Cedar Pointe
Inspection history, citations, penalties and survey trends for this long-term care facility in Rolla, Missouri.
- Location
- 1800 White Columns Drive, Rolla, Missouri 65401
- CMS Provider Number
- 265279
- Inspections on file
- 20
- Latest survey
- April 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cedar Pointe during CMS and state inspections, most recent first.
An LPN administered Lorazepam to a severely cognitively impaired resident without a physician's order, using medication from another resident's supply to calm behavioral symptoms. The medication was given for staff convenience, not as a standard treatment, and was not documented in the medical record, in violation of facility policy and residents' rights to be free from chemical restraints.
Staff did not consistently document the administration of a controlled substance for a resident with severe cognitive impairment and anxiety, and failed to complete required shiftly controlled drug counts on the memory care unit. Review of records showed missing staff signatures on multiple dates, and a discrepancy was found between the documented and observed amounts of Lorazepam. Interviews with staff and leadership confirmed that required procedures for narcotic counts and documentation were not followed.
Staff did not develop or implement comprehensive care plans for two residents with documented histories of wandering and aggression. Despite assessments, incident reports, and staff awareness of these behaviors, the care plans lacked necessary documentation and interventions to address them. The Care Plan Coordinator had not updated the plans to reflect these needs, even though staff regularly discussed resident behaviors.
An LPN at a facility misappropriated narcotic medications from three residents without authorization. The residents, who required pain management for various conditions, were affected when the LPN took their medications and failed to document them properly. The issue was discovered after the LPN exhibited suspicious behavior, leading to a positive drug test for oxycodone and subsequent arrest. Missing narcotic log sheets and medication cards were found in the trash, indicating a breach in medication management procedures.
A resident with multiple cancer diagnoses passed away in the facility, but staff failed to notify the family as required by policy. The LPN on duty admitted the oversight, and the family was informed by hospice hours later. Interviews confirmed the expectation to notify the family, doctor, and coroner, but this was not done.
The facility failed to provide adequate nursing staff as per their Facility Assessment, which required one RN or LPN per shift for each unit. From April to July, the facility consistently scheduled only one LPN for both units during night shifts. Interviews with the DON and administrator revealed they were unaware of the requirement for two licensed nurses per unit, per shift.
The facility failed to maintain RN coverage for at least eight consecutive hours daily, as required. The RN staff schedule showed multiple days without an RN on duty, particularly on weekends. The facility is short two RN positions, with the DON and a CNA instructor covering weekday shifts. The administrator is attempting to hire additional RNs to address the shortage.
The facility failed to implement comprehensive water management policies to prevent Legionella growth and did not adhere to infection control procedures during blood glucose monitoring. An LPN placed glucometers on unsanitized surfaces without barriers, contrary to facility policy, risking pathogen transmission. The maintenance director and administrator lacked awareness of CDC Toolkit requirements and infection control protocols.
Facility staff failed to designate a qualified individual with specialized training as the Infection Preventionist for the infection prevention and control program. The ADON was identified as the Infection Preventionist but had not completed the necessary training and certification. The administrator acknowledged the requirement for certification before assuming the role, while the ADON was unaware of their designation and was still undergoing training.
Facility staff failed to update care plans for several residents following significant events, such as falls and pressure ulcers. A resident with quadriplegia and moderate cognitive impairment had a fall that was not documented in the care plan. Another resident with Alzheimer's and diabetes had a fall and a stage III pressure ulcer that were not updated in the care plan. Additionally, a resident with severe cognitive impairment and behavioral issues had an altercation that was not addressed in the care plan. Interviews revealed a lack of awareness and education among staff regarding these incidents.
The facility failed to implement its Grievance Policy for two residents who reported missing personal items. One resident reported a missing Bluetooth earbud set, and another reported a missing cell phone, but neither received updates or replacements. The grievance binder lacked documentation, and staff interviews revealed inconsistencies in the grievance process, including delays and lack of follow-up.
A resident with intact cognition and a history of falls was found with bruises on the forehead and eye area, but the facility failed to investigate and document the injuries as per policy. The CNA and NP observed the bruises but did not ensure proper documentation or notification. The DON was not informed in a timely manner, resulting in an incomplete investigation. The Administrator acknowledged the expectation for reporting and investigating such incidents, highlighting a breakdown in communication and protocol adherence.
