Current River Nursing Center, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Doniphan, Missouri.
- Location
- 1015 North Grand Avenue, Doniphan, Missouri 63935
- CMS Provider Number
- 265504
- Inspections on file
- 15
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Current River Nursing Center, Inc during CMS and state inspections, most recent first.
The facility failed to follow physician's orders for three residents, leading to deficiencies in care. A resident with multiple conditions did not receive consistent skin assessments and treatments, resulting in worsened skin conditions. Another resident with a pressure ulcer experienced lapses in wound care, with incorrect medication application. A third resident with Alzheimer's was not weighed weekly as ordered, missing opportunities to monitor significant weight loss. Staff interviews revealed a lack of awareness and documentation regarding these issues.
A facility failed to safely transfer two residents, resulting in a hip fracture for one. A resident with hemiplegia was transferred by an RN alone, contrary to the care plan requiring two staff, leading to a fall and hip fracture. Another resident with severe cognitive impairment was transferred without a gait belt, using improper techniques. Staff interviews revealed inadequate training and communication on transfer procedures.
The facility failed to maintain RN coverage for at least eight hours daily and lacked a DON, affecting all residents. Staffing records showed multiple days without RN coverage, and interviews confirmed the absence of a DON since November 2023. The facility relied on agency staff to fill RN gaps, with only one RN as a floor nurse and the ADON and MDS Coordinator being LPNs.
The facility failed to maintain written transfer agreements with hospitals, which are necessary for ensuring timely hospital admissions for residents when needed. Interviews and record reviews showed that no transfer agreements or related policies were available. The Administrator and ADON confirmed the absence of such agreements, affecting all 40 residents.
The facility did not inform the State agency about changes in their DON position. Records showed that the last documented DON was terminated in December 2023, and no DON was scheduled or worked from April to July 2024. The Administrator confirmed the absence of a DON since November 2023.
A facility failed to consistently document a resident's code status, resulting in discrepancies between the care plan, face sheet, and Physician's Order Sheet. The resident had chosen a DNR status, but the Physician's Order Sheet indicated a full code. Staff relied on color-coded sheets in the MAR and physician's orders to determine code status, but the facility lacked a policy to ensure consistent documentation.
The facility failed to maintain a safe and clean environment, with observations revealing damaged shower rooms and unclean, unrepaired wheelchairs for several residents. Staff interviews indicated a lack of awareness and documentation regarding maintenance and cleaning procedures. The Maintenance Director and Administrator acknowledged the issues but cited a lack of funds, although the Corporate QA RN stated funds were available.
A facility failed to assess and document the use of bed and chair alarms for a resident with Alzheimer's and osteoporosis, who experienced multiple falls. The resident was unable to remove the alarms, suggesting potential restraint use. There was no physician's order or assessment for the alarms, and staff interviews confirmed the lack of monitoring and documentation.
The facility failed to provide written transfer/discharge notifications to residents, their responsible parties, and the LTC Ombudsman for six residents transferred to the hospital. The facility lacked a transfer/discharge policy, and the Ombudsman had not received transfer logs since April. The Administrator and ADON expected charge nurses to handle notifications, but there was no clear accountability.
The facility failed to provide written notification of the bed-hold policy to residents and/or their representatives during hospital transfers. Six residents were transferred without receiving the required documentation. The ADON and Administrator acknowledged the expectation for bed-hold policies to be given, but there was no clear accountability for ensuring this was done.
A resident with dementia, dysuria, muscle weakness, repeated falls, and UTIs experienced multiple falls and incidents that were not addressed in their care plan. Despite numerous documented falls and incidents, the care plan had not been updated with new interventions since the previous year. Observations showed improper wheelchair cushion positioning and lack of nonskid footwear, while interviews with staff revealed an expectation for care plan updates that were not executed.
A facility failed to collect timely urine specimens for a resident with symptoms of a UTI, resulting in an emergency room visit. The resident, with a history of dementia and UTIs, had multiple orders for urine analysis that were not completed, and the physician was not notified. Staff interviews revealed a lack of follow-through on lab orders and communication, contributing to the oversight.
The facility failed to follow physician's orders for oxygen administration for several residents, resulting in incorrect oxygen flow rates and undated tubing. A resident with COPD and lung cancer received higher oxygen flow than prescribed, while another with pneumonia and respiratory failure also received incorrect flow rates. Additionally, two residents had undated oxygen tubing, and one was without oxygen for an extended period due to the concentrator being off.
