Clara Manor Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Missouri.
- Location
- 3621 Warwick Boulevard, Kansas City, Missouri 64111
- CMS Provider Number
- 26A293
- Inspections on file
- 24
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 22 (2 serious)
Citation history
Health deficiencies cited at Clara Manor Nursing Home during CMS and state inspections, most recent first.
A resident with a history of cerebral infarction, anxiety, and depression was physically abused by a CMT, resulting in facial injuries and significant distress. Despite the resident reporting the incident to two staff members, the CMT was allowed to continue working the remainder of their shift, contrary to facility policy requiring immediate protection and suspension of staff involved in abuse allegations. Staff interviews and documentation confirmed the delay in removing the CMT, and the resident's injuries were observed and documented by clinical staff.
A resident with cognitive intactness and multiple diagnoses reported being physically abused by a CMT, resulting in visible facial injuries. The incident was disclosed to an LPN, the AIT, and the Administrator, and the facility's investigation confirmed the abuse. Despite facility policy requiring timely reporting of abuse to law enforcement, neither the Administrator nor the DON notified authorities.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with a history of psychiatric disorders and behavioral issues physically assaulted another resident, causing facial swelling and pain. Multiple residents and staff reported ongoing threats and paranoid behavior from the aggressor prior to the incident. Despite these warnings and documented risks, staff interventions were limited to verbal redirection and separation, which did not prevent the assault. The facility did not provide an abuse/neglect policy when requested, and concerns about the aggressor's behavior had been reported but not effectively addressed.
A resident with a history of serious mental illness and escalating behavioral symptoms, including aggression and paranoia, physically assaulted another resident after months of unaddressed and increasing behaviors. Despite repeated reports from staff and residents, the care plan was not updated with appropriate interventions, and recommendations from psychiatric and psychological providers were not implemented. Staff responses were inconsistent, and facility leadership was unaware of the severity of the situation until police intervention was required.
A resident with a history of mental health issues and violent behavior hit another resident in the face, causing swelling and pain. Despite previous reports of the aggressive resident's behavior, the facility failed to implement adequate monitoring or preventive measures. The incident escalated to police involvement, highlighting deficiencies in the facility's abuse prevention and resident safety protocols.
A resident with a history of mental illness and substance abuse exhibited escalating aggressive and paranoid behaviors, culminating in a physical assault on another resident. Despite these behaviors, the resident's care plan was not updated to address safety concerns or provide appropriate interventions. Staff failed to document or communicate the resident's worsening condition, leading to inadequate management of the situation.
The facility failed to ensure the Dietary Manager (DM) met the qualifications for a Certified Dietary Manager (CDM). The DM, hired without the necessary certification or experience, confirmed that the facility had not assisted in obtaining the required qualifications. The Administrator was aware of the DM's lack of qualifications but had not taken further action. This deficiency potentially affected all 89 residents.
The facility failed to follow the planned menu on three occasions, affecting all residents. On two separate days, residents did not receive the meals listed on the menu due to time constraints and ingredient availability. Instead of the planned meals, substitutions were made, such as serving orange ice cream instead of peach crisp and sandwiches instead of the planned entrees.
The facility did not have a certified Infection Preventionist (IP) employed, as required by their policy, which mandates completion of CDC TRAIN programs. The Administrator had not finished the necessary course, and both an LPN and the DON confirmed the absence of an IP since August, affecting the infection prevention and control program for 89 residents.
The facility failed to control a roach infestation affecting the kitchen, dining room, and resident rooms. Observations revealed roaches in various locations, including under the dishwasher and in food storage areas. Staff interviews indicated cleaning challenges and insufficient pest control measures. A resident confirmed seeing roaches in their room, and the Health Inspector noted widespread infestation during a recent visit.
The facility failed to provide the required annual 12 hours of in-service training for CNAs and did not maintain records of training sessions. Interviews revealed a lack of documentation and uncertainty about the number and topics of in-services held. The DON admitted to conducting only eight to nine in-services throughout the year, none of which were documented, and there was no set schedule for observing staff competencies.
The facility did not maintain a sufficient bond amount for resident personal funds, as the bond was $150,000.00 instead of the required $186,000.00 based on the average monthly balance. This affected 56 residents who entrusted the facility with managing their trust accounts. The bookkeeper acknowledged the oversight and lack of a process to monitor the average monthly balance.
The facility failed to maintain a clean environment, with food crumbs and roaches observed in the dining room and dust buildup in restroom vents and fans in multiple resident rooms. The Dietary Manager and Maintenance Director acknowledged the issues, affecting at least 55 residents.
The facility failed to prevent medications from being left at the bedside for three residents, despite lacking physician orders for self-administration. Observations revealed medications unattended in residents' rooms, and staff interviews confirmed this practice, which contradicted facility policy. The Administrator and DON were aware of the issue and had provided staff education on proper medication administration.
The facility failed to maintain a system to ensure all staff had current CPR certifications and that certified staff were available on all shifts, potentially affecting 80 residents requiring CPR. The Administrator admitted to not having a system to track certifications, and staff interviews revealed uncertainty about their certification status.
A facility failed to maintain a resident's nutritional status, resulting in significant weight loss due to inconsistent implementation of physician orders for weekly weights and health shakes. The resident, who was severely cognitively impaired and required substantial assistance with eating, experienced a 7.05% weight loss over several months. Interviews revealed a lack of awareness and documentation by staff, and the newly hired RD was not fully informed of the resident's dietary needs.
The facility failed to maintain sanitary conditions for respiratory equipment for three residents, including improper storage and infrequent cleaning of nebulizer pipes, CPAP masks, and oxygen tubing. Residents reported irregular maintenance, and staff interviews revealed inconsistencies in following cleaning protocols.
The facility failed to post nurse staffing information correctly and accessibly, with sheets often placed in hard-to-reach locations and lacking total hours worked per discipline. Staff interviews confirmed the absence of required details, and the DON acknowledged the deficiency.
The facility failed to ensure proper storage and handling of medications, with issues including lack of temperature logs for medication refrigerators, wet insulin boxes, expired medications, and unclean sinks in medication rooms. Staff interviews revealed confusion over responsibilities for checking refrigerator temperatures and removing expired medications.
The facility failed to maintain proper food safety and hygiene standards, with issues such as a dietary aide's hair not fully restrained, improper storage of jelly, and significant cleanliness lapses in the kitchen. Observations revealed grime under the dishwasher, food buildup on toaster knobs, and dust on fan vent covers, indicating a lack of regular cleaning. Interviews with staff confirmed these oversights, potentially affecting all residents consuming food from the kitchen.
The facility failed to follow TB screening policies for residents and employees, did not sanitize glucometers between uses, and lacked Enhanced Barrier Precautions (EBP) for residents requiring high-contact care. Staff were not educated on EBP, and insulin pens were not sanitized before use, indicating broader infection control issues.
The facility failed to offer and document influenza and pneumococcal vaccines for several residents, as required by their policy. A resident with severe cognitive impairment did not have records of receiving or declining vaccines, and two other residents were not offered vaccines upon admission. Staff interviews revealed inconsistencies in vaccine consent and documentation processes, leading to deficiencies in immunization practices.