Facility staff did not perform required neurological assessments for three residents after unwitnessed falls, as mandated by facility policy. Despite the policy requiring checks every 15 minutes for the first hour, every 30 minutes for the next two hours, and every shift for 72 hours, the medical records for these residents lacked documentation of such assessments. Interviews with an LPN and the DON confirmed the expectation for these checks, which were not completed.
Facility staff failed to properly label and store medications, with multiple undated medication bottles found on a medication cart and in a storage room. Additionally, food items were improperly stored in a medication refrigerator. Interviews with staff revealed a lack of adherence to facility policies regarding medication labeling and storage.
The facility failed to provide six residents with access to their trust fund accounts on weekends, as per their policy allowing access only on weekdays. Interviews with residents and staff revealed that residents were unable to obtain funds for weekend activities, and staff were unaware of the requirement for weekend access. All involved residents were cognitively intact, highlighting the impact of the facility's policy on their ability to manage financial affairs.
The facility failed to provide an ongoing program of activities on weekends, affecting three residents. The activity calendar showed limited scheduled activities, and interviews with residents and staff confirmed the absence of regular weekend activities. The Activities Director mentioned occasional assistance, but overall, there was a lack of coordination and communication regarding weekend activities.
Facility staff failed to protect resident privacy by leaving EHRs open and visible, contrary to HIPAA regulations. A CMT left EHRs open while administering medications, and the medication cart was unattended with visible EHRs. Interviews with the ADON and administrator confirmed staff are instructed to lock screens, but the CMT admitted to oversight.
Facility staff failed to follow professional standards in handling controlled substances, with the DON improperly destroying narcotics without a second witness and failing to document the destruction of Hydrocodone. Additionally, staff pre-prepared medications against policy, risking errors.
Facility staff failed to secure medication carts, leaving them unlocked and unattended, contrary to policy. A CMT repeatedly left a cart with keys in the lock, and a treatment cart with insulin pens was also left unsecured. Interviews confirmed the importance of locking carts to prevent unauthorized access, but staff could not explain the oversight.
Unauthorized Administration of Lorazepam as Chemical Restraint
Penalty
Summary
Facility staff failed to prevent the use of a chemical restraint on a resident when an LPN administered 0.25 ml of Lorazepam to a severely cognitively impaired resident without a physician's order or contacting the physician. The LPN took the medication from another resident's supply and gave it to the resident to calm them after they were observed yelling and keeping others awake. The LPN did not document the administration of the medication in the resident's medical record and did not follow facility policy, which requires staff to obtain a physician's order before administering medications for behaviors. The facility's policies state that residents have the right to be free from chemical restraints and that medications should not be administered for staff convenience or to control behavior unless it is a standard treatment for the resident's condition and properly ordered and documented. Interviews with the LPN, DON, and administrator confirmed that staff are not permitted to administer medications for behaviors without a physician's order and that such actions would be considered a chemical restraint.
Failure to Document Controlled Substance Administration and Complete Shiftly Drug Counts
Penalty
Summary
Facility staff failed to provide services that meet professional standards of quality by not properly documenting the administration of a controlled substance for one resident and by failing to complete required shiftly controlled drug counts on the memory care unit. Review of the facility's policy indicated that narcotics must be counted by two staff members at each shift change, with both staff initialing the count sheet and reporting discrepancies immediately. However, multiple dates were identified where the required staff signatures were missing from the controlled substance shift change forms, indicating that the counts were not consistently performed or documented as required. For one resident with severe cognitive impairment and a diagnosis of anxiety, there was a discrepancy between the documented amount of Lorazepam remaining and the amount observed in the bottle. Staff interviews confirmed that narcotic medications are supposed to be counted each shift by two nurses, and both the DON and administrator acknowledged the policy but noted that counts and documentation had not been consistently completed. The DON stated responsibility for ensuring counts but was not aware of the issue due to other responsibilities and lack of notification.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Behavioral Needs
Penalty
Summary
Facility staff failed to develop and implement comprehensive, person-centered care plans for two residents, as required by facility policy and CMS guidelines. Both residents had documented histories of wandering and physical aggression, but these behaviors were not reflected in their care plans. The care plans lacked documentation and interventions addressing these specific behaviors, despite multiple incidents and staff awareness of the residents' needs. For one resident, assessments indicated moderate cognitive impairment and behavioral symptoms, including physical aggression and wandering. Incident reports documented episodes where the resident entered another resident's room, engaged in verbal and physical aggression, and required staff intervention. Despite these events and staff interviews confirming knowledge of the resident's behaviors, the care plan did not include interventions for wandering or aggression until after the deficiency was identified. The second resident was assessed as severely cognitively impaired with frequent wandering behavior. Observations showed the resident entering another resident's room and lying in their bed, with staff needing to redirect them. Staff interviews confirmed awareness of the resident's wandering, but the care plan did not address this behavior. The Care Plan Coordinator was unaware of the resident's wandering and had not updated the care plan accordingly, despite daily staff meetings to discuss resident behaviors.