The facility failed to conduct annual performance reviews for two CNAs, as required. CNA G and CNA H did not have documented performance reviews for the specified periods. The Administrator and ADON admitted that reviews had not been conducted since the current administrator's tenure began, and they were unaware of any previous reviews. Additionally, the facility lacked a policy on annual training, despite the facility assessment outlining required training topics.
The facility failed to reconcile narcotics at each shift change for three medication carts, as required by policy. A review of narcotic count logs showed numerous missed opportunities for reconciliation over several months, with many instances of no documentation. Interviews with staff confirmed the expected practice, but the logs indicated significant non-compliance.
The facility failed to limit PRN orders for psychotropic medications to 14 days and did not ensure appropriate diagnoses or attempt gradual dose reductions for several residents. Interviews revealed a lack of clarity and follow-through in managing medication regimen reviews and GDRs, contributing to these deficiencies.
The facility failed to monitor and document refrigerator temperatures for medications, including insulin, as required by policy. Numerous instances of missed documentation and out-of-range temperatures were noted, with no follow-up actions taken. The ADON and Administrator confirmed the night charge nurse was responsible for this task, but the facility did not adhere to its policy.
The facility did not establish written agreements with hospice services for two residents admitted to hospice care. Despite the residents being admitted, the necessary one-time agreements with the hospice providers were not completed. The Administrator confirmed that these agreements were required but not executed.
The facility failed to maintain an effective QAPI program, lacking necessary policies and protocols to identify and correct quality deficiencies. Despite a plan outlining the program's purpose and structure, the facility did not adhere to it, with the last documented QAPI meeting held months prior. The absence of regular QAPI meetings, despite daily QAA meetings, indicates a failure to follow the established plan, potentially affecting all 40 residents.
The facility did not ensure the QAA/QAPI committee developed and implemented a plan to correct quality deficiencies using a PIP. The facility's policy required the QAPI committee to prioritize activities and implement PIPs based on data analysis. However, there was no documentation of PIPs in the QAPI binder. The Administrator was unaware of what a PIP was and confirmed no PIPs had been conducted since her tenure.
The facility did not hold quarterly QAPI meetings with the required members, as the Director of Nursing (DON) position was vacant since November 2023. The facility's policy did not specify the necessary members for the QAPI committee, and the last meeting was held without the DON, leading to non-compliance.
The facility failed to document TB testing for four residents, perform proper hand hygiene and glove changes during wound and incontinent care, and lacked a water management program for Legionella. Additionally, the IPCP was outdated and missing critical information.
The facility failed to provide the required twelve hours of annual in-service education for two CNAs. CNA G had no documented training from November 2022 to November 2023, while CNA H had incomplete documentation of training topics and durations from September 2022 to September 2023. The facility's assessment highlighted the need for training in areas such as abuse, neglect, and dementia care, but no policy was provided. The Administrator and ADON confirmed the annual training requirement.
Failure to Follow Physician's Orders for Resident Care
Penalty
Summary
The facility failed to follow physician's orders for three residents, leading to deficiencies in care. Resident #5, diagnosed with multiple conditions including schizophrenia and cellulitis, did not receive consistent skin assessments and treatments as ordered. Observations revealed that the resident's skin condition worsened, with visible redness, swelling, and open areas on the legs. Despite having orders for specific skin treatments and assessments, there were numerous missed opportunities for care, and the resident's care plan did not address cellulitis or venous insufficiency interventions. Interviews with staff indicated a lack of awareness and documentation regarding the resident's condition and refusals of care. Resident #34, with diagnoses including congestive heart failure and a Stage 4 pressure ulcer, also experienced lapses in care. The resident's treatment orders for wound care were not consistently followed, with missed opportunities for skin assessments and incorrect application of wound care products. Observations showed that the wrong medication was used during wound care, and interviews with staff revealed misunderstandings about the treatments ordered. The facility's failure to adhere to physician's orders for wound care could potentially impact the resident's healing process. Resident #40, diagnosed with Alzheimer's disease, was not weighed weekly as ordered, resulting in missed opportunities to monitor the resident's weight. The resident experienced a significant weight loss over three weeks, but the facility failed to document weekly weights as required. Interviews with staff indicated that the resident was not included on the weekly weight list, and there was a lack of oversight in ensuring the order was followed. The physician expected the weights to be completed as ordered, highlighting a gap in the facility's adherence to care protocols.