The facility failed to offer, administer, or document the 2024-2025 COVID-19 vaccine for two residents. One resident, severely cognitively impaired, had no record of the vaccine being offered or administered, while another resident with intact cognition had no documentation of the vaccine being offered or declined upon admission. Staff interviews revealed a lack of time and delegation of responsibilities, with no COVID-19 vaccine policy available for review.
The facility's call system on the 2nd floor was not audible at the nurse's station, affecting 46 residents. Observations showed that call lights in resident rooms and bathing areas were not heard, confirmed by staff interviews. The issue was linked to the panel's volume being too low due to an override from a stairwell door activation.
The facility failed to ensure cleanliness and safety, with a heavy dust buildup under vending machines in the second-floor dining room and a loose threshold at the carport entrance posing a tripping hazard. The Maintenance Director noted the difficulty in cleaning under the machines and acknowledged the threshold issue had persisted for weeks, affecting residents and staff.
A resident who was legally blind and cognitively impaired did not receive dignified feeding assistance. The CNA stood over the resident, failed to prevent spills, and did not offer cleaning assistance. Staff interviews revealed a lack of training and monitoring on feeding assistance, with the DON acknowledging irregular in-services and no set process for feeding residents.
The facility failed to conduct required Criminal Background Checks (CBC) and Employee Disqualification List (EDL) checks for three employees and did not maintain necessary records for two employees. Employee D was hired using outdated checks from another facility, and files for Employees J and K were missing, with no evidence of completed checks. This deficiency highlights lapses in the facility's hiring and record-keeping processes.
A resident with a history of mental health and substance abuse issues was improperly discharged from an LTC facility due to violent behavior. The discharge notice incorrectly stated a transfer to another facility, but the resident was taken to a hospital instead. The facility failed to follow its discharge policy, lacked a physician's order, and provided incorrect discharge documentation. The Ombudsman filed an appeal due to these deficiencies.
The facility failed to notify two residents and their representatives of hospital transfers, and did not provide the Ombudsman with required notifications. Staff interviews confirmed the facility's non-compliance with its own policies regarding discharge notifications and communication with the Ombudsman.
A facility failed to accurately complete the MDS for a resident, leading to an inaccurate care plan. The resident, who was severely cognitively impaired and legally blind, had bed rails that were not documented in the MDS. Staff provided conflicting information about the presence and purpose of the bed rails, and there was no documented assessment for them in the resident's medical chart.
The facility failed to review and revise a resident's care plan regarding bed rails, despite observations showing their use. Staff interviews revealed inconsistencies in awareness of the resident's use of bed rails or positioning bars. Additionally, the facility inaccurately dated another resident's care plan eight days post-discharge, with no prior documentation. The facility's care planning policy was not followed, leading to these deficiencies.
The facility failed to enforce smoking policies, with staff and residents smoking in prohibited areas. Two residents, one with a history of substance abuse and another with cognitive impairments, were found smoking in their rooms. Staff were observed smoking outside designated areas, and monitoring of residents was inconsistent, leading to continued non-compliance.
A facility failed to maintain proper communication with a dialysis center for a resident requiring dialysis. Only six out of 20 required communication forms were present, and three were undated. Staff interviews revealed that nurses were responsible for sending and retrieving these forms, but failed to consistently do so, leading to incomplete documentation of the resident's dialysis treatment details.
A facility failed to follow its Restraint Policy by not assessing or documenting the use of bed rails for a resident who was legally blind and severely cognitively impaired. The resident's care plan and medical records lacked any indication of bed rail use, and staff interviews revealed confusion about whether the resident had bed rails or a positioning bar. The resident's guardian was not informed about the use of such equipment, indicating a communication gap.
The facility failed to label and date foods stored in the resident use refrigerator, as required by policy. Observations revealed expired items and unlabeled food packages, potentially affecting at least three residents. An LPN was unsure of the responsibility for checking and discarding items, highlighting a lapse in adherence to food storage protocols.
The facility failed to keep the outdoor dumpster lids closed, as observed on multiple occasions. Despite expectations from dietary staff for the lids to be closed after trash disposal, observations on two consecutive days showed the lids remained open. Interviews with dietary staff confirmed the expectation for lids to be closed, highlighting a lapse in adherence to procedures.
A facility failed to ensure a resident's care plan was accurate by dating it eight days after the resident's discharge. The resident was admitted, discharged to a hospital, and later informed the facility of staying with a family member. Despite this, the care plan was initiated post-discharge, contrary to the facility's policy requiring timely completion and review. The DON and Administrator confirmed the care plan should not have been completed after discharge.
A resident with a history of alcohol and substance abuse physically assaulted two other residents in separate incidents, causing injuries that required medical attention. Despite the facility's policy to prevent abuse, staff failed to intervene or report the incidents adequately. The Director of Nursing and Administrator acknowledged the expectation for staff to protect residents, but the Administrator questioned the abuse conclusion due to lack of witnesses and alcohol involvement.
The facility failed to report two incidents of resident-to-resident abuse. In one case, a resident was hit in the mouth by another, causing a cut, and in another, a resident was hit, resulting in cheek lacerations. Despite documentation and communication among staff, these incidents were not reported to the DON or Administrator as required by the facility's policy. The Administrator questioned the nature of the incidents due to lack of witnesses and alcohol presence, leading to a failure to report to the state agency.
A resident was hit by another resident, resulting in a cut lip, but the facility failed to investigate the incident as required by their policy. Staff interviews revealed communication breakdowns, with an LPN not notifying the necessary parties and the DON and Administrator being unaware of the incident, leading to no investigation being conducted.
A resident with a history of mental disorder and substance abuse exhibited aggressive behavior, but the facility failed to provide appropriate interventions or communicate effectively with staff. Interviews revealed a lack of training and awareness among staff regarding the resident's needs, contributing to the deficiency in care.
A resident with cognitive intactness and diagnoses of spinal cord dysfunction, depression, and schizophrenia was immediately discharged to a detention center due to violent behavior. The facility failed to follow its policy for proper notification, as the resident refused to sign the discharge notice, leading to a deficiency finding.
A resident with a history of depression and schizophrenia was discharged to a detention center without a completed discharge summary after an altercation with another resident. The facility failed to provide a timely and comprehensive discharge plan, as the Social Services Designee was unavailable, and the Administrator had to handle the discharge. The resident, who had no prior violent behavior, was informed of the discharge and coordinated with a local homeless shelter for temporary placement.
Failure to Immediately Remove Staff After Resident Abuse Allegation
Penalty
Summary
A deficiency occurred when a certified medication technician (CMT) physically abused a resident by placing the palm of their hand over the resident's mouth and squeezing hard, resulting in a scratch on the right cheek and a circular bruise on the left cheek. The resident, who was cognitively intact and used a wheelchair, reported feeling extremely frightened during the incident. The resident had a medical history including cerebral infarction, anxiety, and depression. The incident was witnessed by other residents, and the physical injuries were observed and documented by staff. Despite the resident reporting the abuse to two staff members, the facility failed to immediately protect the resident by allowing the CMT to continue working their shift until later that evening. The facility's policy required immediate protection of suspected victims and immediate suspension or removal of employees involved in abuse allegations. However, the CMT was not suspended until the following day, after the administrator was notified and further investigation took place. Multiple interviews confirmed that the CMT remained on duty after the allegation was reported, and staff were unclear about the required procedures for handling abuse allegations. Documentation and interviews revealed that the resident's injuries were consistent with the reported abuse, and the resident expressed fear of retaliation, initially hesitating to report the incident. Staff statements indicated confusion about the appropriate response, with the administrator and director of nursing acknowledging that the CMT should have been removed from duty immediately. The delay in removing the CMT from the facility after the abuse was reported constituted a failure to protect the resident from further potential harm.
