Claru Deville Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fredericktown, Missouri.
- Location
- 105 Spruce Street, Fredericktown, Missouri 63645
- CMS Provider Number
- 265514
- Inspections on file
- 20
- Latest survey
- February 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Claru Deville Nursing Center during CMS and state inspections, most recent first.
Two residents with psychiatric diagnoses and histories of self-harm were able to access and ingest AA batteries, resulting in ER transfers, while required 15-minute checks were not documented and staff lacked clear procedures or training. Additionally, a resident with a history of ingesting harmful items accessed an unlocked utility room containing safety razors, plastic bags, and hot coffee, and other environmental hazards were observed unsecured. The facility did not have a policy on accidents/incidents, and staff interviews revealed inconsistent monitoring and lack of formal guidance.
A facility failed to protect residents from abuse and neglect, particularly in a secured behavioral unit. A resident was physically abused by a CNA, and residents were deprived of necessary goods and services. The facility's punitive behavior management approach and lack of staff training contributed to the deficiency, affecting residents with complex medical histories.
The facility failed to uphold resident rights and dignity by placing three residents in a secured unit without proper evaluation and implementing a punitive actions and consequences program. Residents faced restrictions such as loss of smoke breaks, personal belongings, and contact with family, often without physician evaluation. These measures, approved by guardians, led to feelings of humiliation and discomfort among residents, with staff acknowledging the potential for escalated behaviors.
The facility failed to provide adequate behavioral health care and services to residents on a secured behavior unit, resulting in the enforcement of a negative consequences program that was not tailored to individual needs. Residents with mental health diagnoses were subjected to loss of privileges and other punitive measures without appropriate behavior plans or crisis intervention strategies, leading to distress and potential escalation of behaviors.
The facility did not implement a Quality Assurance and Performance Improvement (QAPI) program, lacking policies, documentation, and meetings necessary for improving healthcare processes and residents' quality of life. Interviews with the ADON and Administrator revealed the absence of a QAPI policy, plan, and committee members, despite recognizing the need for a formal approach. The Administrator, DON, and ADON expected to have a QAPI policy, plan, and program to monitor and address quality deficiencies, including Performance Improvement Plans (PIPs) and quarterly meetings with required members.
The facility failed to develop and implement a QAPI program to address quality deficiencies, affecting all 74 residents. Interviews revealed the absence of QAPI meetings, policies, or plans, despite the administration's acknowledgment of the need for a formal approach.
The facility failed to conduct quarterly QAA/QAPI committee meetings with the required members and did not provide a QAPI policy or documentation. Interviews revealed that the ADON admitted to not holding QAPI meetings, and the Administrator confirmed the absence of a QAPI policy or plan. The facility's leadership expressed an expectation to have a QAPI policy, plan, and program to monitor quality deficiencies and hold meetings with required members.
The facility failed to implement a Legionella risk management process and did not maintain proper infection control practices during peri care and wound care for residents. The Water Management Program was not followed, and staff did not adhere to hand hygiene and Enhanced Barrier Precautions (EBP) protocols, leading to deficiencies in infection prevention.
The facility failed to provide adequate staff training and competencies to meet the behavioral health needs of residents on a secured behavior unit. Residents with complex mental health issues were subjected to a punitive actions and consequences program without individualized care plans, leading to feelings of humiliation and discomfort. Staff interviews revealed a lack of specialized training and oversight, contributing to the deficiency.
A facility failed to complete a Level I PASARR for a resident with dementia, traumatic brain injury, and schizoaffective disorder upon admission. The absence of this federally mandated assessment was confirmed by the ADON and administration, who acknowledged the expectation for such screenings. The facility also lacked a policy for PASARR.
The facility failed to clean BiPAP and CPAP machines according to manufacturer's guidelines for two residents, leading to a deficiency. One resident reported infrequent cleaning of their CPAP machine, while another stated their BiPAP machine had never been cleaned. Observations confirmed no records of cleaning or tubing changes. Staff interviews revealed inconsistencies in cleaning schedules and procedures, with no formal system in place for maintaining these machines.