Unsafe Resident Transfers Leading to Injury
Penalty
Summary
The facility failed to provide a safe transfer for Resident #23, who had a history of hemiplegia and hemiparesis following a stroke, among other conditions. The resident's care plan required a minimum of two staff for transfers. However, on the day of the incident, a Registered Nurse (RN) attempted to transfer the resident alone using a gait belt. During the transfer, the resident began leaning due to left-sided weakness, and despite the RN's attempt to correct the position, both the RN and the resident fell. The resident sustained a hip fracture and was later admitted to the hospital for surgery. In another incident, the facility failed to safely transfer Resident #8, who had severe cognitive impairment and required substantial assistance for activities of daily living. The resident's care card indicated the need for a mechanical lift with two staff for transfers. However, during an observed transfer, the resident was lifted from a shower chair without a gait belt, and the transfer was conducted by placing arms under the resident's axillary area, which is against the facility's policy. The staff involved were not adequately trained, and the hospice aide led the transfer without proper equipment. Interviews with staff revealed a lack of consistent training and communication regarding transfer procedures. The Assistant Director of Nursing and the Corporate Quality Assurance RN confirmed that the transfers were not conducted safely, as the residents were not transferred using the appropriate equipment or techniques. The facility's failure to adhere to the care plans and policies resulted in unsafe transfer practices for both residents.
Deficiency in RN Coverage and Lack of DON
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, and also failed to have a Director of Nursing (DON) in place. This deficiency had the potential to affect all residents, with a census of 40. The facility's assessment indicated that the DON should work five days a week for eight hours, and licensed nurses should include an RN for eight hours per day when the DON is not available and on weekends. However, the facility's daily nursing staffing sheets revealed multiple days without RN coverage, with 19 out of 102 opportunities missed between April and July 2024. Interviews with facility staff, including the Administrator and the Assistant Director of Nursing (ADON), confirmed the absence of a DON since November 2023 and the reliance on agency staff to fill RN coverage gaps. The facility's current staff list showed only one RN as a floor nurse, with the ADON and Minimum Data Set (MDS) Coordinator being Licensed Practical Nurses (LPNs). The Administrator acknowledged the lack of a DON and the challenges in maintaining consistent RN coverage, despite efforts to use agency staff to address the issue.
Lack of Hospital Transfer Agreements
Penalty
Summary
The facility failed to ensure that written transfer agreements with hospitals were in place to guarantee timely hospital admissions for residents when medically necessary. This deficiency was identified through interviews and record reviews, revealing that the facility did not have any transfer agreements with hospitals, nor could they provide a policy on transfer agreements. During an interview, the Administrator and the Assistant Director of Nursing (ADON) acknowledged that the corporate Quality Assurance Registered Nurse was unable to locate any transfer agreements with hospitals. The Administrator admitted to having no knowledge of any existing transfer agreements. This oversight had the potential to affect all 40 residents of the facility.
Failure to Notify State Agency of DON Changes
Penalty
Summary
The facility failed to notify the State agency responsible for licensing about changes in their Director of Nursing (DON) position. The facility's assessment indicated that the DON should work five days a week for eight hours, and a Registered Nurse (RN) should cover when the DON is unavailable. However, records showed that RN I was hired as the DON in June 2022 and terminated in May 2023, while RN J was hired in November 2023 and terminated in December 2023. The last documented change of DON form was from July 2022, indicating RN I's employment. Nursing schedules from April to July 2024 showed no documentation of a DON being scheduled or working, with 107 days missed. During an interview, the Administrator confirmed that the facility had not had a DON since November 2023.
