Dixon Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Dixon, Missouri.
- Location
- 403 East 10th Street, Dixon, Missouri 65459
- CMS Provider Number
- 265418
- Inspections on file
- 12
- Latest survey
- November 21, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Dixon Nursing & Rehab during CMS and state inspections, most recent first.
The facility did not have a qualified Infection Preventionist (IP) for its Infection Prevention and Control (IPC) program. The DON acknowledged the absence of a licensed IP and is working on hiring someone qualified. The administrator was unaware of the requirement for the IP to dedicate specific hours to infection prevention duties.
The facility failed to provide an ongoing activity program on weekends, affecting residents' mental and psychosocial well-being. The activity calendar showed limited options, with only movies and church services scheduled. Residents expressed dissatisfaction with the lack of engaging activities and the absence of activity staff on weekends. Interviews with staff confirmed the lack of staff-led activities, with the Activities Director and DON acknowledging the issue but citing a lack of available staff.
The facility failed to maintain the required RN coverage of eight consecutive hours per day, seven days a week, due to staffing shortages and scheduling issues. The DON, responsible for scheduling, was the only full-time RN, with one part-time RN, leading to coverage gaps on weekends. The administrator was unaware of the non-compliance due to a misunderstanding of shift timing and staffing challenges, despite efforts to recruit more staff.
The facility failed to implement policies for the Medication Regimen Review (MRR) process and did not communicate pharmacy recommendations to physicians for four residents. The MDS Coordinator did not receive or follow up on the MRR reports for September, leading to a lack of documentation and communication with physicians. Residents involved had various cognitive impairments and medical conditions, and their records lacked necessary documentation of pharmacist reports and physician responses.
Facility staff failed to follow proper hand hygiene and food storage practices. A Dietary Aide was observed handling soiled and clean wares without washing hands and improperly storing items in bulk food bins. The facility's guidelines lacked specific instructions on handwashing and food storage, contributing to these deficiencies.
Facility staff failed to follow policies for pneumococcal vaccinations, resulting in five residents not being assessed or vaccinated according to CDC guidelines. Despite signed consents, there was no documentation of the vaccine being offered, received, or refused. Interviews revealed a lack of awareness and documentation by the MDS Coordinator, DON, and administrator regarding the vaccination status of residents.
The facility failed to notify residents or their representatives of the bed hold policy during hospital transfers, as required by their guidelines. Medical records for four residents lacked documentation of such notifications. Interviews with staff, including an LPN, the DON, and the administrator, revealed a lack of awareness and execution of the policy, with some attributing the oversight to emergencies and the use of agency staff.
Facility staff failed to maintain a medication error rate below five percent, resulting in a 10.34% error rate due to improper insulin administration. A CMT did not prime Humalog Kwik Pens before administering insulin to three residents with Diabetes Mellitus, leading to potential dosing errors. The facility lacked a specific policy for insulin administration, contributing to the issue.
Facility staff failed to store medications safely, with insulin found in pooled water and controlled substances left unlocked. Insulin vials and pens on a medication cart were undated or expired, and staff lacked clarity on cleaning schedules and proper storage protocols.
The facility failed to ensure the activities program was directed by a qualified professional. The AD did not have the required certification, and the facility lacked a policy on AD qualifications. The AD was informed by the Administrator that certification was required after one year of employment. The DON was unaware of the AD's lack of certification and was not involved in the hiring process.
Facility staff failed to use a gait belt during a transfer, resulting in a resident being hospitalized with a shoulder injury. The resident, who required substantial assistance and was non-weight bearing, was lowered to the floor when their leg gave out, and staff heard a popping noise in the shoulder. Staff involved did not follow the facility's policy on gait belt use, and the incident was reported to the appropriate personnel.