Failure to Report Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of abuse to local law enforcement as required by its own policies. A cognitively intact resident with a history of cerebral infarction, anxiety, and depression reported that a Certified Medication Technician (CMT) forcefully grabbed their face and pushed them down the hall after the resident was seen looking for cigarettes on an unlocked medication cart. The resident sustained visible injuries, including a scratch and a bruise on the face, which were observed by staff. The resident disclosed the incident to an LPN, the Administrator in Training (AIT), and the Administrator, expressing fear of further retaliation from the CMT. The facility's investigation confirmed the resident's account, and the Administrator acknowledged that abuse had occurred. Despite this, the Administrator and Director of Nursing (DON) did not notify law enforcement of the incident, contrary to the facility's written policies that require timely reporting of suspected abuse to authorities. The CMT was instructed to leave the facility following the report, but law enforcement was not contacted at any point during or after the investigation.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident. On the evening of 1/10/25, one resident willfully struck another resident in the face, resulting in swelling and pain. The incident was witnessed by other residents, who reported that the aggressor had a history of threatening and violent behavior, including accusations that others were taking his belongings. Staff and residents described ongoing verbal altercations and escalating behaviors prior to the physical assault. The resident who committed the abuse had diagnoses including major depressive disorder, psychoactive substance abuse, and generalized anxiety disorder, and was prescribed multiple psychotropic medications. The care plan for this resident noted a risk for increased behaviors and directed staff to monitor episodes and attempt to determine underlying causes. Despite these documented risks and previous behavioral incidents, staff actions included verbal redirection and separation of the residents, but did not prevent the physical altercation. The aggressor was ultimately removed from the facility by police after further violent behavior. The resident who was assaulted had a history of schizophrenia, major depressive disorder, and chronic pain. After the incident, the resident reported swelling and pain, requested and received pain medication and an ice pack, and declined hospital care. Multiple residents and staff confirmed that the aggressor had exhibited paranoid and threatening behaviors prior to the incident, and some residents expressed fear of the individual. The facility failed to provide an abuse/neglect policy when requested, and staff interviews indicated that concerns about the aggressor's behavior had been reported but not effectively addressed.
Failure to Provide Effective Behavioral Health Interventions Resulting in Resident Assault
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of serious mental illness, including major depressive disorder, schizophrenia, and substance abuse. Despite multiple documented episodes of aggression, paranoia, and hallucinations, the resident's care plan was not updated to reflect new or escalating behaviors, nor were appropriate interventions such as behavior modification strategies, 1:1 monitoring, or safety measures for other residents implemented. The resident exhibited increasing agitation, paranoia, and aggression over several months, which was reported by both staff and other residents, but these reports did not result in timely or adequate changes to the care plan or interventions. The resident's behavioral symptoms included verbal and physical aggression, accusations against other residents, and episodes of paranoia. Staff and residents reported that the resident would yell, threaten, and accuse others of stealing, and that these behaviors escalated to the point where the resident physically assaulted another resident, causing injury. Despite these incidents, documentation shows that the care plan remained largely unchanged, and recommendations from psychiatric and psychological providers were not incorporated into the resident's plan of care. There was also a lack of documentation regarding changes in care or notification of psychiatric or psychological services following episodes of increased aggression or hallucinations. Interviews with staff revealed that while some staff attempted to manage the resident's behaviors by separating him from others or redirecting him, there was inconsistency in reporting and addressing the behaviors. Some staff did not report incidents because they felt they could handle them, while others reported behaviors but were unsure if any action was taken. The DON and Administrator were not aware of the extent of the resident's behaviors until a serious incident occurred, resulting in police intervention and the resident's removal from the facility. The lack of timely and effective behavioral interventions and care plan updates contributed to an unsafe environment for both the resident and others.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident willfully hit them in the face, resulting in swelling and pain. The incident occurred when one resident, who had a history of major depressive disorder, substance abuse, and anxiety, believed that the other resident was going through their belongings. This resident had previously exhibited violent and paranoid behavior, including threatening other residents and accusing them of stealing. Despite these behaviors, the facility did not provide a copy of their Abuse/Neglect policy when requested, and there was no indication that staff had taken adequate measures to prevent the incident. Interviews with various residents and staff revealed that the aggressive resident had been displaying paranoid and volatile behavior, which was reported to the nursing staff. On the night of the incident, the aggressive resident was seen pacing and sweating, and had verbal altercations with the victim. Despite attempts by staff to separate the residents and calm the aggressive resident, the situation escalated, leading to the physical assault. The police were called, and the aggressive resident was arrested and taken to the hospital after assaulting the police and paramedics. The Director of Nursing and the Administrator were not aware of any prior issues between the two residents, although the aggressive resident had been sent to the hospital the previous month for similar behaviors. The facility's failure to monitor the aggressive resident closely and to implement one-on-one monitoring, as expected by the Administrator, contributed to the incident. The lack of a documented Abuse/Neglect policy and the absence of proactive measures to address the aggressive resident's behavior highlight deficiencies in the facility's handling of resident safety and abuse prevention.
Failure to Manage Resident's Aggressive Behavior
Penalty
Summary
The facility failed to effectively manage the behaviors of a resident, leading to a physical assault on another resident. The resident in question had a history of major depressive disorder, substance abuse, generalized anxiety disorder, and schizophrenia. Despite these diagnoses, the resident's care plan was not updated to address their mood, mental status, or anger management. The resident exhibited aggressive and paranoid behaviors, including accusing other residents of theft and physically assaulting another resident, causing injury. The facility's behavior management program was not adequately implemented for this resident. There were no updates or new interventions in the care plan to address the resident's aggression, hallucinations, or safety concerns. The staff failed to document changes in care needed following episodes of increased aggression and did not notify psychology or psychiatry of the resident's worsening behaviors. Despite multiple incidents of aggression and paranoia, the resident's care plan remained unchanged, and there was no evidence of 1:1 monitoring or behavior modification strategies being employed. Interviews with staff and other residents revealed that the resident's behaviors had been escalating over several months, yet these concerns were not effectively communicated to the Director of Nursing or the Administrator. Staff reported the resident's behaviors to nurses, but there was no indication that these reports led to any changes in the resident's care plan. The lack of appropriate interventions and monitoring ultimately resulted in a violent incident, highlighting the facility's failure to provide necessary behavioral health care and services to ensure the safety and well-being of all residents.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) met the necessary qualifications for a Certified Dietary Manager (CDM). The DM, hired on September 7, 2023, did not possess a national certification for food service management and safety, an associate's degree in food service management or hospitality, nor had two or more years of experience in the position of director of food and nutrition services in a nursing facility setting with completed coursework in food safety and management. During interviews, the DM confirmed that the facility had not assisted in obtaining the required qualifications, and the Administrator acknowledged awareness of the DM's lack of qualifications but had not taken further action beyond discussing the need for certification. This deficiency potentially affected all 89 residents in the facility.