The facility exceeded the acceptable medication error rate, reaching 12% due to improper insulin pen use. An RN failed to prime insulin pens as per manufacturer's instructions for three residents, affecting their diabetes management. The DON confirmed the expectation for proper priming.
Two residents with mental health issues were involved in a physical altercation due to one resident's agitation over their position in line. The altercation resulted in injuries to both residents, highlighting a failure in the facility's abuse prevention policy.
The facility failed to properly notify residents and their representatives in writing of transfers to the hospital, as required by policy. For three residents, the facility did not provide essential information such as the reason for transfer, location, and appeal rights. Interviews with staff revealed that paperwork was sent with residents via EMS without retaining copies, leading to inadequate documentation and notification.
The facility failed to inform residents and their representatives of the bed hold policy during hospital transfers. Documentation for three residents lacked necessary signatures and details, and staff interviews revealed that no copies of the bed hold policy were retained at the facility. This led to a deficiency in compliance with the facility's policy.
The facility failed to maintain RN coverage for at least eight consecutive hours per day, seven days a week, affecting all 68 residents. Staffing sheets showed no RN coverage on several days, and agency RNs were not replaced when unavailable. Efforts to recruit RNs were hindered by competition with agency pay rates.
Failure to Prevent Self-Harm and Secure Hazardous Items for Residents with Psychiatric Diagnoses
Penalty
Summary
The facility failed to provide adequate protective oversight and maintain an environment free from accident hazards for residents with psychiatric diagnoses and a history of self-harm on a secured behavioral unit. Two residents with documented histories of self-injurious behavior, including battery ingestion, were able to access and swallow AA batteries on separate occasions, resulting in emergency room transfers and medical interventions. In one instance, a resident reported ingesting batteries obtained from another resident, while another resident, after making threats of self-harm, ingested batteries from a personal radio. Documentation of required 15-minute checks for one of these residents was not provided, and staff interviews revealed inconsistent understanding and implementation of monitoring protocols, with some staff unaware of the need for documentation or lacking training on the procedures. Additionally, the facility environment was not adequately secured to prevent access to hazardous items. During an observation, a resident with a history of ingesting harmful items was able to open an unlocked clean utility room containing safety razors, plastic grocery bags, and hot coffee carafes. Other hazards, such as a bucket of mop water with cleaning chemicals and tubes of toxic acrylic paint, were also accessible in resident areas. Staff interviews confirmed that doors to hazardous areas were left unlocked and that staff were expected to lock them but did not consistently do so. The facility did not provide a policy regarding accidents or incidents, and staff interviews indicated a lack of clear procedures for determining and documenting resident monitoring levels, such as 15-minute checks or 1:1 supervision. Decisions about monitoring were left to the charge nurse's discretion, and there was no formal policy or training provided to guide staff actions. This lack of structured oversight and environmental controls contributed to repeated incidents of self-harm and exposure to accident hazards among residents with known risks.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, particularly in the secured behavioral unit, affecting three residents. One resident was subjected to physical abuse by a CNA who physically forced the resident to the ground and restrained them, causing humiliation. This incident was part of a broader issue where residents were deprived of necessary goods and services, such as being forced to sleep on a mattress on the floor, leading to physical discomfort. The facility's policy on abuse and neglect was not effectively implemented, as evidenced by the presence of a punitive 'Actions and Consequences' list posted in a resident's bathroom. This list outlined various actions and corresponding consequences, such as losing smoke breaks or snack cart privileges, which were applied to residents for behaviors like arguing or refusing medication. This approach to behavior management was not aligned with the residents' rights to participate in their care and be free from abuse, as it imposed disciplinary measures that could be considered abusive. The residents involved had complex medical histories, including diagnoses of bipolar disorder, schizophrenia, and nicotine dependence, which contributed to their behavioral challenges. The facility's failure to administer prescribed nicotine replacement therapies further exacerbated these challenges. Additionally, the lack of proper training for staff, particularly agency staff, in handling behavioral incidents and the use of physical restraint, contributed to the deficiency. The facility's inadequate response to these issues resulted in an Immediate Jeopardy situation, indicating a serious threat to the health and safety of the residents.
