Edgewood Manor Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Raytown, Missouri.
- Location
- 11900 Jessica Lane, Raytown, Missouri 64138
- CMS Provider Number
- 265425
- Inspections on file
- 29
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Edgewood Manor Health Care Center during CMS and state inspections, most recent first.
Two residents were not protected from misappropriation and exploitation of their personal funds by staff. One resident, cognitively intact but with Lewy body disease and anxiety, authorized a $400 withdrawal from a trust account for a recliner; the money was given to a social services director, no chair was ever delivered, no refund was documented, and the resident later reported that the staff member had taken the money. Another cognitively intact resident with COPD, morbid obesity, and cirrhosis, who had a known history of giving money to others, was able to provide large sums of cash and debit card access to staff to help with rent, utilities, and a trip, with another resident assisting in accessing the lockbox and handing over funds while stating the PIN aloud. Multiple staff and resident statements, along with law enforcement reports, described and corroborated these transactions, and the facility’s investigation substantiated misappropriation of funds at the facility level.
The facility did not ensure that ordered laboratory tests were completed for three residents with complex medical conditions, despite physician orders and an integrated EMR system. Staff and laboratory representatives confirmed that lab work was not performed as scheduled, and no results were documented in the residents' records.
The facility did not ensure a clean and comfortable environment, as evidenced by unswept dining room floors, dirty carpets, unclean resident rooms and bathrooms, and persistent urine odors. Staff and residents reported inconsistent cleaning, with some rooms not cleaned for extended periods. Housekeeping was understaffed, lacked written schedules, and could not keep up with daily and deep cleaning tasks, resulting in unsanitary conditions throughout the facility.
A resident with a history of borderline intellectual functioning and paranoid schizophrenia was physically abused by another resident diagnosed with alcohol abuse and adjustment disorder. During a smoke break, one resident struck another on the buttocks twice, with the second strike causing pain and emotional distress. The incident was reported immediately, confirmed by video footage, and determined to be abuse under the facility's policy.
A resident with intellectual disabilities and mental health disorders was subjected to verbal and physical abuse by an LPN and a CNA after requesting a snack. The LPN escalated the situation by slamming a snack container and using derogatory language, while the CNA physically restrained and struck the resident during the altercation. Multiple staff witnessed the incident but did not intervene, and the staff failed to use appropriate de-escalation techniques.
Staff failed to report an incident where a resident, with a history of mental health and cognitive conditions, was involved in a physical altercation with an LPN and several CNAs at the nurse's station. The event, witnessed by multiple staff, included inappropriate language, physical pushing, and a physical confrontation, but was not reported as abuse in accordance with facility policy. Interviews revealed staff either did not recognize the actions as abuse or assumed others would report, resulting in incomplete and delayed reporting.
A facility failed to ensure staff were properly trained to address the behavioral health needs of a resident with intellectual and mental health diagnoses. Despite care plan interventions requiring non-physical de-escalation, staff engaged in a physical and verbal altercation with the resident after failing to redirect or manage escalating behavior appropriately. Staff interviews revealed confusion about behavioral interventions and a lack of consistent training, contributing to the incident.
The facility operated its van for resident transport without current licensing, title, or required inspections, despite staff and corporate awareness of the issue. A resident dependent on dialysis was regularly transported in the van, which had expired tags, no proof of insurance, and an uninspected lift. Staff interviews and documentation confirmed ongoing use of the van without resolving its legal and safety deficiencies.
A resident identified as a fall risk suffered a tibial fracture after an Agency CNA attempted a solo transfer without using the required sit-to-stand lift and two-person assistance. The facility's policies on safe handling and fall prevention were not followed, and the fall investigation was incomplete. Staff interviews revealed a lack of communication and documentation regarding the resident's transfer needs.
The facility failed to ensure proper medication management and storage, with medication carts left unlocked and containing non-medical items. Narcotic counts were not consistently verified, leading to discrepancies in records. Additionally, medication refrigerators were not maintained within the required temperature range, with inadequate documentation and corrective actions.
The facility was cited for multiple food safety and sanitation deficiencies, including unclean walk-in refrigerator and freezer floors, lack of operable thermometers, and failure to prevent foreign materials in food. Damaged foodstuffs were not properly separated, and cutting boards and utensils were not maintained in good condition. Additionally, hot food temperatures were not consistently measured or documented, and trash dumpsters were not kept lidded.