Menu Deviations in Dietary Services
Penalty
Summary
The facility failed to adhere to the planned menu on three separate occasions, potentially affecting all 89 residents. On 11/17/24, during lunch service, the facility did not serve the Homemade Peach Crisp as listed on the menu. Instead, residents received orange ice cream because the dietary staff ran out of time to prepare the peach crisp. On 11/19/24, during lunch, residents were served a rye swirl bread sandwich with fries instead of the planned Sweet and Sour Chicken with Steamed Rice and Oriental Vegetables. The chicken intended for the Sweet and Sour Chicken was used earlier as a substitute for another meal due to a defrosting issue with pulled pork. During the dinner service on 11/19/24, the facility deviated from the menu again. Residents were supposed to receive a Classic Patty Melt with Crispy French Fries, but instead, they were offered a choice of ham with cheese, turkey with cheese, or grilled cheese sandwiches, and no fries were served. The fries were used during the lunch meal, leading to their absence at dinner. These deviations from the menu were confirmed through observations and interviews with the dietary staff, who cited time constraints and ingredient availability as reasons for the discrepancies.
Absence of Certified Infection Preventionist
Penalty
Summary
The facility failed to employ a certified Infection Preventionist (IP) as required, impacting their infection prevention and control program. The facility's policy mandates that the IP must complete training programs through CDC TRAIN and maintain documentation of these certifications in their personnel record. However, interviews revealed that the facility had not had an IP since August, and the Administrator admitted to starting but not completing the necessary course. Both an LPN and the Director of Nursing confirmed the absence of an IP at the facility, which had a census of 89 residents.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to implement effective pest control measures, resulting in a significant presence of roaches in various areas, including the kitchen, dining room, and resident rooms. Observations revealed dead and live roaches in multiple locations such as under the microwave table, behind the reach-in refrigerator, inside electrical outlets, and under the dishwasher where grime and food debris had accumulated. The Dietary Manager acknowledged the presence of roaches and the difficulty in cleaning certain areas due to tight spaces. The Maintenance Director confirmed that exterminators visited the facility twice a month, but the pest issue persisted. Further observations showed roaches crawling on walls, tables, and ceilings in the kitchen and dining areas. Roaches were also found in food storage areas, such as the spice storage table and tea bag box, and even inside a delivery tray cart. The Dietary Manager expressed frustration with the ongoing pest problem, noting that the roaches began appearing in September 2024. Interviews with staff indicated that cleaning under the dishwasher had not been done for about four months, contributing to the pest issue. Roaches were also observed in resident rooms, with one cognitively intact resident confirming previous sightings of roaches in their room. The facility's extermination service records showed sporadic visits over the past six months, with the Maintenance Director planning to increase the frequency of visits. The Health Inspector from the municipal Health Department corroborated the presence of roaches and grime during a recent inspection, highlighting the widespread nature of the infestation. The Director of Operations became aware of the problem shortly before the survey and initiated more frequent extermination visits.
Failure to Provide Required CNA In-Service Training
Penalty
Summary
The facility failed to provide the required annual 12 hours of in-service training for Certified Nursing Assistants (CNAs) and did not maintain records indicating the subject of, and attendance at, all in-service sessions. Interviews with the Administrator and various staff members revealed a lack of documentation and uncertainty about the number and topics of in-services held over the past year. The facility's policy mandates that CNAs complete a minimum of 12 hours of continuing education annually, but the Administrator was unable to locate any records of such training. Additionally, CNAs reported that it had been a long time since they received any in-service education, particularly on handling resident behavioral issues. The Director of Nursing (DON) acknowledged that in-services should be held monthly and that CNAs should receive at least 12 hours of training annually. However, the DON admitted to conducting only eight to nine in-services throughout the year, none of which were documented. The DON also mentioned that individual education was provided when needed but was not documented. The facility does not offer online computer education, and there was no set schedule for observing staff competencies. This lack of structured and documented training and education led to the deficiency identified in the report.
Insufficient Bond Amount for Resident Personal Funds
Penalty
Summary
The facility failed to ensure that the bond amount for resident personal funds was sufficient to cover the average monthly balance for the 12-month period from November 2023 through October 2024. The average monthly balance of reconciled bank statements was $123,720.44, which, when rounded up to the nearest thousand and multiplied by 1.5 as per the Resident Fund Bond Worksheet instructions, required a bond amount of $186,000.00. However, the facility's bond was only $150,000.00, which was insufficient. This deficiency potentially affected 56 residents who allowed the facility to manage their trust accounts. During an interview, the bookkeeper acknowledged the need to increase the bond amount and admitted to not having a process in place to regularly check the average monthly balance.
Facility Fails to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by several observations of unclean conditions. In the dining room, there was a buildup of food crumbs on the handrails, and roaches were observed crawling near the end of the handrail. The Dietary Manager acknowledged responsibility for cleaning the handrails and was aware of the presence of roaches. Additionally, a Dietary Aide mentioned that cleaning of the handrails would be initiated on a weekly basis after noticing the accumulation of crumbs. Further observations revealed a significant buildup of dust in various areas of the facility, including restroom ceiling vents and personal fans in multiple resident rooms. The Maintenance Director admitted to not having noticed the dust on the fan blades and had not yet cleaned the ceiling vents. Despite having cleaned a fan the previous day, dust was still present. These conditions potentially affected at least 55 residents residing in the affected rooms or using the areas, with the facility census being 89 residents.
Medication Mismanagement at Bedside
Penalty
Summary
The facility failed to ensure medications were not left at the bedside for three residents, which was observed during a survey. Resident #23, who was diagnosed with depression, psychosis, and vascular dementia, was found with six pills in a medication cup on the bedside tray table while asleep. The resident's care plan indicated the need for supervision and administration of medications by staff, and there was no physician's order for self-administration of medications. Resident #27, diagnosed with depression and psoriasis, was observed with Nystatin powder at the bedside, despite not having a physician's order to self-administer medications. The resident claimed that the physician allowed them to keep the medication at the bedside for self-application. However, the care plan did not reflect the ability to self-administer medications, and there was no official order supporting this practice. Resident #50, with a history of traumatic brain injury and substance abuse, was found with two pills in a medication cup on the nightstand while not present in the facility. The resident reported that staff would leave medications for them to take upon return. Interviews with staff, including a CMT and an LPN, confirmed that medications were left at the bedside, contrary to the facility's policy and without physician orders for self-administration. The Administrator and DON acknowledged the issue and stated that staff had been educated on proper medication administration procedures.
Deficiency in CPR Certification Tracking and Staffing
Penalty
Summary
The facility failed to ensure that all staff members had current CPR certifications on file and that certified staff were available on all shifts. This deficiency had the potential to affect 80 residents who were designated as full code status, meaning they would require CPR in an emergency. The facility's policy required at least one CPR-certified staff member per shift, but a review of staffing schedules revealed that 16 out of 41 sampled shifts lacked verified CPR-certified staff. Interviews with staff, including the Administrator, revealed that there was no effective system in place to track CPR certifications or ensure compliance with the facility's policy. The Administrator acknowledged the lack of a system to monitor CPR certifications and admitted difficulty in obtaining copies of CPR cards from staff. Interviews with various staff members, including CNAs and LPNs, indicated uncertainty about their CPR certification status, with some not being current or unsure if they had been offered training. The Director of Nursing and the Administrator both recognized the need for CPR-certified staff on each shift but confirmed the absence of a reliable tracking system for CPR certifications and renewals.