Inconsistent Documentation of Resident's Code Status
Penalty
Summary
The facility failed to consistently document the code status for a resident, leading to a discrepancy in the resident's medical records. The resident's care plan and face sheet indicated a Do Not Resuscitate (DNR) status, while the Physician's Order Sheet showed a full code status. Additionally, the Medication Administration Record (MAR) included a red DNR code sheet, which was meant to indicate the resident's DNR status. This inconsistency in documentation could lead to confusion among staff regarding the resident's wishes in the event of a medical emergency. Interviews with the resident and facility staff revealed that the resident had discussed and decided on a DNR status with their family. However, the facility did not have a policy regarding a resident's code status, and staff relied on color-coded sheets in the MAR and physician's orders to determine a resident's code status. The Assistant Director of Nursing explained that red sheets indicated DNR, green sheets indicated full code, and purple sheets could show either status. Despite these systems, the documentation did not consistently reflect the resident's chosen code status, highlighting a gap in the facility's record-keeping practices.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, as evidenced by the poor condition of shower rooms and wheelchairs. Observations revealed that the 500 Hall shower room had an elevated tiled shower base and discolored caulking, while the 300 Hall shower room had missing tiles, an unattached fiberglass shower unit, and missing ceramic tile base sections. Interviews with staff indicated that these issues had been reported verbally but were not documented in the maintenance logs, and there were no plans to repair the damage despite the showers being used by residents. The facility also failed to clean and repair wheelchairs for several residents. Observations showed that Resident #22's wheelchair was dirty, with stained and pilled arm wraps and a seat cushion hanging over the edge. Resident #20's wheelchair had cracks and splits, and was dirty with food and debris. Resident #9's wheelchair was missing an armrest, and Resident #6's wheelchair had exposed foam fill on the armrests. Interviews with staff revealed a lack of awareness and documentation regarding the cleaning and maintenance of wheelchairs, with some staff unsure of the procedures and others indicating that repairs were reported verbally but not documented. The Maintenance Director and Administrator acknowledged the issues but cited a lack of funds for new wheelchairs, although the Corporate QA RN stated that funds were available. The maintenance logs did not document any repair concerns for the shower rooms or wheelchairs, and there was no documentation of when wheelchairs were cleaned. The facility's failure to address these issues resulted in a deficiency in providing a safe and homelike environment for residents.
Failure to Assess and Document Use of Bed and Chair Alarms
Penalty
Summary
The facility failed to properly assess and document the use of bed and chair alarms for a resident diagnosed with Alzheimer's Disease, altered mental status, and osteoporosis. The resident, who required assistance for toileting and was dependent for most activities of daily living, experienced multiple falls, some unwitnessed, over a period of time. Despite these incidents, there was no documentation of a physician's order for the bed and chair alarms, nor was there an assessment conducted to determine if these alarms were being used as restraints. Observations revealed that the resident was unable to remove the bed and chair alarms, indicating a potential restraint use. The facility's policy required documentation of the date and time the alarms were ordered, the type of restraint, reasons for use, and the resident's response, none of which were completed. Interviews with facility staff, including the MDS Coordinator and the Administrator, confirmed that assessments and monitoring of the alarms were not conducted as expected, and there was a lack of physician's orders for the alarms.
Failure to Provide Transfer/Discharge Notifications
Penalty
Summary
The facility failed to provide written notification of transfer or discharge to residents, their responsible parties, and the Office of the Long-Term Care (LTC) Ombudsman for six residents. These residents were transferred to the hospital on various dates, but there was no documentation of the required written notifications. The facility also did not have a transfer or discharge policy in place. This deficiency affected all six sampled residents, with the facility census being 40. Interviews revealed that the Ombudsman had not received transfer logs from the facility since April 2024. The Administrator acknowledged that it was her responsibility to send these logs monthly, but this had not been done. The Assistant Director of Nursing (ADON) and the Administrator stated that they expected transfer and discharge notices to be given for each hospital transfer/discharge, with the charge nurse responsible for ensuring this. However, there was no clear accountability, as management was supposed to check on these notices, but it was not assigned to a specific individual.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed-hold policy to residents and/or their representatives at the time of transfer to a hospital for six residents. This deficiency was identified through interviews and record reviews, revealing that none of the sampled residents received the required documentation. The facility census was 40, and the affected residents were transferred to the hospital on various dates without the necessary bed-hold policy notification. During an interview, the Assistant Director of Nursing and the Administrator acknowledged the expectation that bed-hold policies should be given for each hospital transfer or discharge. They indicated that the charge nurse responsible for transferring or discharging the resident should ensure the policy is provided. However, it was noted that there was no clear accountability, as management expected the policies to be placed under office doors and checked, but it was not solely one person's responsibility to ensure completion.