The facility failed to maintain a comprehensive infection prevention and control program, including deficiencies in managing Legionella and tuberculosis screening for new employees. Staff did not practice Enhanced Barrier Precautions (EBP) for residents with specific medical conditions, and hand hygiene practices were insufficient. The facility lacked necessary policies and documentation of infection control training.
The facility did not designate a qualified Infection Preventionist (IP) for its Infection Prevention and Control program. The MDS Coordinator, who worked part-time as the IP, had not completed the CDC's IP course and was not certified. Despite the DON and Administrator being certified, the MDS Coordinator lacked the necessary training and certification.
The facility failed to maintain a safe and homelike environment, with issues such as a missing plumbing cover creating a tripping hazard, lack of Braille on room numbers in certain halls, and damaged furniture and fixtures in resident rooms. Interviews revealed delays in addressing these deficiencies due to the need for corporate approval for replacements.
The facility failed to accurately assess the dental status of two residents and address unintended weight changes for another. One resident had multiple dental issues not reflected in the MDS, while another had missing teeth undocumented. Additionally, a resident experienced significant weight fluctuations without proper documentation or follow-up, indicating a lack of communication and care planning.
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their specific needs. A resident's care plan did not include dental interventions despite poor dental condition, while another's care plan lacked focus on diabetes and mental health issues despite high-risk medication use. Additionally, a resident's dental issues were overlooked, and another's skin and wound care needs were not addressed, indicating a lack of communication and assessment by the staff.
A facility failed to notify a resident about care plan meetings and did not update care plans for falls, pain, and infections for several residents. A resident with cognitive impairments was unaware of care plan meetings, while another experienced multiple falls without corresponding care plan updates. Additionally, residents with recurrent infections and chronic pain lacked comprehensive care plans addressing their conditions.
The facility failed to provide the required 12 hours of annual in-service training for CNAs, as per their policy. A review showed that none of the CNAs received the necessary training, including dementia care and behavioral training. Interviews revealed inconsistencies in the training process, with CNAs reporting irregular in-service meetings and reliance on review sheets. The DON acknowledged the training requirements, but records did not reflect compliance.
The facility failed to post complete daily nurse staffing information, omitting the total hours worked and facility census. Observations showed that staffing sheets in common areas and nursing stations lacked these details, and some areas had no posted staffing. Interviews confirmed the absence of required information, which could affect residents, staff, and visitors.
The facility failed to notify residents and their representatives of hospital transfers in writing and did not inform the Ombudsman for three residents. The facility's policy requires written notification and Ombudsman notification for transfers, but these were not documented for the residents involved. Staff interviews revealed a lack of awareness and responsibility for these notifications.
The facility failed to provide bed hold notifications to three residents upon transfer to a hospital, as required by policy. For one resident, there was no documentation of a bed hold policy when sent to the ER. Another resident was discharged to a hospital twice without receiving a bed hold policy, confirmed by the resident. A third resident requested hospital transport, but no bed hold policy was documented. Staff interviews revealed inconsistencies in the process of providing and documenting bed hold policies.
The facility failed to provide the required NOMNC and SNF ABN to two residents discharged from Medicare Part A services. The deficiency occurred because the facility's policy lacked instructions to issue these notices at least two days before coverage ended, and there was no designated staff to provide them during the absence of a Social Services Director.
A resident's MDS was inaccurately completed, failing to document missing teeth and dental issues upon admission. The resident, who had difficulty chewing and desired dentures, had not seen a dentist since admission. Interviews revealed that the MDS Coordinator and DON were unaware of the dental concerns, although they acknowledged that dental assessments should be part of the initial clinical admission assessment.
A resident in an LTC facility experienced a significant decline in health, including a blood infection, a fall, and weight loss, but the facility failed to complete a required significant change assessment. The resident, who was previously independent, now required a wheelchair and more assistance. Interviews with staff confirmed the oversight.
A resident in an LTC facility was found to be self-administering inhalers and nebulizer treatments without a physician's order or evaluation. The resident experienced delays in receiving medications, with some administered outside the prescribed time frame. Additionally, the facility ran out of the resident's pain medication, leading the resident to call 911 for pain control. Despite receiving two pharmacy deliveries a day, the facility failed to ensure the availability of prescribed medications.
A facility failed to follow physician's orders for PT/INR lab draws for a resident on Coumadin, missing 23 lab results over several months. The resident, with a history of DVT and other conditions, was supposed to have labs drawn twice weekly. Interviews revealed a lack of awareness and communication among staff regarding the lab schedule.