Misappropriation of Narcotic Medications by LPN
Penalty
Summary
The facility staff failed to prevent the misappropriation of narcotic medications belonging to three residents. This incident involved an LPN who took the medications without authorization. The facility's Abuse Policy defines misappropriation as the wrongful use of a resident's belongings without consent. The issue came to light when the ADON was notified of the LPN's suspicious behavior during a shift. Upon investigation, the ADON and LPN C discovered that three narcotic log sheets and medication cards were missing from the medication cart. The missing items were later found in the trash, and the LPN was arrested after a positive drug test for oxycodone. The residents affected by this incident were cognitively intact and had specific medical conditions requiring pain management. One resident had unspecified pain and was prescribed oxycodone for severe pain. Another resident had arthritis and knee pain, with a prescription for hydrocodone. The third resident had necrosis of an amputation stump and was also prescribed hydrocodone. The narcotic log books for these residents did not contain the necessary log sheets for their medications, indicating a failure in medication management and documentation. Interviews with facility staff revealed that the LPN exhibited odd behaviors, such as not signing out narcotics properly and disappearing for extended periods. The ADON and Human Resources conducted a drug test, which confirmed the LPN's use of oxycodone without a prescription. The police were called, and the LPN was found with narcotic record sheets and medication packages in their vehicle. This incident highlights a significant breach in the facility's procedures for handling controlled substances, leading to the misappropriation of residents' medications.
Failure to Notify Family of Resident's Passing
Penalty
Summary
Facility staff failed to notify the responsible party of a resident's passing, as required by the facility's policy. The resident, who had been admitted to the facility with multiple cancer diagnoses and was receiving hospice services, passed away. The nurse's notes documented the time of death but did not include any record of contacting the next of kin or family. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the expectation was to notify the family, doctor, administrative staff, and coroner when a resident passes. However, the LPN admitted to not contacting the family, stating it had slipped through the cracks, and later asked hospice to make the notification. The resident's next of kin reported not being notified by the facility and only learned of the passing through hospice hours later. This oversight indicates a failure to adhere to the facility's policy on notifying the family or responsible party in the event of a resident's death. The facility's census at the time was 67, and the deficiency was identified through interviews and record reviews conducted by surveyors.
Inadequate Staffing in Accordance with Facility Assessment
Penalty
Summary
The facility failed to provide adequate nursing staff in accordance with their Facility Assessment, which outlined the staffing requirements necessary to meet the needs of their residents. The assessment, dated April 10, 2024, specified that for an average census of 70-80 residents, each unit (West and East) required one Registered Nurse (RN) or Licensed Practical Nurse (LPN) per shift. However, a review of the facility's night shift staff schedules from April 20, 2024, to July 18, 2024, revealed that the facility consistently scheduled only one LPN for both the West and East units, failing to meet the staffing requirements as directed in the facility assessment. Interviews conducted on July 18, 2024, with the Director of Nursing (DON) and the administrator confirmed the staffing deficiencies. The DON acknowledged that while a licensed nurse was always scheduled for each shift, the facility did not always have two licensed nurses as required. The DON was unaware that the facility assessment mandated two licensed nurses at night. Similarly, the administrator was not aware of the requirement for two licensed nurses per unit, per shift, as stated in the facility assessment.
RN Staffing Deficiency
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required by their Resident Services Policy. The facility's RN staff schedule for June and July 2024 showed multiple days without an RN on duty, specifically on weekends. Interviews revealed that the facility is currently short two RN positions, with the Director of Nursing (DON) and a Certified Nurse Aide (CNA) instructor, who is also an RN, covering shifts during the week. The administrator acknowledged the staffing shortage and the lack of RN coverage on weekends, indicating efforts to hire additional RNs.
