Clark County Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Kahoka, Missouri.
- Location
- 1260 North Johnson Street, Kahoka, Missouri 63445
- CMS Provider Number
- 265485
- Inspections on file
- 13
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Clark County Nursing Home during CMS and state inspections, most recent first.
A resident with a history of constipation, hemorrhoids, iron deficiency anemia, and opioid use experienced severe difficulty with bowel movements and rectal pain. An RN twice assessed the resident, found a large fecal impaction, and digitally removed the mass, but did not document the event or notify the physician. In the following days, the resident developed ongoing rectal bleeding and appeared pale, tired, and weak. Although a CBC was ordered after the bleeding was reported, staff were unable to obtain the blood sample for several days and did not notify the physician of this failure or the resident’s worsening condition until after critical lab results were finally obtained, at which point the resident was sent to the hospital.
Facility staff performed a urinary catheterization and urine drug screen on a cognitively intact resident without obtaining consent from the resident or their emergency contact and without a physician order for the drug screen. The DON conducted these procedures based on observed changes in the resident's condition and behavior, but there was no documentation of urinary retention or notification to the physician or family. Interviews confirmed that consent and proper orders were not obtained, and the facility lacked a policy for such procedures.
The facility failed to properly label and manage food items in storage and maintain cleanliness of food service equipment. Observations showed unlabeled and expired food items in storage, and a buildup of debris on the ice machine and dishwasher. Interviews revealed inconsistencies in staff responsibilities and cleaning schedules, contributing to these deficiencies.
The facility failed to follow infection control standards during blood glucose monitoring and did not properly store oxygen tubing and nebulizer equipment, leading to potential contamination risks. Additionally, the facility lacked a comprehensive Legionella control policy, failing to conduct a water assessment or develop a management program in line with CDC and ASHRAE standards.
The facility failed to complete federally mandated Significant Change in Status Assessments (SCSA) for four residents who experienced significant changes in their conditions. These residents showed declines in activities of daily living, weight loss, and new health issues, yet the required assessments were not performed. Interviews revealed a lack of adherence to guidelines, contributing to the deficiency.
The facility failed to follow proper medication administration techniques for insulin pens and eye drops for three residents. An RN did not wait the recommended time after administering insulin to two residents with diabetes, and a CMT did not apply pressure or instruct a resident to keep their eyes closed after administering ketotifen eye drops. These actions were inconsistent with the manufacturers' guidelines.
The facility failed to ensure safe wheelchair propulsion for three residents, leading to potential accident hazards. A resident with severe cognitive impairment was propelled without foot pedals, causing their feet to slide on the floor. Another resident, dependent on staff for long-distance mobility, was also propelled without foot pedals, struggling to keep their feet off the ground. A third resident's foot dragged on the floor while being pushed by staff. The DON and Administrator acknowledged the need for foot pedals to prevent injuries.
The facility failed to conduct necessary assessments and obtain informed consent for the use of bed rails for several residents, leading to deficiencies in care. A resident with severe cognitive impairment used side rails without documented assessment or consent. Another resident used side rails for mobility and boundary limitations without documented risk assessment or consent. A third resident had consent from a family member but lacked a documented entrapment risk assessment. The DON acknowledged the lack of documentation and consent.
The facility failed to properly label and dispose of medications, and did not securely store controlled substances. Insulin for two residents was not dated or discarded within 28 days, and Ativan was not stored in a locked compartment. Expired medications were not timely destroyed, including those of a deceased resident. Staff interviews revealed inconsistent responsibility for medication checks.
A facility failed to assess pressure alarms as restraints for a resident with severe cognitive impairment and a history of falls. The resident expressed agitation and a feeling of being restrained by the alarms, which were intended to prevent falls. Despite the resident's distress and attempts to disable the alarms, the facility did not evaluate their use as restraints. Interviews revealed the resident felt restricted and fearful, while the facility's leadership did not consider the alarms to be restraints.