Failure to Uphold Resident Rights and Dignity
Penalty
Summary
The facility failed to ensure and promote an environment that maintained or enhanced each resident's quality of life, recognizing their rights and allowing them to exercise these rights without coercion, interference, discrimination, or reprisal. Three residents were placed in a secured unit without proper evaluation for appropriate placement, and their rights were removed based on directives from their guardians. The facility's actions included implementing a program where residents' privileges, such as smoke breaks and personal belongings, were taken away as consequences for certain behaviors, which was perceived as punitive by some staff and residents. Resident #11, diagnosed with bipolar disorder, schizophrenia, and nicotine dependence, was subjected to a list of actions and consequences that included losing smoke breaks and personal items for behaviors such as arguing or refusing medication. The resident expressed feeling humiliated by these measures, particularly after an incident where they punched a staff member and subsequently lost smoking privileges. The resident's care plan indicated that these measures were approved by the guardian, but there was no physician evaluation to determine the appropriateness of these interventions. Resident #61, with diagnoses including schizophrenia and oppositional defiant disorder, experienced similar restrictions, including limited contact with family and removal of personal belongings. The resident was observed wearing a hospital gown as a consequence of self-harming behavior, which they reported made them feel bad. Resident #68, diagnosed with borderline intellectual functioning and borderline personality disorder, also faced restrictions such as wearing a hospital gown and having their mattress placed on the floor as a consequence of self-harming behavior. Both residents expressed feelings of embarrassment and discomfort due to these measures. The facility lacked a formal tracking tool for behaviors and consequences, and there was no physician evaluation to assess the benefit of these interventions for the residents' mental health.
Failure to Provide Adequate Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to residents on the secured behavior unit, impacting their physical, mental, and psychosocial well-being. The facility did not develop resident-specific interventions or behavior plans as indicated by pre-admission behavioral health screenings. Instead, a program of negative consequences was enforced for residents exhibiting certain behaviors, which included the loss of privileges such as smoke breaks and snack carts. This approach was not tailored to individual needs and lacked a crisis intervention plan. Resident #11, diagnosed with bipolar disorder and schizophrenia, was subjected to an actions and consequences list that resulted in the loss of smoke breaks and other privileges following altercations with staff. The resident expressed feelings of humiliation due to these consequences. Similarly, Resident #61, with a history of schizophrenia and oppositional defiant disorder, experienced self-harming behavior and was made to wear a hospital gown as a consequence, which the resident found distressing. The facility did not provide a behavior plan or crisis intervention plan for this resident, despite the Level II screening recommendations. Resident #68, with borderline intellectual functioning and a history of self-harm, was also subjected to the actions and consequences program. The resident was made to wear a hospital gown and sleep on a mattress on the floor as a result of self-harming behavior. The facility did not provide the necessary support services or behavior plans as indicated by the Level II screening. Interviews with staff revealed that the actions and consequences program could escalate behaviors, and there was no tracking tool for behaviors, leading to inconsistent enforcement of consequences.
Lack of QAPI Program Implementation
Penalty
Summary
The facility failed to implement a Quality Assurance and Performance Improvement (QAPI) program, which is essential for improving healthcare processes and residents' quality of life. The facility, with a census of 74 residents, did not have a QAPI policy or any documentation related to such a program. Interviews revealed that the Assistant Director of Nursing (ADON) acknowledged the absence of QAPI meetings. The Administrator admitted to lacking a QAPI policy, plan, or a list of committee members, although he recognized the need for a more formal approach. Furthermore, the Administrator, Director of Nursing (DON), and ADON collectively expressed the expectation of having a QAPI policy, plan, and a program to monitor and address quality deficiencies, including Performance Improvement Plans (PIPs) and quarterly meetings with required members such as the Medical Director, Administrator, DON, Infection Preventionist, and two other staff members.
