. The walk-in freezer had a box of omelets that were not sealed and bags of calzones and sausage without use-by dates. The dry storage room contained a bag of spaghetti and individually wrapped slices of bread without dating. The Assistant Dietary Manager confirmed these observations and admitted a lack of knowledge regarding use-by dates, which could lead to uncertainty about the usability of food items. These failures placed all residents at risk for foodborne illnesses.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program (IPCP) as evidenced by several deficiencies. Firstly, the Minimum Data Set Coordinator (MDSC) admitted to not updating the infection surveillance binder, failing to track and trend infection incidents, and not recording corrective actions for several months. This lapse occurred because the facility had been without an Infection Preventionist (IP) since October 2024, and the MDSC was attempting to manage the infection surveillance until a new IP was hired or trained. The Administrator acknowledged the incomplete aspects of the IPCP due to staffing issues, and the Regional Nurse Consultant was unaware of the lapse in infection surveillance. Secondly, the facility's Maintenance Director did not implement measures to prevent the growth of water-borne pathogens in the water fountain, as identified in the facility's Water Management Program Risk Assessment. The Maintenance Director admitted to forgetting to test the water fountain's pH levels, despite testing the water throughout the building weekly. The Regional Director of Plant Operations, responsible for monitoring the testing, had not identified the oversight since the risk assessment was completed in June 2024. Lastly, the facility staff failed to clean and disinfect a multi-use glucometer between residents as per the manufacturer's instructions. During an observation, an LPN used the glucometer on two residents without cleaning it between uses. The LPN admitted to forgetting to clean the device and did not follow the instructions on the disinfecting wipe container. The Regional Director of Clinical and Reimbursement Services confirmed that staff are trained to clean and disinfect glucometers according to protocol, and the Director of Nursing stated that the expectation is for nursing staff to follow infection control practices and policies.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, R74 and R10, which reflected their current medical needs. R74, who was receiving hospice services, did not have a care plan that included hospice care, despite the facility's policy requiring coordinated care plans for residents receiving such services. The Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) acknowledged that a hospice care plan should have been completed when R74 started receiving hospice services. Similarly, R10, who was diagnosed with diabetes mellitus and had physician orders for regular blood sugar checks, did not have a care plan addressing their diabetic care. The MDSC confirmed that R10's care plan was incomplete, lacking focus, measurable goals, or interventions related to diabetes management. These omissions in care planning placed the residents at risk of having unmet care needs.
Medication Error Due to Distraction
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. A Certified Medication Technician (CMT) mistakenly administered medications intended for another resident to Resident 89. This error occurred when the CMT, after preparing the medications for Resident 147, became distracted and inadvertently entered Resident 89's room, administering the wrong medications. The medications given included metoprolol tartrate, metformin, gabapentin, glipizide, and simvastatin, none of which were ordered for Resident 89 by her physician. Resident 89, who was moderately cognitively impaired, was admitted to the facility with multiple diagnoses, including a fracture of the left femur, acute posthemorrhagic anemia, and urinary incontinence. At the time of the incident, Resident 89 was not on any high-risk drug class medications and had no known drug allergies. The error was discovered when the CMT realized the mistake after Resident 89 questioned the number of medications she received, prompting the CMT to check the orders and report the error to a Registered Nurse (RN). The RN assessed Resident 89 immediately after being informed of the error and found her vital signs to be stable with no signs of adverse reactions. The Director of Nursing (DON) was notified, and an investigation revealed that the CMT did not follow the medication administration rights, such as verifying the resident's identity with at least two identifiers. The DON confirmed that the CMT had not been monitored for medication errors since the incident, although no further errors had been reported.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure an effective antibiotic stewardship program, as evidenced by the Minimum Data Set Coordinator (MDSC) not completing an infection screening evaluation for a resident diagnosed with a urinary tract infection (UTI). This oversight occurred for one of four residents reviewed for UTIs out of a sample of 33 residents. The resident in question was admitted with a diagnosis of UTI, and despite a physician's order for a urine culture, the MDSC did not perform the necessary evaluation to confirm the appropriateness of the prescribed antibiotic, Cephalexin. The laboratory results indicated mixed gram-negative and gram-positive organisms and yeast, yet the MDSC failed to assess whether the correct antibiotic was ordered, which is a critical step in preventing antibiotic resistance. Additionally, the facility's Antibiotic Stewardship Program lacked documentation of tracking or trending antibiotic usage and infection occurrences within the facility. The Monthly Infection Log for February and March 2025 showed that infection screening evaluations were not completed. Interviews revealed that the MDSC had not conducted infection screening evaluations for residents on antibiotics since January 2025 and had not completed infection preventionist training. The facility's administrator and regional nurse consultant acknowledged the gaps in the infection control program, citing staffing challenges as a contributing factor.