Two residents in an LTC facility received inadequate pressure ulcer care, leading to deficiencies in their treatment and care plans. One resident developed an unstageable pressure ulcer on the right heel, with staff failing to update the care plan or implement proper interventions. Another resident had multiple pressure ulcers, with the facility failing to maintain the low air loss mattress at the correct weight setting. Observations and staff interviews revealed a lack of communication and oversight in implementing and maintaining appropriate interventions.
A facility failed to provide restorative nursing services to a resident who developed contractures in the knees and hips, despite being admitted without such limitations. The resident, with severe cognitive impairment and other diagnoses, became dependent on staff for several activities. The facility lacked a system to identify and prevent contractures, and the resident was not included in the restorative nursing program, nor were there orders for physical therapy evaluation or treatment.
A facility failed to provide trauma-informed care for a resident with PTSD, as their care plan lacked specific interventions for PTSD triggers. The resident avoided communal areas due to feeling overwhelmed, and staff relied on word of mouth to learn about triggers, which were not documented in care plans. The DON confirmed the absence of a trauma-informed care policy.
The facility failed to provide written notices of transfer to two residents when they were transferred to the hospital. One resident with moderate cognitive impairment was admitted with COVID-19 and hip pain, while another was transferred twice due to medical issues, including cardiac dysrhythmia. The Director of Nursing and Administrator were unaware of the requirement for written notices, and staff only verbally informed families of transfers.
The facility failed to provide a written bed hold policy notice to residents or their representatives during hospital transfers. This deficiency was identified for three residents who were transferred for medical evaluation and treatment. Interviews revealed that the facility did not issue bed hold notices, claiming they take all residents back and were unaware of the requirement.
Failure to Document Digital Fecal Impaction Removal and Notify Physician of Bleeding and Delayed Labs
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards of quality by not documenting a significant procedure, not promptly notifying the physician of changes in condition, and not communicating inability to obtain ordered labs for one resident with constipation and hemorrhoids. The resident had a history of constipation, hemorrhoids, and iron deficiency anemia, and was receiving multiple laxatives, hemorrhoid treatments, low-dose aspirin, an iron supplement, and an opioid (tramadol). A Significant Change MDS from the prior month documented moderately impaired cognition, maximum assistance for toileting and transfers, and no constipation. Facility policy required prompt physician notification and documentation in the medical record when there were changes in a resident’s condition or a need to significantly alter treatment. On 1/11/26, the resident experienced severe difficulty having a bowel movement and reported feeling fecal material stuck in the rectum, causing pain. A CNA reported this to an RN, who assessed the resident twice that day. The RN found the rectum dilated with a firm, softball-sized fecal mass and, after initial lubrication and reassessment, digitally removed the fecal impaction in several passes, after which the resident passed additional loose stool. The RN later acknowledged not documenting the impaction, the digital removal procedure, or the resident’s complaints in the nurse’s notes, and did not notify the physician of the impaction or the intervention, stating he/she did not believe it was necessary because the resident was not bleeding and was able to have a bowel movement afterward. Nurse’s notes for that date contained no record of the impaction, the resident’s pain, or the digital removal. On 1/13/26, nurse’s notes documented rectal bleeding that continued even without bearing down, and administration of a hemorrhoidal suppository. On 1/14/26, the nurse documented speaking with the physician about bleeding hemorrhoids and blood loss, and a CBC was ordered; however, staff were unable to obtain the blood sample and there was no documentation that the physician was notified of this inability. On 1/16/26, notes showed the resident passed a bright red rectal clot larger than a quarter and then a large amount of dark blood, with the DON notified and a hemorrhoidal suppository given. The DON attempted multiple blood draws without success, and later that evening the resident was documented as very pale, tired, and weak, but there was still no documentation that the physician was notified of these changes or of the continued inability to obtain the ordered lab. The CBC was finally obtained on 1/17/26, and the lab reported a critically low hemoglobin of 5.5 g/dL and critically high white blood cell count to the charge nurse, after which the physician was notified and the resident was sent to the hospital. In interviews, the DON confirmed she did not notify the physician about the failed lab draws until 1/17/26, and the physician stated his expectation that he be notified when manual fecal removal is performed and when staff are unable to obtain ordered labs.