Lack of QAPI Program and Policy
Penalty
Summary
The facility failed to ensure the Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This deficiency had the potential to affect all 74 residents in the facility. The facility did not provide a QAPI policy or any documentation related to a QAPI program. During interviews, the Assistant Director of Nursing (ADON) admitted that they do not have QAPI meetings, and the Administrator acknowledged the absence of a QAPI policy or plan, despite knowing the need for a more formal approach. The Administrator, Director of Nursing (DON), and ADON collectively expressed the expectation to have a QAPI policy, plan, and a program to monitor and track quality deficiencies, along with Performance Improvement Plans (PIPs) for those deficiencies.
Failure to Conduct QAPI Meetings and Maintain Required Documentation
Penalty
Summary
The facility failed to conduct quarterly Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee meetings with the required members. The facility, with a census of 74, did not provide a QAPI policy or any documentation related to a QAPI program. During interviews, the Assistant Director of Nursing (ADON) admitted that they do not hold QAPI meetings. The Administrator also confirmed the absence of a QAPI policy or plan and acknowledged the need for a more formal approach. Additionally, the Administrator, Director of Nursing (DON), and ADON expressed an expectation to have a QAPI policy, plan, and program to monitor and track quality deficiencies, including Performance Improvement Plans (PIPs) for those deficiencies, and to hold QAPI meetings at least quarterly with the required members, such as the Medical Director, Administrator, DON, Infection Preventionist, and two other staff members.
Failure to Implement Infection Control and Legionella Risk Management
Penalty
Summary
The facility failed to implement a risk management process specific to Legionnaires' disease, which could potentially affect all residents, staff, and the public. The facility's Water Management Program to Reduce Legionella Growth Policy was not followed, as there was no water management committee in place, and the Maintenance Director did not conduct a checklist for monthly water management inspections. The Maintenance Director only performed random water temperature checks, which were within range, but did not address other necessary inspections to prevent Legionella growth. In addition, the facility did not maintain proper infection control practices during peri care for a resident. Two CNAs failed to wash or sanitize their hands between glove changes while providing peri care, and they did not wash or sanitize their hands after removing gloves and before leaving the resident's room. This lack of adherence to hand hygiene protocols was observed during the care of a resident, and the CNAs admitted to not following proper procedures due to the resident's impatience and personal nerves. Furthermore, the facility did not implement Enhanced Barrier Precautions (EBP) during wound care for another resident. An RN did not follow EBP guidelines, as there was no sign regarding EBP or PPE located near or outside the resident's door. The RN also failed to use a barrier for clean supplies and did not wash hands before and after providing wound care. The Administrator, DON, and ADON acknowledged that they expected staff to follow proper hand hygiene and EBP protocols, but these were not adhered to during the observed care.
Deficiency in Behavioral Health Competency and Training
Penalty
Summary
The facility failed to provide staff with the necessary competencies and skills to meet the behavioral health needs of residents on the secured behavior unit. This deficiency was observed through the lack of specialized training for staff working on the unit, as well as the absence of policies or procedures regarding staffing needs and criteria for admission to the unit. The facility's failure to implement a mental health behavior training program for staff further contributed to the deficiency, affecting the care and safety of residents. Three residents were specifically highlighted in the report, each with complex behavioral and mental health needs. One resident, diagnosed with bipolar disorder and schizophrenia, was subjected to a punitive actions and consequences list that included the loss of privileges such as smoke breaks and snack carts for various behaviors. This resident expressed feelings of humiliation due to these consequences. Another resident, with a history of schizophrenia and oppositional defiant disorder, was observed wearing a hospital gown as a consequence of self-harming behavior, which made the resident feel bad and embarrassed. The third resident, with borderline personality disorder and a history of self-harm, was also made to wear a hospital gown and sleep on a mattress on the floor as a consequence of self-harming behavior, leading to feelings of embarrassment and physical discomfort. Interviews with staff revealed that the actions and consequences program was in place without proper training or oversight, and some staff felt that the consequences could escalate resident behaviors. The Director of Nursing acknowledged the lack of written policies for the behavior unit and the absence of required training for staff before working on the unit. The facility's reliance on a punitive system without individualized care plans or interventions to monitor and protect residents from abuse contributed to the deficiency, impacting the well-being of all residents on the secured behavioral unit.