Failure to Update Care Plan for Resident with Recurrent Falls and UTIs
Penalty
Summary
The facility failed to update and revise care plans with specific interventions tailored to meet the individual needs of a resident, identified as Resident #22. The resident, who was admitted with diagnoses including dementia, dysuria, muscle weakness, repeated falls, and urinary tract infections (UTIs), experienced multiple falls and incidents that were not adequately addressed in the care plan. Despite the resident's recurrent falls and UTIs, the care plan had not been updated with new interventions since November of the previous year. The resident's medical records and nurses' notes documented numerous falls and incidents, including unwitnessed falls, falls from a wheelchair, and skin tears, yet the care plan did not reflect any new strategies to mitigate these risks. Observations showed that the resident's wheelchair cushion was improperly positioned, and there was no mention of nonskid footwear or assessments for UTIs, which were contributing factors to the resident's condition. The facility's policy required ongoing assessment and revision of care plans as changes occurred in the resident's condition, but this was not adhered to. Interviews with facility staff, including the Minimum Data Set (MDS) Coordinator and the Assistant Director of Nursing (ADON), revealed an expectation that the care plan should have been updated to address the resident's falls and recurrent UTIs. However, the responsibility for updating the care plans was not effectively executed, leading to a deficiency in the care provided to the resident.
Failure to Obtain Timely Urine Specimens Leads to Emergency Room Visit
Penalty
Summary
The facility failed to obtain timely urine specimens for a resident who exhibited symptoms of a urinary tract infection (UTI) and did not notify the physician when the specimens were not collected. This oversight resulted in the resident being sent to the emergency room. The resident, who had a history of dementia, dysuria, muscle weakness, repeated falls, and UTIs, had orders for urine analysis (UA) with culture and sensitivity (C&S) on multiple occasions, specifically on 03/19/24, 05/07/24, and 06/01/24. However, there was no documentation of completed UA lab results for these dates, nor was there any notification to the physician about the uncompleted orders. Interviews with facility staff revealed a lack of follow-through on lab orders and communication with the physician. The Assistant Director of Nursing (ADON) acknowledged that a specimen collected on 05/07/24 was rejected due to incorrect labeling, and no subsequent specimen was collected. The ADON also admitted that it was the nursing staff's responsibility to follow up on lab orders and results, which did not occur in this case. The physician expressed an expectation for the facility to follow orders and be notified if they were not completed. The failure to collect and process the urine specimens as ordered led to the resident's emergency room visit and subsequent diagnosis of a UTI.
Failure to Follow Oxygen Administration Orders
Penalty
Summary
The facility failed to adhere to physician's orders for oxygen administration for three residents, resulting in discrepancies in the oxygen flow rates. Resident #6, diagnosed with COPD and lung cancer, was observed receiving oxygen at higher flow rates than the prescribed 3 liters per minute (LPM). Despite the resident's awareness of the correct setting, the oxygen flow was consistently higher, reaching up to 5 LPM. Similarly, Resident #36, with diagnoses including pneumonia and respiratory failure, was observed receiving oxygen at 4 LPM and 3.5 LPM, contrary to the physician's order of 2 LPM. Additionally, the facility did not ensure that oxygen tubing was dated when changed for two residents. Resident #195, with pneumonia and atherosclerotic heart disease, was observed with undated oxygen tubing and a nasal cannula that was improperly stored. The resident's portable oxygen tubing was also undated and not stored in a sealed container. Resident #245, with multiple diagnoses including COPD and heart failure, was observed with undated oxygen tubing and a humidifier. The resident was also found without oxygen for an extended period due to the concentrator being turned off, despite having orders for continuous oxygen. The facility's policy on oxygen administration was not followed, as evidenced by the lack of adherence to prescribed oxygen flow rates and the failure to date oxygen tubing. These deficiencies were observed during multiple instances and interviews with the residents confirmed the discrepancies between the prescribed and administered oxygen settings. The facility's failure to comply with its own policy and physician orders resulted in inadequate respiratory care for the affected residents.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that two Certified Nurse Assistants (CNAs), identified as CNA G and CNA H, received their annual performance reviews. This deficiency was identified through interviews and record reviews. CNA G, who was hired on November 8, 2022, had no documentation of an annual performance review in their employee file for the period from November 8, 2022, to November 8, 2023. Similarly, CNA H, hired on September 5, 2019, also lacked documentation of an annual performance review for the period from September 5, 2022, to September 5, 2023. During an interview, the Administrator and Assistant Director of Nursing (ADON) acknowledged that annual performance reviews for CNAs should have been conducted, but none had been done since the current administrator started, and they were unaware of any previous reviews or their locations. Additionally, the facility did not provide a policy regarding annual training, despite the facility assessment dated March 7, 2024, indicating that staff competencies and annual training requirements should include topics such as Abuse, Neglect, Exploitation and Misappropriation, Care/Management for persons with dementia, Infection Control, Culture change, Person-centered care, Disaster planning, Communication, and Resident rights.