Failure to Obtain Consent for Urinary Catheterization and Drug Screen
Penalty
Summary
Facility staff failed to honor a resident's rights by performing a urinary catheterization and obtaining a urine drug screen without notifying or obtaining permission from the resident or their emergency contact. The resident was documented as cognitively intact, alert, and oriented, and was their own responsible party. The facility's policy states that residents have the right to be fully informed about their care and to make decisions regarding their treatment, including the right to refuse care and to have their physician and family notified of significant changes. The resident's medical record showed an open-ended order for straight catheterization as needed for urinary retention, but there was no documentation of urinary retention at the time of the procedure, nor was there a physician order for urine collection or drug screening. Nursing notes indicated that the Director of Nursing (DON) performed the straight catheterization and drug screen based on observed changes in the resident's condition and behavior, as well as reports of possible marijuana use. However, there was no documentation that the resident or their emergency contact was informed or gave consent for these procedures, and no physician order was obtained for the drug screen. Interviews with facility staff, including the DON and the Administrator, confirmed that no permission or physician order was obtained prior to the procedures. The DON acknowledged that she should have obtained consent from the resident or their emergency contact and that the facility lacked a policy for obtaining drug screens or following physician orders for such procedures. The resident's physician also stated that staff should probably get permission before performing a urine drug screen.
Deficiencies in Food Labeling and Equipment Maintenance
Penalty
Summary
The facility failed to properly label and manage food items in both the dry storage and walk-in cooler areas. Observations revealed that several food items, such as cornflakes, pork gravy mix, and cheddar cheese sauce mix, were opened and resealed without proper labeling of opened dates or expiration dates. Additionally, prepared food items like egg salad and tomato sauce in the walk-in cooler were not discarded after their labeled use-by dates. Interviews with the Dietary Manager and Supervisor confirmed that dietary staff were expected to label food items correctly and remove expired items, but these practices were not consistently followed. The facility also failed to maintain cleanliness and proper maintenance of food service equipment, specifically the ice machine and dishwasher. Observations showed a buildup of white scaly material and rust-colored run marks on the ice machine, as well as debris accumulation on the dishwasher's surfaces and piping. The Dietary Manager and Supervisor indicated that dietary staff were responsible for cleaning these machines, but there was uncertainty about the frequency of cleaning. The Maintenance Technician was unaware of the condition of the ice machine and stated that it was due for cleaning. Interviews with the Administrator highlighted that both the dietary and maintenance departments were responsible for ensuring the cleanliness and proper labeling of food items and equipment. However, the lack of consistent monitoring and adherence to cleaning schedules contributed to the deficiencies observed. The Administrator expected staff to label food items when opened and remove items past their use-by dates, as well as maintain clean and sanitized equipment areas.
Infection Control and Legionella Management Deficiencies
Penalty
Summary
The facility failed to adhere to infection control standards during blood glucose monitoring for three residents. Staff did not appropriately sanitize the glucometer after use, nor did they use a barrier to prevent contamination. The glucometer was cleaned with alcohol wipes instead of the recommended Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant wipes, as per the manufacturer's instructions. This improper cleaning method was due to incorrect guidance from nurse managers, as reported by the staff involved. Additionally, the facility did not store oxygen tubing and nebulizer equipment properly when not in use, leading to potential contamination risks for three residents. Oxygen tubing was found lying on the floor or bed without being stored in a protective bag, and nebulizer equipment was left uncovered on surfaces. Staff interviews revealed a lack of awareness and adherence to proper storage protocols, contributing to the deficiency. The facility also lacked a comprehensive policy for Legionella control, failing to conduct a facility water assessment or develop a water management program in line with CDC and ASHRAE standards. The facility's policy did not include a water management team, a water flow map, or specific control parameters for water monitoring. Interviews with staff indicated a lack of knowledge and implementation of necessary measures to prevent Legionella growth, further contributing to the deficiency.