Failure to Complete PASARR for Resident
Penalty
Summary
The facility failed to complete a Level I Preadmission Screening and Resident Review (PASARR) for a resident upon admission, as required by federal mandate. The resident, who was part of a sample of 18 residents, had diagnoses including dementia, traumatic brain injury, and schizoaffective disorder-bipolar type. Despite these conditions, there was no documentation of the necessary Level I pre-screening in the resident's medical record. Interviews with the Assistant Director of Nursing and the facility's administration confirmed that the PASARR was not completed, and they acknowledged the expectation for such assessments to be conducted prior to admission. Additionally, the facility did not provide a policy for PASARR, indicating a lack of procedural adherence in this area.
Failure to Clean BiPAP and CPAP Machines as per Guidelines
Penalty
Summary
The facility failed to adhere to the manufacturer's guidelines for cleaning BiPAP and CPAP machines for two residents, leading to a deficiency. Resident #39, diagnosed with obstructive sleep apnea and insomnia, was observed using a CPAP machine without any record of cleaning or tubing changes. The resident reported that the machine was cleaned infrequently by the nursing staff. Similarly, Resident #46, who has sleep apnea and uses a BiPAP machine, stated that the machine had never been cleaned to their knowledge. Observations confirmed the absence of any dates indicating the last cleaning or tubing/filter changes for both residents. Interviews with facility staff revealed inconsistencies in the cleaning schedule and procedures for BiPAP and CPAP machines. A CNA mentioned that the machines were filled with distilled water every shift and cleaned every two to three days, but had no experience with the cleaning process. A registered nurse stated that the cleaning was done during the night shift, while the DON and ADON acknowledged the lack of a formal system for cleaning and maintaining the machines. An LPN mentioned that filters and tubing were changed weekly, but there was no specific cleaning protocol in place. The facility's policy on oxygen administration did not address the use of BiPAP and CPAP machines, contributing to the deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 12%. This was observed during medication administration, where three errors were made out of 25 opportunities. The errors involved the improper use of insulin pens for three residents, two of whom were part of the sample and one who was not. Specifically, the Registered Nurse (RN) failed to prime the insulin pens with two units of insulin as per the manufacturer's instructions before administering the medication to the residents. The observations revealed that the RN did not follow the correct procedure for priming the Humalog KwikPen and NovoLog FlexPen, which is essential for accurate dosing. During interviews, the RN admitted to not priming the pens as required, and the Director of Nursing and Assistant Director of Nursing confirmed that they expected insulin pens to be primed according to the manufacturer's instructions. This deficiency affected the care of residents with diabetes, as the facility's policy did not address the use of insulin pens, potentially impacting the management of their condition.
Failure to Prevent Resident Altercation
Penalty
Summary
The facility failed to protect residents from abuse when two residents were involved in a verbal and physical altercation. The incident occurred when one resident became agitated and verbally aggressive due to their position in line to see the unit coordinator. This resident, who has a history of aggressive behaviors and mental health diagnoses, including bipolar disorder and PTSD, threatened another resident. The second resident, who also has a history of mental health issues, attempted to calm the first resident, which escalated into a physical fight. During the altercation, the first resident charged at the second resident, grabbing their hair and not letting go. In response, the second resident struck the first resident in the face multiple times and poked them in the eyes. Both residents ended up on the ground, and staff intervened to separate them. The first resident was sent to the emergency room for evaluation due to injuries sustained during the fight, including redness and a small scrape on the eyelid. The second resident suffered a bald spot from hair being pulled out, bruising on the hand, and a small abrasion on the elbow. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the failure to prevent the altercation between the two residents. Despite the presence of staff and the facility's policy to protect residents from harm, the situation escalated to physical violence. The incident highlights the need for better management of residents with behavioral issues and more effective intervention strategies to prevent such occurrences.