Facility staff failed to document the administration of Milk of Magnesia for a resident who did not have a bowel movement for several days, despite a physician order. The facility's policy lacked guidance on documentation, and interviews revealed a lack of a system to audit daily reports. Staff were expected to follow physician orders and document bowel movements, but no medication was administered as required.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) to oversee its Infection Prevention and Control (IPC) program. The facility's policy requires an IP who is qualified through education, training, and experience, and who has completed the CDC Long Term Care Infection Preventionist module. However, during interviews, the Director of Nursing (DON) admitted that the facility currently lacks a licensed IP and is in the process of hiring someone qualified for the role. The DON also mentioned plans to complete the necessary modules to serve as a backup IP. Additionally, the administrator indicated that the DON and an agency employee are handling the IP role, but was unaware of the requirement for the IP to dedicate a specific number of hours to infection prevention duties.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing activity program designed to meet the residents' interests, mental, and psychosocial well-being on weekends for five out of 14 sampled residents. The facility's policy, dated March 2012, mandates an ongoing program of activities to meet these needs. However, the activity calendar for October and November 2024 showed only a movie on Saturdays and church on Sundays, with no other activities scheduled. Interviews with residents revealed dissatisfaction with the lack of weekend activities, with some describing the existing activities as childish and expressing a desire for more engaging options like Bible studies or social gatherings. Residents also noted the absence of activity staff on weekends, leading to a lack of structured activities. Interviews with facility staff, including CNAs, LPNs, the Activities Director, the DON, and the administrator, confirmed the absence of staff-led activities on weekends. The Activities Director mentioned setting out puzzles and coloring materials, but acknowledged no specific activities for residents with dementia or visual impairments. The DON and administrator were aware of the requirement for staff-led activities but cited a lack of available staff to conduct them. The administrator also noted that activities were intended to be self-directed on weekends, with occasional movies and church services, but was unaware of the need for staff-led activities during this time.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. The facility's RN staff schedule from May to November 2024 showed multiple instances where there was no RN coverage for the required duration on weekends. The facility census was 30, and the absence of RN coverage was noted on specific dates across several months, indicating a pattern of non-compliance with the regulatory requirement. Interviews with facility staff revealed that the Director of Nursing (DON) was responsible for maintaining the schedule and was aware of the requirement for RN coverage. However, the DON was the only full-time RN, with one part-time RN available, which contributed to the coverage gaps. The facility administrator acknowledged the regulation but was unaware that the coverage was not being met due to a misunderstanding of shift timing and challenges in staffing. Efforts to recruit additional staff were mentioned, including using a new hiring platform and advertising through radio and online platforms.
Failure to Implement Medication Regimen Review Policies
Penalty
Summary
The facility failed to develop and implement policies and procedures to address appropriate timeframes for the Medication Regimen Review (MRR) process and failed to communicate pharmacy recommendations to the physician for four residents. The MDS Coordinator did not receive the MRR reports for September from the pharmacy and did not follow up with the Director of Nursing (DON) or the pharmacist, resulting in a lack of communication with the physician. The facility did not have a specific written policy to address the timeframes for the MRR process, although staff had been in-serviced on what to do. Resident #2, who was severely cognitively impaired and had multiple diagnoses including Traumatic Brain Injury and Schizophrenia, did not have documentation of the pharmacist's report or the physician's response to recommendations in their medical record. Similarly, Resident #4, who was moderately cognitively impaired with diagnoses such as anemia and Heart Failure, also lacked documentation of the pharmacist's report or physician's response. Resident #12, who was cognitively intact with conditions like High Blood Pressure and Diabetes Mellitus, had a blank Section N2001 and no documentation of the pharmacist's report or physician's response. Resident #19, who was severely cognitively impaired with diagnoses including Alzheimer's Disease and Stroke, also had a blank Section N2001 and lacked documentation of the pharmacist's report or physician's response. Interviews with facility staff revealed that the MDS Coordinator was responsible for communicating the MRR reports to the physician and documenting them in the electronic medical record (EMR). However, the MDS Coordinator did not receive the reports for September and did not follow up, resulting in the reports not being communicated to the physician. The DON and the administrator were not aware that the reports were not being addressed or uploaded to the residents' EMR. The facility's corporate Quality Assurance nurse confirmed the absence of a specific written policy for the MRR process timeframes.