Failure to Complete Significant Change Assessments
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for four residents, despite significant changes in their conditions. This assessment is federally mandated and should be completed within 14 days after a significant change in a resident's physical or mental condition that impacts more than one area of their health status. The report highlights that the facility did not perform these assessments for four residents out of a sample of 22, despite observable declines in their activities of daily living (ADL) and other health indicators. Resident #18 experienced a decline in ADL functions, requiring increased assistance for oral hygiene, dressing, and transfers, and became occasionally incontinent of bowel. Despite these changes, no SCSA was completed. Similarly, Resident #8 showed a decline in independence, requiring more assistance in various ADL areas, experienced significant weight loss, and developed a new swallowing disorder, yet no SCSA was documented. Resident #13 also had changes in hearing, range of motion, and required more assistance in ADL areas, but again, no SCSA was completed. Resident #28 had changes in mobility, weight, and required more assistance in ADL areas, with new pain management interventions, but the facility did not complete an SCSA. Interviews with the MDS coordinator and the Director of Nursing revealed a lack of understanding and adherence to the RAI manual guidelines, contributing to the failure to complete the necessary assessments. The MDS coordinator admitted to not using the RAI manual properly, and the Director of Nursing expected the SCSA to be initiated within a few days of a change, but this was not done as required.
Improper Medication Administration Techniques
Penalty
Summary
The facility failed to adhere to proper medication administration techniques for insulin pens and eye drops for three residents. Resident #58, diagnosed with diabetes mellitus, received an insulin injection from RN B who did not wait for the recommended count of six after administering 40 units of Tresiba insulin. Similarly, Resident #2, also with diabetes mellitus, was administered eight units of Humalog insulin by RN B, who again did not wait for the recommended count of five after administration. These actions were contrary to the administration instructions provided by the manufacturers of the insulin pens. Additionally, Resident #21, who had an order for ketotifen eye drops for allergic conjunctivitis, did not receive the medication according to professional standards. CMT C administered the eye drops without applying pressure to the lacrimal gland or instructing the resident to keep their eyes closed for the recommended two to three minutes. This was inconsistent with the administration guidelines for ketotifen ophthalmic eye drops. Both RN B and CMT C acknowledged their deviations from the expected procedures during interviews.
Failure to Use Wheelchair Foot Pedals Poses Accident Hazards
Penalty
Summary
The facility failed to ensure that three residents in wheelchairs were propelled safely, leading to potential accident hazards. Resident #28, who had severe cognitive impairment and was dependent on wheelchair mobility, was observed being propelled by a CNA/CMT without foot pedals on the wheelchair. The resident's feet slid on the floor, creating a sliding sound, and the staff did not apply foot pedals or ensure the resident's feet were safe, despite being instructed to always use foot pedals to prevent injury. Resident #17, who had moderate cognitive impairment and was dependent on staff for wheelchair mobility over long distances, was also propelled without foot pedals. The resident struggled to keep their feet off the ground, causing the wheelchair to stop when their feet hit the floor. Despite the resident's care plan indicating the need for staff assistance with long-distance wheelchair mobility, staff did not use foot pedals, citing busyness as a reason for not retrieving them. Resident #11, who used a wheelchair for mobility and had a history of falls, was pushed by the Social Services Director without foot pedals. The resident's foot dragged on the floor during the transport, which the staff did not notice. The Director of Nursing and the Administrator acknowledged that staff should not propel residents without foot pedals, especially over long distances, and that foot pedals were available in bags on the wheelchairs.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to complete necessary assessments and obtain informed consent for the use of bed rails for several residents, leading to deficiencies in care. Resident #17, who had severe cognitive impairment and a history of falls, was using one-fourth side rails for assistance with bed positioning. However, there was no documentation of a side rail assessment or an assessment of the resident's risk for entrapment prior to the use of the side rails. The Director of Nursing (DON) acknowledged that while she completed a mental assessment, she did not document it, intending to do so at a later date. Resident #54, who also had severe cognitive impairment and required substantial assistance for mobility, was using one-fourth side rails for bed mobility and boundary limitations. The facility did not document an assessment of the resident's risk for entrapment, nor did they obtain consent from the resident or family for the use of the side rails. The DON admitted that she could not find a consent form for the resident and explained that the resident used the side rail to identify the edges of the bed. Resident #18, with a history of falls and severe cognitive impairment, was using one-fourth side rails for assistance and boundary limitations. Although a family member had signed a consent form, there was no documentation of an assessment for the risk of entrapment. The resident's care plan indicated the use of side rails for assistance, but the facility failed to document the necessary assessments prior to their use. The DON confirmed that assessments should be completed before using side rails and that consent should be obtained beforehand.