Failure to Notify Residents and Representatives of Transfers
Penalty
Summary
The facility failed to properly notify residents and their representatives in writing of a facility-initiated transfer to the hospital for three residents. The facility's policy on discharge and transfer requires that residents and their representatives be informed of the transfer, including the reason for the transfer, the location to which the resident is being transferred, and their right to appeal. However, the facility did not adhere to these requirements for the three residents involved. For Resident #1, the Emergency Transfer Notice was sent a day after the transfer and lacked critical information such as the specific reason for the transfer, the location of the transfer, and details about the right to appeal. Additionally, the notice was not signed by facility staff. Resident #2's medical record showed no documentation of written notification to the resident or their representative regarding the transfer to the hospital. Similarly, Resident #3's Emergency Transfer Notice was missing essential information, including the reason for the transfer, the location, and appeal rights, and was also unsigned. Interviews with facility staff, including a Registered Nurse, the Director of Nursing, the Social Service Director, and the Administrator, revealed that the facility's process involved sending paperwork with the resident via Emergency Medical Services without retaining copies at the facility. The staff indicated that notifications and bed hold policies were mailed to guardians or responsible parties, but no copies of the transfer notices were kept or sent to the representatives, leading to a lack of proper documentation and notification as required by the facility's policy.
Failure to Inform Residents of Bed Hold Policy
Penalty
Summary
The facility failed to inform residents and/or their legal representatives of the bed hold policy at the time of transfer to the hospital for three residents. The facility's policy requires notification of the bed hold policy upon admission, at the time of transfer, and during non-covered therapeutic leave. However, for the three residents sampled, there was no documentation that the residents or their representatives were informed of the bed hold policy at the time of their hospital transfers. Specifically, the records for these residents lacked signed authorizations for bed hold, did not address the daily rate amount, and were not signed by either the resident, their representative, or a facility representative. Interviews with facility staff revealed that while the bed hold policy and transfer paperwork are sent with the resident to the hospital, no copies are retained at the facility. The Registered Nurse mentioned that the paperwork is sent with the Emergency Medical Services, but no copies are made. The Director of Nursing confirmed that no copies of the transfer or bed hold notices are made at the time of discharge, and the Social Services Director stated that they send the bed hold policy to the guardian or representative to sign and return, but do not follow up if it is not returned. This lack of documentation and follow-up led to the deficiency noted in the report.
RN Staffing Deficiency
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled for at least eight consecutive hours per day, seven days a week, as required by regulations. This deficiency had the potential to affect all 68 residents in the facility. A review of the Nursing Daily Staffing Sheets for the period from April 1, 2024, to May 1, 2024, revealed that there was no RN scheduled for several days, specifically from April 13 to April 14, April 17 to April 18, and April 26 to April 27. On some occasions, an agency RN was scheduled but called in, and no replacement was found. Overall, there was no RN coverage for six out of the 31 days reviewed. Interviews with facility staff, including an RN and the Administrator, highlighted the challenges in maintaining consistent RN coverage. The RN mentioned working Monday through Thursday and one full weekend a month, while the Administrator acknowledged the absence of a formal RN coverage policy and the reliance on agency staff to fill gaps. The Director of Nursing (DON) stated that she is always on call and attempts to arrange agency staff when necessary. Despite efforts to recruit RNs through various channels, including online advertisements and outreach to student nurses, the facility struggled to compete with agency pay rates, contributing to the staffing deficiency.
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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