Failure to Maintain Nutritional Status and Document Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional status for a resident, resulting in an unplanned weight loss. The deficiency was identified through observation, interview, and record review, revealing that the facility did not follow physician instructions for weighing residents. Specifically, a resident experienced a significant weight loss of 5.77% in 30 days and 7.05% from June to October 2024, without proper documentation or notification to the physician or registered dietician (RD). The facility's policy required the Director of Nursing (DON) or Assistant DON to establish a weight schedule, and nursing staff were responsible for obtaining and documenting weights. However, there were multiple instances where weights were not recorded as ordered, and health shakes prescribed to address weight loss were inconsistently provided. Interviews with Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) revealed a lack of awareness and documentation regarding the resident's weight loss and the administration of health shakes. The resident, who was severely cognitively impaired and required substantial assistance with eating, was on a Low Concentrated Sweets diet and had diabetes. Despite orders for weekly weights and health shakes, the facility failed to ensure these interventions were consistently implemented and documented. The RD, who had recently joined the facility, was not fully aware of the resident's weight history or dietary needs, further contributing to the deficiency.
Inadequate Cleaning and Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory equipment such as oxygen tubing, CPAP machines, and nebulizers were cleaned and stored in a sanitary condition for three residents. Resident #22, who was admitted with COPD, had a nebulizer pipe that was not stored in a bag or dated, and it was observed hanging off the nightstand and touching the floor. The resident reported that staff did not change or clean the pipe regularly, and the mouthpiece was noted to be yellowed. Resident #34, who used a CPAP machine for sleep apnea, had a CPAP mask that was not stored in a bag and was mixed with personal belongings in a drawer. The resident was unsure of when the mask was last cleaned, and the mask was observed to be slightly yellow tinged. The care plan did not mention cleaning or storage instructions for the CPAP equipment. Resident #62, who had COPD and chronic respiratory failure, had oxygen tubing and a nebulizer mask that were not stored in bags and were found on the floor. The resident indicated that staff changed the tubing infrequently and did not use detergent to clean the nebulizer mask. Interviews with staff revealed inconsistencies in the cleaning and storage practices for respiratory equipment, despite education provided by the administration.
Failure to Post Accessible and Complete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted correctly and accessibly at the beginning of each shift. Observations over several days revealed that staffing sheets were either not posted or not readily accessible to residents and visitors. On multiple occasions, the staffing sheets were placed in locations that were not easily visible or reachable, such as on top of nurse's station counters or hanging on walls above counters, making them inaccessible to residents in wheelchairs and visitors. Additionally, the staffing sheets did not include the total hours worked per nursing discipline, which is a required detail. Interviews with staff, including a Certified Medication Technician and a Certified Nursing Assistant, indicated a lack of awareness about the location of the staffing sheets and confirmed that the sheets did not list the total hours worked. The Director of Nursing acknowledged that while the sheets were posted daily, they did not include the total hours worked for each nursing discipline. This oversight in posting and detailing staffing information could potentially affect all visitors and residents in the facility, as it does not comply with the requirement to provide transparent and accessible staffing information.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to maintain proper storage and handling of medications in the medication rooms on both the first and second floors. Observations revealed that the medication refrigerator on the first floor lacked a temperature log, and the thermometer inside showed a temperature of 46 degrees Fahrenheit. Insulin boxes stored in the refrigerator were found wet, with one box tearing apart when moved, and water running off another box. Additionally, an opened vial of Tuberculosis skin test had expired several months prior. The only sink in the medication room was observed to be dirty and rusty. Interviews with staff indicated a lack of clarity regarding responsibility for checking refrigerator temperatures and ensuring the removal of expired medications. On the second floor, similar issues were noted, with no temperature log available for the medication refrigerator, which showed a temperature of 38 degrees Fahrenheit. An expired vial of Tuberculosis skin test was also found. Staff interviews revealed that the night nurse was supposed to check and document refrigerator temperatures and remove expired medications, but this was not being done. Housekeeping was expected to clean the medication rooms daily, including the sink, but this was not occurring. The Director of Nursing and Administrator were unaware of the issues with the wet insulin boxes and the lack of temperature logs.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain proper food safety and hygiene standards in the kitchen, as observed during a survey. Dietary Aide A was seen working with hair not fully restrained, which is a violation of food safety protocols. Additionally, a bottle of jelly was not refrigerated as required by its label, indicating a lapse in following storage instructions. The kitchen also had several areas with significant cleanliness issues, including grime buildup under the dishwasher, food grime on bread toaster knobs, and dust accumulation on fan vent covers in the walk-in refrigerator. These conditions were observed over a period of time, suggesting a lack of regular cleaning and maintenance. Interviews with dietary staff revealed a lack of adherence to expected practices. Dietary staff acknowledged the oversight in refrigerating items and the infrequent cleaning of kitchen equipment and areas. The Dietary Manager admitted that the fan vent covers had not been cleaned since May 2024, and the area under the dishwasher had not been cleaned since July 2024. The fan closest to the steam table was also found to have a heavy buildup of dust, which had not been addressed for some time. These deficiencies potentially affected all residents consuming food from the kitchen, given the facility's census of 89 residents.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to adhere to its tuberculosis (TB) screening policy for residents and employees. Five residents did not receive annual TB screenings as required, and there was no documentation of TB testing or screening for several new employees. The Director of Nursing (DON) admitted to being too busy to complete the necessary screenings, and the Administrator confirmed that if the screenings were not documented, they were not done. Additionally, the facility did not maintain a TB log as required by their policy. Infection control practices were not followed during blood glucose monitoring for five residents, as the glucometer was not sanitized between uses. The facility's policy required glucometers to be cleaned and disinfected if used for multiple residents, but observations showed this was not done. The DON acknowledged the expectation for staff to disinfect the glucometer and the area where it was placed, but there was no recent in-service training on the proper procedure. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with multidrug-resistant organisms (MDROs) or those requiring high-contact care. There was no policy for EBP, and staff were not educated on its requirements. Observations showed a lack of personal protective equipment (PPE) and signage for EBP, and the DON and Administrator were unaware of the EBP requirements. Additionally, insulin pens were not sanitized before use, contrary to the facility's policy, indicating a broader issue with infection control practices.