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper labeling and timely disposal of medications, as well as secure storage of controlled substances. Insulin vials and pens for two residents were not dated when opened, and one insulin vial was not discarded within the designated 28-day period after opening. Additionally, a schedule IV controlled substance, Ativan, was not stored in a separately locked compartment as required, and expired medications were not destroyed in a timely manner. Specifically, a bottle of liquid Ativan was found in an unlocked refrigerator, and expired Xanax tablets were found in the emergency narcotic box. Further observations revealed that expired medications belonging to a deceased resident were not destroyed, including albuterol sulfate inhalation solutions and nystatin topical powder. Interviews with staff indicated that there was a lack of consistent responsibility for checking and disposing of expired medications, with the Licensed Practical Nurse and Director of Nursing acknowledging that all nursing staff should be involved in this process. The facility's failure to adhere to medication management protocols resulted in deficiencies related to medication labeling, storage, and disposal.
Failure to Assess Pressure Alarms as Restraints
Penalty
Summary
The facility failed to assess the use of pressure alarms as a restraint for a resident with severe cognitive impairment and a history of falls. The resident, who was admitted to the facility due to repeated falls at home, was equipped with pressure alarms on both the bed and chair as a fall prevention measure. Despite the alarms being intended for safety, the resident expressed agitation and a feeling of being restrained, as documented in staff notes and interviews. The resident's medical history included dementia with behavioral disturbances, Parkinsonism, and major depressive disorder, among other conditions. The resident required assistance with mobility and had a durable power of attorney for healthcare decisions. Despite the resident's severe cognitive impairment, there was no evidence that the facility evaluated the use of the alarms as a restraint, even after the resident expressed distress and attempted to disable the alarms. Interviews with the resident and their spouse revealed dissatisfaction with the alarms, which the resident felt restricted their freedom and caused fear of getting up. The Director of Nursing and the Administrator did not consider the alarms to be restraints, as they believed the alarms did not prevent movement. However, the resident's repeated expressions of feeling trapped and the lack of a documented assessment of the alarms as restraints highlight a deficiency in the facility's approach to the resident's care.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their treatment and care plans. Resident #42, who had severe cognitive impairment and a diagnosis of diabetes mellitus, osteoporosis, and dementia, developed an unstageable pressure ulcer on the right heel. The facility staff did not update the resident's care plan to include the new wound or the intervention to float the resident's heels. Observations showed that the resident's heels were pressed against a pillow, contrary to the care plan, and the bed did not have a pressure-reducing mattress as documented. The resident experienced pain during wound care, and the wound was not treated with Betadine as ordered. Resident #1, with severe cognitive impairment and diagnoses of Alzheimer's disease, dementia, and anxiety disorder, had multiple pressure ulcers, including on the right buttocks and elbow. The facility failed to maintain the low air loss mattress at the correct weight setting, which was overinflated and too firm for the resident's weight. The care plan did not document the development of new open areas or the discontinuation of the feather tick mattress and addition of an air mattress. Observations confirmed the mattress was consistently set too high, and the resident's wounds showed signs of worsening. Interviews with staff, including the Wound Care Nurse and the Director of Nursing, revealed a lack of communication and oversight in implementing and maintaining appropriate interventions for pressure ulcer care. The Wound Care Nurse was responsible for overseeing wound care and quality measures but acknowledged gaps in ensuring interventions were followed. The Director of Nursing expected staff to ensure proper mattress settings and heel positioning, but these expectations were not met, contributing to the deficiencies in care for both residents.