Deficiencies in Hand Hygiene and Food Storage Practices
Penalty
Summary
The facility staff failed to adhere to proper hand hygiene practices, as observed during multiple instances involving a Dietary Aide (DA) identified as F. DA F was seen handling soiled kitchen wares with bare hands and subsequently handling clean wares without washing hands. This included activities such as precleaning soiled wares, handling clean silverware, and preparing drinks for residents. Additionally, DA F was observed opening a trash can with bare hands and then handling clean items without washing hands. The facility's handwashing guidelines, dated May 2015, did not specify when staff should wash their hands, contributing to the deficiency. The facility also failed to store food in a manner that prevents potential contamination. Observations revealed that bulk food storage bins contained inappropriate items such as a foam cup in a sugar bin and a metal scoop in a flour bin. These items were not supposed to be stored in the bins, as confirmed by staff interviews. The facility's policies lacked guidance on bulk food storage, which contributed to the improper storage practices observed. Interviews with staff and the Corporate Quality Assurance nurse confirmed the expectations for hand hygiene and food storage, which were not met in these instances.
Failure to Administer Pneumococcal Vaccines as per Policy
Penalty
Summary
The facility staff failed to adhere to their policies and procedures for the immunization of residents against pneumococcal disease, as recommended by the CDC. Specifically, five residents, all over the age of 65, were not assessed or vaccinated according to the guidelines. The facility's policy requires consultation with the resident's physician to determine the need for vaccinations and mandates that pneumococcal vaccinations be administered to adults aged 65 and older unless contraindicated. However, the medical records of these residents showed that although they had signed consents for the pneumococcal vaccine, there was no documentation indicating that they were offered, received, or refused the vaccine. Interviews with facility staff, including the MDS Coordinator, DON, and the administrator, revealed a lack of awareness and follow-through regarding the vaccination status of residents. The MDS Coordinator acknowledged responsibility for checking immunizations upon admission but admitted to not documenting refusals in the preventative health tab. The DON and the administrator both expressed expectations that vaccines should be administered within a week of admission if not previously received and that refusals should be documented. However, they were unaware that several residents had not received their pneumococcal vaccines, indicating a breakdown in communication and procedure adherence within the facility.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility staff failed to provide written notification of the bed hold policy to residents or their representatives at the time of transfer to a hospital for four residents. The facility's policy requires that residents and their representatives be informed of the bed hold guidelines upon admission, during hospital transfers, and at the time of non-covered therapeutic leave. However, the medical records for these residents did not contain documentation that such notifications were provided when they were discharged and subsequently readmitted. Interviews with facility staff revealed a lack of awareness and execution of the bed hold policy. An LPN admitted to not knowing the policy specifics, while the DON acknowledged that the charge nurse is responsible for ensuring the policy is followed but was unaware it was not being done. The administrator also noted that the nurse responsible for sending a resident out should handle the bed hold process but suggested that emergencies might have led to oversight. The facility's use of agency staff was mentioned, with an assumption that they had been educated on the policy.