Deficiency in Vaccine Offering and Documentation
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal vaccines were offered, administered, or documented for several residents, leading to deficiencies in their immunization practices. Specifically, three residents were not offered the flu vaccine, and two residents were not offered the pneumococcal vaccine five years after their previous vaccination. The facility's policy required that all newly admitted residents be offered these vaccines, with documentation of acceptance or declination, but this was not consistently followed. Resident #23, who was severely cognitively impaired, had received a flu vaccine in 2021 but had no documentation of receiving or declining the flu vaccine for the 2023 or 2024 seasons. Additionally, there was no record of a pneumococcal vaccine being offered or administered five years after the last one in 2017. Resident #22's records also lacked documentation of receiving or declining the flu vaccine upon admission. Similarly, Resident #79, who had multiple health conditions, was not offered or documented as having received or declined the influenza and pneumococcal vaccines upon admission. Interviews with facility staff revealed inconsistencies in the process of obtaining vaccine consents and documentation. The Licensed Practical Nurses (LPNs) and the Director of Nursing (DON) indicated that the responsibility for offering and documenting vaccines was shared among staff, but there were lapses in execution. The administrator admitted to not having time to ensure vaccines were offered and documented, relying on other staff members to fulfill these duties. This lack of coordination and adherence to policy resulted in the failure to provide necessary immunizations to residents, as evidenced by the missing documentation and delayed vaccine clinics.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure the 2024-2025 COVID-19 vaccine was offered, administered, or documented for two residents out of five sampled for immunizations. Resident #23, who was severely cognitively impaired, had received initial COVID-19 immunizations and a booster in previous years, but there was no documentation of the 2024-2025 vaccine being offered or administered. Resident #79, with intact cognition, had a record indicating the COVID-19 vaccine was due, but there was no documentation of the vaccine being offered, administered, or declined upon admission. A form indicating the resident declined the vaccine was only provided after the surveyor's request. Interviews with facility staff revealed that the usual process involved a nurse manager obtaining vaccine consents, and any nurse could administer the vaccines once consents were obtained. However, the Director of Nursing and the Administrator admitted that they had not had time to ensure the vaccines were offered and documented this year, delegating the task to other nursing staff. Despite having a pharmacy visit the facility to administer vaccines on two occasions, the facility did not have a COVID-19 vaccine policy available for review.
Call System Audibility Issue on 2nd Floor
Penalty
Summary
The facility failed to ensure that the call system was audible at the nurse's station on the 2nd floor, potentially affecting 46 residents. Observations on November 18, 2024, revealed that when call lights were activated in various resident rooms and bathing areas, there was no audibility at the nurse's station. This issue persisted throughout multiple checks between 10:04 A.M. and 11:27 A.M., indicating a consistent problem with the call system's audibility. Interviews with staff members, including an LPN, a CNA, and the Maintenance Director, confirmed the issue. The LPN mentioned that they keep up with residents despite not hearing the call lights, while the CNA noted that the call lights only blinked on the panel without sound. The Maintenance Director identified the problem as related to the panel, and the Corporate Maintenance Person explained that the volume was turned down too low due to an override caused by the North Stairwell door activation. The panel required resetting after the stairwell door was opened, which contributed to the deficiency.
Facility Safety and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents and staff. Observations revealed a significant buildup of dust under the vending machines in the second-floor dining room. The Maintenance Director acknowledged the difficulty in cleaning under the machines due to their weight and indicated that the vending machine company would need to be contacted to move them for cleaning. Additionally, the threshold of the door between the carport and the basement entrance was found to be loose, posing a tripping hazard. This issue had been present for a few weeks, as confirmed by the Maintenance Director. These deficiencies potentially affected at least 25 residents who used the carport as a smoking area and an unknown number of staff who accessed the facility through that door.
Failure to Ensure Dignified Feeding Assistance
Penalty
Summary
The facility failed to ensure that Resident #56, who was legally blind and severely cognitively impaired, was treated with dignity and respect during assisted feeding. The resident required substantial assistance with eating, as noted in their care plan and Minimum Data Set (MDS). However, during an observation, a Certified Nursing Assistant (CNA) did not provide appropriate assistance, allowing the resident to spill milk on themselves and the floor without offering a napkin or cleaning assistance. The CNA stood over the resident, rather than sitting beside them, and did not communicate effectively, simply saying 'eat' while placing food in front of the resident's mouth. Interviews with staff revealed a lack of training and monitoring regarding feeding assistance. CNA D admitted to not receiving specific training from the facility on how to assist the resident with dining. Other CNAs and Licensed Practical Nurses (LPNs) also indicated that they had not received recent training on feeding assistance since their initial CNA classes. The Director of Nursing (DON) acknowledged that in-services were not held regularly, and individual education was not documented, leading to inconsistent practices among staff. The facility's policies on feeding assistance and resident rights emphasized the importance of dignity and respect, yet these were not adhered to in practice. The DON confirmed that there was no set process for feeding residents, and staff were expected to rely on their initial training. This lack of structured training and monitoring contributed to the deficiency in providing dignified and respectful care to Resident #56 during meals.
Failure to Conduct Background Checks and Maintain Employee Records
Penalty
Summary
The facility failed to conduct a Criminal Background Check (CBC) and Employee Disqualification List (EDL) check for three sampled employees, specifically Employees D, J, and K. Additionally, the facility did not maintain records of the Social Security number, date of birth, date of employment, experience and education, references, and the result of background checks for Employees J and K, as required by section 660.317 of the Revised MO Statutes. The facility's policy mandates that all prospective employees must have a CBC and EDL check prior to employment, and these checks should be completed no longer than five days before the first day of employment. However, Employee D was hired using a CBC and EDL check conducted by a different facility within the corporate network, and no recent checks were performed when Employee D was hired by the current facility. Furthermore, the files for Employees J and K were not available, and there was no evidence that CBC and EDL checks had been completed for them. During an interview, the Administrator admitted that the files for Employees J and K could not be found. This lack of documentation and failure to conduct the necessary background checks represent a significant deficiency in the facility's hiring and record-keeping processes, potentially compromising the safety and well-being of the residents.
Inadequate Discharge Planning and Coordination
Penalty
Summary
The facility failed to plan, coordinate, and provide a safe and appropriate discharge for a resident, resulting in a deficiency. The resident, who had been admitted with diagnoses including Major Depressive Disorder, psychoactive substance abuse, and Generalized Anxiety Disorder, was given an immediate discharge notice due to extreme violent behavior, drug use, and being a danger to themselves and others. The discharge notice incorrectly stated that the resident would be transferred to another facility, Facility B, but the resident was instead transported to a hospital by Emergency Medical Services. Facility B was unaware of any arrangements for the resident's transfer. The facility's Discharge and Transfer Resident policy required that all discharges be ordered by the attending physician and that involuntary discharges be reviewed by the Safety Committee. However, there was no physician order for the discharge of the resident, and the discharge notice was issued without proper coordination. The resident was handcuffed by police, sedated by paramedics, and taken to a local hospital, indicating a lack of proper planning and communication regarding the discharge process. Interviews with facility staff revealed that the Administrator was responsible for initiating the discharge and claimed to have made arrangements with Facility B, but this was not corroborated by Facility B's staff. Additionally, the discharge notice provided to the resident contained outdated and incorrect information, including the contact details for the Ombudsman and the appeals unit. The Ombudsman filed an appeal against the discharge, highlighting the deficiencies in the discharge process and documentation.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify residents and their representatives of transfers to a hospital, including the reason for the transfer in writing, and did not provide the Ombudsman with a copy of the notification for two residents. This deficiency was identified during a review of the facility's practices and policies, which revealed that the facility did not adhere to its own Bed-Hold Policy and Readmission procedures. Specifically, the policy required written notice to be provided to the resident and a family member or legal representative at the time of transfer, and for the discharge to be logged and faxed monthly to the Ombudsman office. For Resident #14, the facility's records showed that the resident was sent to the hospital on two occasions without documentation of notification to the resident, family, or legal representative. Additionally, there was no discharge notice sent to the Ombudsman for these transfers. Similarly, Resident #30 was transferred to the hospital twice without proper notification to the resident, family, or legal representative, and no discharge notice was sent to the Ombudsman. Interviews with facility staff, including an LPN, the Social Services Designee (SSD), and the Director of Nursing (DON), confirmed that the facility did not send a list of residents discharged to the hospital to the Ombudsman monthly, as required. The staff also acknowledged that they did not send written notices of discharge to the residents or their representatives, and the facility did not notify the Ombudsman of residents returning from the hospital.