Deficiencies in Water Management and Infection Control Procedures
Penalty
Summary
The facility staff failed to develop and implement comprehensive policies and procedures for the inspection, testing, and maintenance of the facility's water systems, which are crucial to inhibiting the growth of waterborne pathogens such as Legionella. The absence of a detailed water management program, including a water system flow diagram and specific control measures, was noted. The maintenance director admitted to performing only basic checks and cleaning procedures, lacking a thorough understanding of the CDC Toolkit requirements. This oversight potentially exposes residents to the risk of Legionnaire's Disease, a serious type of pneumonia caused by Legionella bacteria. Additionally, the facility staff did not adhere to appropriate infection control procedures during blood glucose monitoring for three residents. An LPN was observed placing glucometers on unsanitized surfaces without using a barrier, both before and after testing residents' blood sugar levels. This practice was contrary to the facility's policy, which mandates placing glucometers on clean surfaces to prevent the transmission of infectious agents. The Director of Nursing and the administrator were unaware of these lapses in protocol, which could lead to the spread of bloodborne pathogens or bacteria. Interviews with the LPN and the Director of Nursing revealed a lack of awareness and adherence to infection control expectations. The LPN acknowledged the importance of using a barrier but failed to do so due to the unavailability of one at the time. The Director of Nursing expressed that placing glucometers on unsanitized surfaces poses a risk for infection transmission, highlighting a gap in staff training and compliance with infection prevention protocols.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
Facility staff failed to designate a qualified individual with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist for the facility's infection prevention and control program. The facility, with a census of 70, did not provide a policy for specialized training for the Infection Preventionist. During an interview, the administrator stated that the Assistant Director of Nursing (ADON) was designated as the facility's Infection Preventionist. However, the ADON had only started the required training classes the previous month and was not yet certified. The administrator acknowledged that the training and certification needed to be completed before the ADON could officially assume the role of Infection Preventionist. In a subsequent interview, the ADON expressed unawareness of being the designated Infection Preventionist, as they were still enrolled in the Centers for Disease Control and Prevention Infection Preventionist training and had not completed the certification. The ADON mentioned being only halfway through the training modules and was aware that certification was required before assuming the title of Infection Preventionist.
Failure to Update Care Plans After Significant Events
Penalty
Summary
The facility staff failed to review and revise care plans for several residents following significant events, such as falls and the development of pressure ulcers. For Resident #13, the care plan was not updated to reflect a fall that occurred on 06/11/24, despite the resident having moderate cognitive impairment and a diagnosis of quadriplegia. Similarly, Resident #21's care plan did not include documentation of a fall on 06/26/24, which resulted in a major injury, even though the resident was assessed as cognitively intact. Resident #36 also experienced a fall on 04/24/24, but the care plan lacked any updated interventions. Resident #44's care plan was missing documentation for a fall on 07/04/24 and a stage III pressure ulcer, despite the resident having multiple diagnoses, including Alzheimer's disease and diabetes mellitus. Resident #52, who has severe cognitive impairment, suffered a fall on 07/06/24, but the care plan was not updated to include this incident. Additionally, Resident #5's care plan did not document a stage IV pressure ulcer, even though the resident was assessed with severe cognitive impairment and diabetes mellitus. The facility also failed to address and update care plans regarding behaviors for Resident #4, who has severe cognitive impairment and a history of behavioral symptoms. Despite a documented altercation on 06/22/24, the care plan did not include strategies for managing the resident's behaviors. Interviews with staff, including CNAs and LPNs, revealed a lack of awareness and education regarding these incidents, and the Director of Nursing acknowledged the responsibility of the Care Plan Coordinator to update care plans with necessary interventions.
Failure to Implement Grievance Policy for Missing Items
Penalty
Summary
The facility failed to implement its Grievance Policy for two residents who reported missing personal items. Resident #7, assessed as cognitively intact, reported a missing Bluetooth earbud set to the administrator but did not receive any update or replacement. The administrator was unaware of the missing item. Similarly, Resident #25, also assessed as cognitively intact, reported a missing cell phone to both the administrator and the business office manager but did not receive any update or replacement. The business office manager acknowledged the report but had not discussed further actions with the administrator. The facility's grievance binder contained only two grievance forms from 2024, indicating a lack of documentation for past grievances. Interviews with the business office manager, director of nursing, and administrator revealed inconsistencies in the grievance process, including delays in filling out grievance forms and a lack of follow-up on reported grievances. The facility did not maintain evidence of grievance resolutions for the required three-year period, as stipulated in their policy.