Failure to Prime Insulin Pens Leads to Medication Errors
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than five percent, resulting in a 10.34% error rate. This was observed during the administration of insulin using Humalog Kwik Pens to three residents. The errors occurred because the Certified Medication Technician (CMT) did not prime the insulin pens before administering the insulin, as required by the manufacturer's instructions. The lack of priming could lead to incorrect dosing due to air bubbles in the pen. The facility did not have a specific policy for insulin administration, which contributed to the errors. Resident #4, #12, and #26, all diagnosed with Diabetes Mellitus, were affected by these errors. Each resident received insulin injections as part of their treatment plan. The CMT administered insulin without priming the pen, contrary to the manufacturer's guidelines, which state that priming is necessary to ensure the correct dose is delivered. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that priming should occur before each administration to avoid medication errors.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility staff failed to store medications safely and effectively, as observed in the medication storage room and on a medication cart. An observation revealed an unopened box of insulin medications with an illegible label saturated in a pool of water inside the medication room refrigerator. Interviews with the Director of Nursing (DON) and Certified Medication Technicians (CMTs) indicated a lack of clarity regarding the cleaning schedule for the medication refrigerators, which are supposed to be cleaned at the end of each month and as needed. The DON acknowledged that water should not be pooled inside the refrigerators. Additionally, the medication room was found unlocked, with an unlocked refrigerator containing controlled substances such as Lorazepam and an opened bottle of Whisky. The DON and other staff members confirmed that controlled substances should be stored behind double locks to prevent unauthorized access. However, the refrigerator was left open, and the staff did not provide a clear explanation for this oversight. Furthermore, the 200/400 hall medication cart contained several insulin vials and pens that were either undated, past expiration, or had illegible open dates. Interviews with CMTs and an LPN revealed that insulin should be labeled with the open date and is considered expired 28 days after opening. The staff responsible for administering insulin are expected to check expiration dates and discard expired medications. However, there was no system in place to double-check and ensure expired medications were removed from the medication carts.
Unqualified Activities Director
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional. The facility's policies did not include a policy regarding the qualifications for the Activity Director (AD) position. During an interview, the AD admitted to not having an activities director certification and stated that the Administrator informed them they needed to work at the facility for one year before obtaining certification. The Director of Nursing (DON) was unaware that the current AD was not certified and acknowledged that there were trainings available for certification but was not involved in the hiring process. The Administrator mentioned being told by the Director of Operations that the AD needed to work for one year before getting certified.
Failure to Use Gait Belt Results in Resident Injury
Penalty
Summary
Facility staff failed to use a gait belt to transfer a resident from a bedside commode to a chair, resulting in the resident being sent to the hospital with a significant injury. The resident was assessed as cognitively intact and required substantial to maximal assistance from staff with transfers, being non-weight bearing. During the transfer, the resident's leg gave out, and staff lowered the resident to the floor, hearing a popping noise in the resident's left shoulder. The facility's policy on gait belt use was not followed, as staff did not use a gait belt during the transfer. CNA B and CNA C were involved in the transfer and did not utilize a gait belt, despite the resident's known need for assistance. CNA B mentioned that the resident had refused the use of a gait belt in the past, but was unaware of the proper protocol to follow in such situations. Interviews with staff, including the LPN, MDS Coordinator, Administrator, and DON, confirmed that the resident required two-person assistance for transfers, which should have included the use of a gait belt or mechanical lift. The staff involved in the incident did not use a gait belt and instead placed their hands under the resident's arms, leading to the injury. The incident was reported to the appropriate personnel, and the resident was assessed and transferred to the hospital.
Removal Plan
- Facility staff investigated the cause of the resident's injury.
- In-serviced staff on how to perform a safe transfer of a resident with a gait belt.
- Staff corrected the deficient practice.
Failure to Document Medication Administration for Resident
Penalty
Summary
Facility staff failed to document the administration of medication for a resident, leading to a deficiency in meeting professional standards of quality. The facility's policy on physician orders lacked specific guidance on documenting medication administration. A resident, assessed as cognitively intact, had a physician order for Milk of Magnesia to be administered if they did not have a bowel movement in three days. However, the Medication Administration Record (MAR) showed no administration of the medication from September 20 to September 27, despite the resident not having a bowel movement during this period. Interviews with facility staff, including an LPN, CNA, MDS Coordinator, Administrator, and DON, revealed that staff were expected to follow physician orders and document bowel movements every shift. The nighttime charge nurse was responsible for printing a daily bowel movement report, which the day charge nurse would review. However, there was no documentation of medication administration after the resident did not have a bowel movement for over three days, and no system was in place to audit the daily reports. The deficiency was identified as a failure to follow physician orders and ensure proper documentation and administration of medication.
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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