Inaccurate MDS Assessment for Bed Rail Use
Penalty
Summary
The facility failed to accurately complete the Resident Assessment Instrument/Minimum Data Set (RAI/MDS) for a resident, leading to an inaccurate care plan. Specifically, the facility did not properly assess and record the use of bed rails for a resident who was severely cognitively impaired and legally blind. The resident's MDS indicated that bed rails were not in use, yet observations showed that the resident's bed had rails on both sides. Interviews with staff revealed inconsistencies in their understanding of whether the resident had bed rails or positioning bars, and there was no documented assessment for bed rails in the resident's medical chart. The Director of Nursing (DON) and other staff members provided conflicting information regarding the presence and purpose of the bed rails, with some referring to them as positioning bars. The facility's policy required that bed rail assessments be conducted and documented, but this was not done for the resident in question. The lack of a proper assessment and documentation led to a discrepancy between the resident's actual needs and the care plan, as the use of bed rails or positioning bars was not accurately reflected in the MDS or the resident's medical records.
Deficiencies in Care Plan Review and Documentation
Penalty
Summary
The facility failed to review and revise a resident's person-centered care plan, specifically regarding the use of bed rails for a resident who was legally blind and severely cognitively impaired. The resident's care plan did not indicate the use of bed rails, although observations showed that the resident's bed had rails on both sides. Interviews with various staff members, including CNAs and LPNs, revealed inconsistencies in their awareness and understanding of the resident's use of bed rails or positioning bars. The Director of Nursing (DON) confirmed that the resident had a positioning bar, which should have been documented in the care plan and the Minimum Data Set (MDS). Another deficiency was identified when the facility failed to ensure the accuracy of a resident's care plan by dating it eight days after the resident had been discharged. The resident was discharged with no return anticipated, yet the care plan was initiated post-discharge, with no documentation showing a care plan was developed and utilized prior to the resident's discharge. The DON and the Administrator acknowledged that the care plan should not have been completed after the resident's discharge. The facility's policy for care planning, dated 2022, outlined the need for effective communication of a resident's comprehensive plan of care, development of new care plans for new conditions, and quarterly reviews. The policy also specified the roles of various staff members in the care planning process. However, the facility failed to adhere to these guidelines, resulting in deficiencies related to the care planning for the two residents.
Non-Compliance with Smoking Policies in LTC Facility
Penalty
Summary
The facility failed to ensure that both staff and residents adhered to the designated smoking areas, leading to multiple instances of smoking in prohibited areas. Observations revealed that kitchen staff members were smoking outside the kitchen door, despite the presence of 'No Smoking' signs and combustible materials like dried leaves nearby. Additionally, a half-smoked cigarette was found in a women's restroom, which also had a 'No Smoking' sign, indicating non-compliance with the facility's smoking policy. Two residents, identified as Resident #50 and Resident #55, were found to be smoking in their rooms, contrary to the facility's smoking policy. Resident #50, who had a history of traumatic brain injury, psychoactive substance abuse, and alcohol abuse, was observed with a lighter and cigarettes in their room. The resident's room frequently smelled of marijuana, and drug paraphernalia was found during a deep clean. Despite being placed on 15-minute checks, there were lapses in monitoring, and the resident continued to smoke in their room. Resident #55, who had a history of amnesia and polyneuropathy, admitted to smoking in their room and was observed with smoking materials in their possession. Interviews with staff revealed a lack of consistent enforcement of the smoking policy and inadequate monitoring of residents known to smoke in prohibited areas. The facility's policies required residents found smoking in non-designated areas to be placed on 15-minute checks, but these checks were not consistently documented or performed. Staff members were also observed smoking in non-designated areas, indicating a broader issue of non-compliance with the facility's smoking policies. The facility's failure to enforce its smoking policies and adequately supervise residents and staff contributed to the deficiencies observed.
Failure in Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure proper communication and collaboration with the dialysis center for a resident requiring dialysis services. The facility's policy required a communication record to be sent with the resident each day they attended dialysis, and the form was to be completed by the nursing home. However, for one resident, only six forms were present when there should have been 20 for the period from October through mid-November. Additionally, three of these forms were not dated, indicating a lack of consistent documentation and communication. Interviews with staff revealed that the nurses were responsible for sending the dialysis forms with the resident and retrieving them upon return. If the form was not returned, the nurse was expected to contact the dialysis center to obtain the necessary information. The Director of Nursing confirmed that the forms were crucial for documenting the resident's weight before and after dialysis, among other details. The failure to consistently receive and document this information resulted in a lack of knowledge about the resident's dialysis treatment details, such as weight changes, which are critical for ongoing care management.
Failure to Follow Bed Rail Policy for Resident Safety
Penalty
Summary
The facility failed to ensure resident safety by not adhering to their Restraint Policy regarding the use of bed rails. A resident, who was legally blind and severely cognitively impaired, was observed with bed rails attached to their bed, despite the facility's policy requiring a thorough assessment and documentation process before bed rails are used. The resident's care plan and medical records did not reflect the use of bed rails, and there was no documented assessment or physician order for their use. Interviews with staff revealed inconsistencies in their understanding of whether the resident had bed rails or a positioning bar, and there was no clear communication with the resident's guardian regarding the use of such equipment. The facility's policy mandates that residents with compromised mobility be assessed for bed rail use upon admission and reassessed monthly. However, the resident's records showed no such assessments were completed. Staff interviews indicated a lack of awareness and understanding of the resident's equipment, with some staff believing the resident had a positioning bar rather than bed rails. The Director of Nursing (DON) also mentioned that a physician order and care plan indication were necessary for a positioning bar, which were absent in this case. The resident's guardian was not informed or consulted about the use of bed rails or a positioning bar, highlighting a communication gap between the facility and the resident's representative.
Deficiency in Food Labeling and Storage
Penalty
Summary
The facility failed to ensure that foods stored in the resident use refrigerator were labeled with a resident's name and the date the food was brought in, as required by their policy. This deficiency was identified through observation, interview, and record review. Specifically, the refrigerator at the 2nd floor nurse's station contained a package of ham and a container of milk that were expired, as well as two packages of food that were not labeled with a resident's name or the date they were brought in. During an interview, an LPN stated that they had not worked on their shift for several days and were unsure of whose responsibility it was to check and discard items from the refrigerator. This practice potentially affected at least three residents whose food was stored in the refrigerator, with the facility census being 89 residents.
Failure to Maintain Closed Dumpster Lids
Penalty
Summary
The facility failed to maintain the outdoor dumpster with the lids closed, as observed on multiple occasions. On 11/17/24, the dumpster lid was observed open at 9:08 A.M., 9:58 A.M., and 10:15 A.M. Similarly, on 11/18/24, the lid remained open during observations at 9:49 A.M., 1:27 P.M., 2:06 P.M., and 2:47 P.M. Additional observations on the same day at 11:20 A.M. and 12:33 P.M. confirmed the lid was still open. Interviews with the dietary staff, including a dietary staff member and the Dietary Manager, revealed that they expected facility staff to close the lids after disposing of trash, indicating a failure to adhere to expected procedures.