Failure to Investigate and Document Bruises of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate and document bruises of unknown origin for a resident, as directed by the facility's policy. The facility's Abuse Policy and Procedures/Investigation Protocols require a comprehensive investigation for injuries of unknown source, including documentation, notification of responsible parties, and a series of assessments and interviews. However, the resident's medical record did not contain documentation of the bruises or an investigation into the injury. The resident, who has intact cognition, is dependent on staff for certain activities and has a history of falls, was observed with bruises on the forehead and lateral right eye area. Interviews revealed that the CNA noticed the bruises during a shower but did not document them, assuming the nurse was already aware. The NP also observed the bruises but did not communicate with staff, assuming they were already informed. The DON was not notified in a timely manner and admitted to not knowing how to proceed with the investigation. The Administrator confirmed the expectation for such incidents to be reported and investigated, but acknowledged the delay in notification and investigation. This lack of communication and failure to follow protocol led to the deficiency.
Failure to Conduct Neurological Assessments After Unwitnessed Falls
Penalty
Summary
Facility staff failed to adhere to professional standards of practice by not completing neurological assessments for three residents following unwitnessed falls. The facility's policy mandates that after an incident involving a head injury or an unwitnessed fall, a nurse must perform neurological assessments and document the results on a flow sheet. These assessments should include checks every 15 minutes for the first hour, every 30 minutes for the next two hours, and every shift until 72 hours have passed. However, the medical records for three residents, who experienced unwitnessed falls, did not contain the required neurological checks as per the facility's policy. Resident #7, assessed as cognitively intact, had an unwitnessed fall with no injury documented, but lacked the necessary neurological checks. Resident #21, also cognitively intact, experienced an unwitnessed fall with a major injury, yet their medical record did not include the required assessments. Resident #36, with moderate cognitive impairment and dependent on assistance for mobility, had an unwitnessed fall with no injury, but similarly, their record was missing the neurological checks. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the expectation for neurological checks following unwitnessed falls, which were not completed in these cases.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Facility staff failed to store and label medications in a safe and effective manner, as observed during a survey. The survey revealed that multiple opened multi-dose medication bottles, such as vegetable laxative, diphenhydramine, ibuprofen, calcium, and milk of magnesia, were undated on the west wing medication cart. Additionally, the [NAME] wing medication storage room contained undated bottles of dietary supplements and Vitamin D3. This lack of proper labeling contravenes the facility's policy, which mandates that staff record the open date on multi-dose medication containers. Furthermore, the survey found that the medication refrigerator in the [NAME] wing medication storage room contained various food items, including a cinnamon roll, sandwiches, pizza, butter, soda, chipotle ranch, lime juice, leftovers, and coffee. This is contrary to the facility's policy, which requires medications to be stored separately from food. Interviews with staff, including a certified medication technician (CMT), a licensed practical nurse (LPN), the Director of Nursing (DON), and the administrator, revealed a lack of awareness and adherence to the facility's policies regarding medication labeling and storage. The DON acknowledged the issue of food being stored with medications and mentioned ongoing efforts to find a solution.
Residents Denied Weekend Access to Trust Funds
Penalty
Summary
The facility failed to ensure that six residents had appropriate access to their trust fund accounts during weekends. The facility's policy allowed residents to access their funds only from Monday to Friday, between 9:00 A.M. and 4:00 P.M., excluding holidays. This policy required residents to request funds on Fridays if they needed money for the weekend. Interviews with the residents revealed that they were unable to access their funds on weekends, which affected their ability to engage in activities such as dining out or shopping with family. All six residents involved were assessed as cognitively intact, indicating they were aware of their financial needs and the limitations imposed by the facility's policy. Interviews with facility staff, including an LPN, the Business Office, the DON, and the administrator, confirmed that there was no staff available on weekends to provide residents with access to their funds. The staff members were unaware that residents were required to have access to their money on weekends. This lack of awareness and the facility's restrictive policy led to the deficiency, as residents were unable to manage their financial affairs as needed during weekends.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the residents' interests on weekends for three residents out of a census of 70. The facility's policy requires an ongoing program to support residents in their choice of activities, including both group and individual activities. However, the activity calendar for June 2024 showed a lack of scheduled activities on weekends, with only occasional bingo and church services. Interviews with residents revealed dissatisfaction with the lack of weekend activities, as they expressed a desire for more engagement during these times. Interviews with facility staff, including a CNA, LPN, Activities Director, DON, and Administrator, confirmed the absence of scheduled activities on weekends. The Activities Director mentioned that an assistant helps with activities one weekend a month, but otherwise, weekend activities are left to the receptionist or CNAs if they have time. The DON and other staff were unaware of any scheduled weekend activities, indicating a lack of coordination and communication regarding the activity program. This deficiency highlights the facility's failure to adhere to its policy and meet the residents' needs for weekend activities.