Failure to Implement Abuse and Neglect Policy
Penalty
Summary
The facility failed to implement its abuse and neglect policy by not providing necessary education to staff following two separate allegations of inappropriate conduct by staff members towards residents. The first incident involved an alleged sexual assault on a resident with moderate cognitive impairment and physical limitations, including dementia and mobility issues. The second incident involved inappropriate touching of a resident who was cognitively intact but had significant physical limitations, including dependency on a wheelchair and assistance for mobility and toileting. Despite these serious allegations, the facility did not conduct any additional training on abuse and neglect for its staff after being made aware of the incidents. The Director of Nursing confirmed that the last training session was conducted prior to these events, and the Administrator admitted to not providing further training following the new allegations. This lack of action contravenes the facility's policy, which mandates regular and situational training to prevent and address abuse and neglect.
Failure to Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual assault involving a resident to law enforcement. A Certified Nurse Aide observed a Physical Therapist Assistant with their hand inside a resident's brief, but the Administrator did not contact law enforcement, believing it was not necessary as it was not rape. The Director of Nursing also did not think law enforcement should be contacted since the alleged perpetrator was removed from the building and the resident was protected. The resident involved had moderately intact cognition but was dependent on staff for various needs due to cognitive and physical impairments. In another incident, the facility did not report an allegation of sexual abuse to the Department of Health and Senior Services within the required two-hour timeframe. A resident reported inappropriate touching by a Physical Therapist Assistant, but the Administrator did not report the allegation due to the resident's history of delusions and the belief that the allegation was untrue. The resident was cognitively intact but had functional limitations and was dependent on a wheelchair. The facility's policy requires immediate reporting of suspected criminal sexual abuse to the Administrator and Director of Nursing Services, who must then notify proper authorities within two hours. However, in both cases, the facility did not adhere to this policy, resulting in a failure to report the allegations to the appropriate authorities in a timely manner.
Failure to Investigate Allegations of Inappropriate Conduct
Penalty
Summary
The facility failed to conduct a thorough investigation and follow proper procedures in response to allegations of inappropriate conduct by Physical Therapy Assistants (PTAs) with residents. In the first incident, a Certified Nurse Aide (CNA) reported observing PTA A with his hand inside a resident's brief. The facility did not notify the physician, contact law enforcement, or have the resident assessed for a medical exam. The investigation was deemed unsubstantiated based on the lack of witnesses and the denial by PTA A, despite the CNA's detailed account of the incident. In the second incident, another resident alleged that PTA B touched them inappropriately. The facility again failed to notify the physician and did not conduct a thorough investigation. The resident reported feeling uncomfortable with PTA B's actions, which included touching their leg and making inappropriate comments. Despite the resident's clear account and history of similar allegations, the facility did not report the incident to the appropriate authorities, citing the resident's history of delusions as a reason for dismissing the claim. Both incidents highlight significant lapses in the facility's adherence to its abuse prevention and prohibition program. The facility's policy mandates immediate reporting and thorough investigation of such allegations, including notifying law enforcement and conducting medical assessments. However, these steps were not followed, resulting in a failure to protect the residents and ensure their safety.
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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.
Trusted data from CMS and state health departments
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