Failure to Reconcile Narcotics at Shift Change
Penalty
Summary
The facility failed to ensure that staff reconciled narcotics at each shift change for three out of three medication carts, potentially affecting all residents. The facility's policy required that all Schedule II-V medications be counted at every change of shift by two Certified Medication Technicians (CMT) or one CMT and one licensed nursing staff, with both personnel signing verification of the correct count. However, a review of the narcotic count logs for the 100/200, 300/400, and 500 Hall Nurse carts revealed numerous missed opportunities for reconciliation over several months, with many instances of no documentation of the narcotic reconciliation being completed. Interviews with staff, including a CMT and the Assistant Director of Nursing (ADON), confirmed that the expected practice was for the off-going and on-coming staff to complete the narcotic count and sign the log. The ADON stated that the narcotic counts should be completed at the beginning and end of each shift and any other time there was a change in the involved staff. Despite these expectations, the logs showed significant non-compliance with the policy, indicating a systemic issue in the reconciliation process.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to adhere to regulations regarding the use of psychotropic medications for several residents. Specifically, the facility did not limit the use of PRN orders for psychotropic medications to 14 days for two residents, and did not ensure an appropriate diagnosis or attempt a gradual dose reduction (GDR) for three residents. Resident #3 had a PRN order for lorazepam without a 14-day stop date, and Resident #33 also had a similar order without a stop date, along with an inappropriate diagnosis for quetiapine. Resident #5 had multiple psychotropic medications prescribed without a documented GDR evaluation since December 2022. Resident #31 had several psychotropic medications prescribed, but there was no documentation of GDR attempts or responses to pharmacy consultant recommendations. Interviews with facility staff revealed a lack of clarity and follow-through in the process of managing medication regimen reviews (MRRs) and GDRs. The Assistant Director of Nursing (ADON) and the Minimum Data Set (MDS) nurse were responsible for handling MRRs, but there was uncertainty about when GDRs should be completed. The Administrator acknowledged that MRRs were sent to physicians, but responses were not always received, and there was no effective system in place to ensure follow-up. This lack of coordination and oversight contributed to the deficiencies in managing psychotropic medication use in the facility.
Failure to Monitor Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to properly monitor refrigerator temperatures for stored medications, including insulin, which is used to treat diabetes. This deficiency was identified through interviews and record reviews, revealing that the facility did not consistently document refrigerator temperatures as required by their policy. The policy mandates that all refrigerators used for resident medication must be checked daily, with temperatures logged in a binder at the nurse's station. However, numerous instances of missed documentation were noted across several months, with significant gaps in April, May, June, and early July. Additionally, there were instances where recorded temperatures were outside the acceptable range of 36 - 42 degrees, specifically on July 1st and July 4th, without appropriate follow-up actions being taken. Interviews with the Assistant Director of Nursing (ADON) and the Administrator confirmed that the responsibility for checking and documenting refrigerator temperatures fell to the night charge nurse, with the ADON overseeing the logs. Despite this, the facility did not adhere to its policy, as evidenced by the lack of documentation and failure to address out-of-range temperatures. This oversight had the potential to affect all residents, given the importance of maintaining proper storage conditions for medications like insulin.
Failure to Establish Hospice Agreements
Penalty
Summary
The facility failed to establish a written agreement with hospice services for two residents out of eight sampled, despite both being admitted to hospice care. Resident #3 was admitted to hospice services on April 5, 2024, and Resident #33 on March 19, 2023. However, the facility did not provide hospice agreements with the respective hospice service providers for these residents. During an interview, the Administrator acknowledged that the facility typically completed one-time agreements with hospice providers that were not the primary company used by the facility. In these cases, the necessary one-time agreements were not completed upon the residents' admission to the hospice program.