Failure to Protect Resident Privacy
Penalty
Summary
The facility staff failed to maintain the confidentiality of personal medical information for three residents, as observed during a survey. The facility's policy on Resident Confidentiality and HIPAA mandates that protected health information should only be discussed with those directly responsible for a resident's care and treatment. However, observations revealed that a Certified Medication Technician (CMT) left residents' Electronic Health Records (EHR) open and visible to others, compromising their privacy. Specifically, the CMT left the EHR open while administering medications to three residents, and the medication cart was left unattended with the EHR visible at the nurse's station. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the administrator, confirmed that staff are instructed to lock or close screens when not at the medication cart to protect resident information. The CMT admitted to having a habit of leaving EHR records open, acknowledging it as an oversight. The ADON and administrator expressed awareness of the importance of following HIPAA regulations but were unsure why the EHRs were not being locked as required.
Improper Handling and Documentation of Controlled Substances
Penalty
Summary
The facility staff failed to adhere to professional standards regarding the handling and destruction of controlled substances. Specifically, the Director of Nursing (DON) was involved in the improper destruction of narcotics for Resident #4, where 30 Oxycodone tablets were documented as wasted without a second witness signature, as required by the facility's policy. The Assistant Director of Nursing (ADON) discovered the discrepancy and reported it to the administrator after confirming with a Registered Nurse (RN) that they did not participate in the destruction, contrary to the DON's claim. Additionally, the Certified Medication Technician (CMT) involved was pressured by the DON to sign off on the destruction, despite not being a nurse, and feared job loss for questioning the DON's actions. For Resident #5, the facility failed to maintain proper documentation for the destruction of a card of Hydrocodone. The DON signed out the medication, but no destruction sheet was found in the records. A family member of another resident reported that the Hydrocodone was removed from the narcotic box after they expressed a preference for it to be used only as a last resort. The DON claimed to have wasted the narcotics but could not recall who witnessed the destruction, and no documentation was available to verify the claim. Additionally, the facility staff did not follow proper procedures for medication administration. An observation revealed that medication cups with various pills were pre-prepared and labeled with handwritten last names, without listing the medication names. A CMT admitted to removing all medications needed for a 12-hour shift from the ISTAT at once to save time and due to a belief that opening the ISTAT incurred costs. The ADON and administrator confirmed that pre-popping medications was against policy due to the risk of errors, and staff were expected to administer medications immediately after gathering them.
Medication Storage Deficiency Due to Unlocked Carts
Penalty
Summary
Facility staff failed to ensure the secure storage of medications, leading to a deficiency in maintaining a safe environment for residents. The facility's policy, revised in December 2012, mandates that medication carts must be kept closed and locked when not in the direct sight of the medication nurse or aide. However, observations on multiple occasions revealed that a Certified Medication Technician (CMT) left the medication cart unlocked and unattended in the hallway, with keys left in the lock. This occurred at various times throughout the day, indicating a repeated oversight in following the facility's medication storage policy. Further observations showed a treatment cart left unlocked and unattended, containing 15 insulin pens, which were accessible to unauthorized individuals. Interviews with the Assistant Director of Nursing (ADON) and the CMT confirmed that the carts should be locked to prevent access by other staff, residents, or visitors. The CMT admitted to accidentally leaving the cart unlocked, acknowledging the importance of securing the cart for resident safety. The facility administrator also confirmed the requirement for carts to be locked when not attended, but could not explain why this protocol was not being followed.
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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