Failure to Provide Restorative Nursing Services for Resident with Contractures
Penalty
Summary
The facility failed to provide restorative nursing services to a resident who was initially admitted without contractures and had no limitations in range of motion. Over time, the resident developed contractures in the knees and hips, which were not addressed by the facility's restorative nursing program. The facility lacked a system to identify residents at risk for decreased range of motion or to prevent the development of contractures. The Director of Nursing confirmed that there was no policy in place for range of motion, contractures, or their prevention and improvement. The resident, who had severe cognitive impairment and diagnoses including heart dysrhythmia and diabetes mellitus, was initially independent in many activities of daily living. However, as the resident's condition changed, they became dependent on staff for several activities and developed contractures in both knees. Despite these changes, the resident was not included in the facility's restorative nursing program, and there were no physician orders for physical therapy evaluation or treatment. Observations showed the resident in a fetal position with contractures, and staff confirmed the resident's contracted state.
Deficiency in Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to implement a system to ensure trauma-informed care for residents with PTSD, as evidenced by the case of a resident with PTSD and major depressive disorder. The resident's care plan lacked specific interventions to address PTSD triggers, and there was no documentation of trauma-informed care assessments in the resident's medical record. The resident expressed that the facility did not provide counseling and that he/she avoided the dining room and group activities due to feeling overwhelmed by commotion. The facility's Director of Nursing confirmed the absence of a policy for trauma-informed care and acknowledged that staff were still learning about residents' triggers, which were not consistently documented in care plans. Interviews with facility staff, including the MDS Coordinator and the DON, revealed that the facility did not have specific interventions for residents with PTSD and relied on word of mouth to communicate residents' triggers. The MDS Coordinator was unsure if the resident's care plan included PTSD-related behavioral issues, and the DON admitted that triggers and behaviors were not systematically monitored or included in care plans. The Administrator stated that all residents were treated as if they had PTSD, but the lack of formalized procedures and documentation indicated a deficiency in providing trauma-informed care.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to provide a written notice of discharge with the required information to two residents when they were transferred to the hospital. Resident #13, who had moderate cognitive impairment, was sent to the hospital with a high fever and was admitted with COVID-19 and hip pain. There was no documentation in the resident's medical record indicating that a written notice of transfer was issued to the resident or their representative. Similarly, Resident #48, who had a durable power of attorney for healthcare decisions, was transferred to the hospital on two occasions due to medical issues, including a cardiac dysrhythmia and syncopal episodes, but no written notice of transfer was provided to the resident's representative. During interviews, the Director of Nursing and the Administrator acknowledged that the facility did not issue written notices of transfer for facility-initiated transfers and were unaware of the requirement to do so. The Director of Nursing stated that staff verbally informed families when a resident was going to the hospital but did not provide information on how to appeal the transfer, ombudsman contact information, or information on mental health advocacy. The facility's failure to provide written notices of transfer with the required information was identified as a deficiency during the survey.
Failure to Provide Bed Hold Policy Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide a written notice of the bed hold policy to residents or their representatives when residents were transferred to the hospital for medical evaluation and treatment. This deficiency was identified for three residents out of a sample of 22. Resident #13, who had moderate cognitive impairment, was sent to the hospital with a high fever and was diagnosed with COVID-19 and hip pain. There was no documentation that the resident or their representative received a bed hold policy notice upon hospital admission. Similarly, Resident #61, who had a durable power of attorney for healthcare, was sent to the hospital due to shortness of breath, and no bed hold policy notice was documented. Resident #48, also with a durable power of attorney, was transferred to the hospital twice for medical issues, including a cardiac dysrhythmia, but again, no bed hold policy notice was provided. Interviews with the Director of Nursing and the Administrator revealed that the facility did not issue bed hold policy notices because they claimed to take all residents back and were unaware of the requirement to provide such notices during transfers or discharges. This lack of awareness and failure to provide the necessary documentation led to the deficiency being cited by surveyors.
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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