Failure to Maintain Effective QAPI Program
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by the absence of policies and protocols necessary to identify and correct quality deficiencies. The facility's QAPI plan, dated September 2022, outlined the purpose and structure of the program, including the establishment of performance indicators and regular reporting by the QAPI Steering Committee. However, a review of the facility's QAPI binder revealed that the facility did not adhere to its own plan, as it lacked documentation of necessary policies and protocols for tracking and measuring performance, as well as setting goals and thresholds for performance measurement. The last documented QAPI meeting occurred several months prior, and the facility had not conducted any subsequent meetings, despite the requirement for quarterly meetings. During an interview, the Administrator confirmed that the last QAPI meeting was held in February, and acknowledged that the facility had not held any since. Although Quality Assurance and Assessment (QAA) meetings were reportedly conducted daily with department heads, the absence of regular QAPI meetings indicates a failure to follow the established plan, potentially affecting all 40 residents in the facility.
Failure to Implement Performance Improvement Projects
Penalty
Summary
The facility failed to ensure that the Quality Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies using a Performance Improvement Project (PIP). The facility's policy, dated September 2022, outlined that the QAPI committee should prioritize activities, endorse policies, and monitor improvements through a self-assessment. It also stated that the QAPI Steering Committee should implement PIP topics indicated by data analysis. However, a review of the QAPI binder showed no documentation of the required PIP documentation. During an interview, the Administrator admitted to not knowing what a PIP was and confirmed that no PIPs had been conducted since she became the administrator, with no documentation of previous PIPs available.
QAPI Committee Membership Deficiency
Penalty
Summary
The facility failed to maintain quarterly Quality Assurance and Improvement Program (QAPI) committee meetings with the required members. The facility's policy, dated September 2022, did not specify the necessary members for the QAPI committee. A review of the QAPI attendance sheets from February 21, 2024, revealed that the Director of Nursing (DON) did not attend the meeting. During an interview, the Administrator confirmed that the last QAPI meeting was held on February 21, 2024, and acknowledged the absence of a DON since November 2023. The QAPI committee required the DON to be a member, but the position had been vacant, leading to non-compliance with the committee's membership requirements.
Deficiencies in Infection Control and Documentation
Penalty
Summary
The facility failed to provide appropriate documentation of tuberculosis (TB) testing for four residents out of five sampled. This included missing annual screenings, improper timing between test administration and reading, and lack of documentation for two-step testing. These deficiencies indicate a lack of adherence to the guidelines for TB testing and documentation as required by the Missouri Department of Health and the facility's own policies. The facility also failed to perform proper hand hygiene and glove changes during wound care and incontinent care. In one instance, an LPN did not change gloves or perform hand hygiene when transitioning from dirty to clean care during wound treatment for a resident with a coccyx wound. Similarly, during incontinent care for another resident, CNAs did not change gloves or perform hand hygiene when moving from dirty to clean tasks, leading to potential cross-contamination. Additionally, the facility lacked a water management program to monitor for Legionella bacteria, which could affect all residents, staff, and the public. The Maintenance Supervisor was unaware of such a program and only checked water temperatures in random rooms. Furthermore, the facility's Infection Prevention and Control Program (IPCP) was outdated, lacking an annual review, and missing critical information such as pathogen names and lab results in the antibiotic stewardship logs.
Deficiency in Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to conduct at least twelve hours of annual in-service education for two Certified Nurse Assistants (CNAs), identified as CNA G and CNA H, as required by regulatory authorities and facility policy. CNA G, hired on November 8, 2022, had no documentation of any annual in-service training from November 2022 through November 2023. CNA H, hired on September 5, 2019, had documentation of eight topics covered in annual in-service training from September 2022 through September 2023, but there was no record of the duration of each training session. The facility's assessment, dated March 7, 2024, outlined the need for staff competencies and annual training in areas such as abuse, neglect, dementia care, and infection control, but the facility did not provide a policy regarding these annual training requirements. During an interview, the Administrator and Assistant Director of Nursing confirmed that aides should receive 12 hours of training annually, including specific topics like abuse, neglect, and dementia care.
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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