Inaccurate Care Plan Completion Post-Discharge
Penalty
Summary
The facility failed to ensure the accuracy of a resident's care plan by dating it eight days after the resident had been discharged. The resident was admitted to the facility and later discharged to the hospital with an anticipated return date. However, the resident did not return as expected and instead informed the facility that they would be staying with a family member. Despite this, the care plan was initiated after the resident's discharge, with all focus areas, goals, and interventions dated after the resident had left the facility. The Director of Nursing (DON) and the Administrator acknowledged that care plans should be reviewed every three months and that the resident's care plan should not have been completed post-discharge. The facility's policy required the comprehensive care plan to be completed within 21 days of admission, and the care plan schedule was to follow the Resident Assessment Instrument (RAI) requirements. The failure to adhere to these standards resulted in the care plan being inaccurately dated after the resident's discharge.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, who was known to have a history of alcohol and psychoactive substance abuse. On two separate occasions, this resident, who smelled strongly of alcohol, physically assaulted two other residents without provocation. The first incident involved the resident entering another resident's room and hitting them in the mouth, causing a cut on the lower lip. The second incident involved the resident becoming agitated and striking another resident in the cheeks, resulting in cuts that required stitches. The facility's policy on abuse and neglect, revised in 2022, clearly states that residents have the right to be free from abuse and that the facility is responsible for preventing abuse by anyone, including other residents. Despite this policy, the facility did not take adequate measures to prevent the resident with a known history of substance abuse from harming others. Interviews with staff revealed that there was a lack of intervention when the resident became agitated, and the incidents were not properly reported to the medical staff responsible for the resident's care. The Director of Nursing and the Administrator expressed expectations that staff should have intervened to prevent the violent behavior and protect vulnerable residents. However, the Administrator questioned the conclusion of abuse due to the lack of witnesses and the fact that both residents involved in the incidents smelled of alcohol. This indicates a failure in the facility's response to the incidents and a lack of adherence to their own policies regarding resident safety and abuse prevention.
Failure to Report Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to report two incidents of resident-to-resident abuse involving Resident #2, Resident #6, and Resident #1. On 7/3/24, Resident #2 hit Resident #6 in the mouth, causing a small cut on the lower lip. Despite the incident being documented by LPN C and communicated to the oncoming nurse, it was not reported to the Director of Nursing (DON) or the Administrator. Similarly, on 7/22/24, Resident #2 hit Resident #1, resulting in lacerations on both cheeks. This incident was reported to the DON and Administrator by LPN B, but no report was made to the state agency. The facility's policy on abuse and neglect, revised in 2022, mandates immediate reporting of abuse incidents to the charge nurse, who should then inform the DON and/or Administrator. The policy also requires that any abuse resulting in serious bodily injury be reported to all required entities within two hours. However, the staff failed to adhere to these procedures, as evidenced by the lack of notification to the DON and Administrator regarding the incident on 7/3/24 and the absence of a report to the state agency for both incidents. Interviews with staff and residents revealed a breakdown in communication and reporting. LPN A did not recall notifying anyone about the 7/3/24 incident, assuming it was the responsibility of another nurse. The DON and Administrator were unaware of the 7/3/24 incident until much later, and the Administrator questioned whether the 7/22/24 incident constituted abuse, citing the lack of witnesses and the presence of alcohol. This confusion and failure to report highlight significant deficiencies in the facility's handling of abuse allegations.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of resident-to-resident abuse involving two residents. On 7/3/24, one resident entered another resident's room and hit them in the mouth, resulting in a cut lip. Despite the incident being reported to the police, who took the aggressor to the hospital due to lack of jail space, the facility did not conduct an investigation as required by their policy. The facility's policy mandates immediate investigation of all abuse allegations by administrative staff, but this was not followed. Interviews with staff revealed a breakdown in communication and responsibility. LPN A did not notify the necessary parties, assuming it was the responsibility of another nurse. LPN C believed they had documented the incident and informed the DON and Administrator, but this was not confirmed. The DON and Administrator were unaware of the incident and thus did not initiate an investigation. The lack of notification and documentation led to a failure in addressing the abuse allegation appropriately.
Failure to Manage Resident's Behavioral and Substance Abuse Needs
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with a history of mental disorder, substance abuse, and aggressive behavior. The resident, who had a history of homelessness and substance abuse, was admitted to the facility after a psychiatric evaluation. Despite the resident's complex needs, including a need for a structured environment and behavioral support, the facility did not implement adequate interventions to manage the resident's behavior. The resident exhibited aggressive and intoxicated behavior on multiple occasions, yet there was no documentation of interventions or communication with the Director of Nursing, Administrator, or physician. Interviews with facility staff revealed a lack of training and awareness regarding the resident's history and needs. Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) reported not having received mental health education or training in de-escalation techniques. Staff members were unaware of the resident's history of violence and substance abuse, which contributed to their inability to manage the resident's behavior effectively. The facility's policy for behavior management was not followed, and staff did not document or communicate the resident's behaviors and needs adequately. The facility's leadership, including the Director of Nursing and the Administrator, acknowledged gaps in staff education and communication. The Social Worker, who was responsible for handling PASRRs, was new to the role and had not integrated PASRR recommendations into the care plans. The lack of a formal education process for staff on mental illness and behaviors further exacerbated the situation, leading to the deficiency in providing appropriate care and services to the resident.
Improper Notification for Immediate Discharge
Penalty
Summary
The facility failed to provide proper notification for an immediate discharge of a resident, which was a deficiency identified during the survey. The facility's policy on discharge and transfer requires an order from the attending physician and a written instruction with verbal explanation regarding care and treatment to the resident or their responsible party. In this case, the resident was discharged immediately due to being considered a danger to others, following an altercation with another resident. The discharge notice was hand-delivered, but the resident refused to sign it, and the discharge was executed by police transport to a detention center. The resident involved was cognitively intact and had diagnoses including non-traumatic spinal cord dysfunction, depression, and schizophrenia. The facility's administrator justified the discharge by citing the resident's violent behavior, which was deemed uncontrollable and a threat to the safety of others. However, the report indicates that the proper notification process, as outlined in the facility's policies, was not followed, leading to the deficiency finding.
Failure in Discharge Planning for Resident
Penalty
Summary
The facility failed to adequately plan for the discharge of a resident, leading to a deficiency in discharge planning. The resident, who was cognitively intact and had diagnoses including non-traumatic spinal cord dysfunction, depression, and schizophrenia, was discharged to a local county detention center without a completed discharge summary. The discharge was prompted by an incident where the resident hit another resident, leading to police involvement and the resident's removal from the facility. However, the discharge summary was not completed until the following day, and the resident was not provided with a proper discharge plan at the time of the incident. Interviews with staff and other residents revealed that the resident had no prior history of violent behavior, although there were reports of the resident acting strangely and leaving the facility under the influence of substances. The Social Services Designee, who was responsible for completing the discharge summary, was unable to do so immediately due to an impending vacation, leaving the task to the Administrator. The Administrator conducted an investigation and determined that the resident had also hit another resident, leading to the decision to discharge the resident for being a danger to others. The resident was informed of the discharge and refused to sign the immediate discharge notice. The facility contacted the Ombudsman and coordinated with a local homeless shelter for the resident's temporary placement. Despite these actions, the lack of a timely and comprehensive discharge plan, including the absence of a completed discharge summary at the time of the resident's removal, constituted a failure in the facility's discharge planning process.
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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