A resident with morbid obesity and lower extremity dysfunction did not receive necessary podiatry care despite multiple requests and staff awareness. The resident experienced pain from long toenails and had not seen a podiatrist since admission. Staff, including CNAs, an LPN, and the DON, were aware of the need but failed to ensure an appointment was made. The Social Services Director, responsible for scheduling, was unaware of the need, and no documentation was available to support the resident's request.
A facility failed to ensure proper communication and assessment for a resident with ESRD requiring dialysis. The resident's care plan lacked specific orders for post-dialysis assessments, and staff were unaware of necessary protocols. The dialysis communication binder was missing, leading to inconsistent communication with the dialysis center. The DON and RDO acknowledged the expectations for communication and assessment, but the facility did not maintain these protocols, resulting in a deficiency.
The facility failed to ensure that pharmacist recommendations from the Medication Regimen Review (MRR) were reviewed and responded to by physicians for two residents. One resident, with type 2 diabetes and gout, had no physician response to a recommendation for uric acid level monitoring. Another resident, with cognitive impairment and epilepsy, also had unaddressed recommendations. The DON was unaware of the recommendations in the EHR, and the consultant pharmacist noted delays in addressing recommendations.
Two residents in the facility did not receive necessary dental services, despite documented dental issues and expressed needs for care. One resident had multiple missing and discolored teeth, with a dentist recommending extractions that were not scheduled. Another resident had missing teeth and wanted dentures, but their dental needs were not documented or addressed. Facility staff, including the DON and SSD, were unaware of these issues, leading to deficiencies in the residents' care.
A facility failed to document and monitor hospice care for a resident with dementia and Alzheimer's, lacking records of hospice staff visits, a care plan, and physician details. Interviews revealed staff were unaware of hospice visits, and the DON admitted all hospice care information should be documented, highlighting a deficiency in hospice care management.
The facility failed to ensure that two residents received or were educated about pneumococcal vaccinations, as required by policy. Documentation of vaccine status was missing in their medical records. Interviews revealed that the DON was responsible for ensuring immunizations, and the process for offering and administering vaccines needed improvement.
The facility failed to document the COVID-19 vaccine offer and status for two residents, as required by their policy. The DON was responsible for ensuring immunizations were done and documented in the EHR. Despite procedures to offer the vaccine within the first week of admission, there was no documentation for these residents, indicating a lapse in protocol.
A resident's wallet containing approximately $1100 was misappropriated after being found in the laundry by the EVS manager. The wallet was placed in the facility's safe by the social worker without counting the money. Conflicting reports about the amount of money were given by staff, and the resident's bank records confirmed withdrawals totaling $1100. The facility's policies on resident rights and abuse and neglect were not adequately followed, leading to the misappropriation.
A resident with mental health diagnoses was subjected to undignified treatment when an agency CNA slapped their hand and made inappropriate comments during incontinence care. The resident, dependent on staff for daily needs, confirmed the incident, stating they were not hurt or scared. The facility's policy emphasized treating residents with dignity, which was not upheld in this case.
A resident with schizophrenia and seizures eloped from the facility without staff knowledge, due to inadequate monitoring and failure to follow elopement protocols. The resident was found the next morning at a family member's house.
The facility failed to protect a resident from abuse when another resident with a history of severe mental illness and aggressive behavior struck them on the head. Despite signs of escalating behavior, the aggressive resident was not sent for a psychiatric evaluation, leading to the incident and resulting in physical harm to the victim.
A facility failed to provide appropriate treatment for a resident with multiple mental disorders who consistently refused medications, leading to an assault on another resident. Despite documented medication refusals and escalating behaviors, the facility did not take adequate preventive measures or ensure the safety of other residents.
Failure to Protect Residents From Misappropriation and Exploitation of Personal Funds
Penalty
Summary
The deficiency involves failures to protect residents from misappropriation and exploitation of their personal funds by facility staff. One cognitively intact resident with Lewy body disease and anxiety authorized a $400 withdrawal from their trust account for a recliner chair. The Business Office Manager (BOM) issued a trust check for this amount and gave it to the Social Services Director (SSD) to purchase the chair. The SSD later told the BOM that a recliner had been ordered through the SSD’s personal Amazon account, that it was of poor quality, and that it had been returned with an $80–$86 restocking fee, but no documentation of this transaction or any refund was found. No recliner was ever delivered to the resident, and no funds were ever redeposited into the resident’s trust account. Over several months, the BOM repeatedly inquired by email and phone about the status of the chair or the funds, but the SSD did not respond. The resident became distressed, reporting to staff, hospice, and visitors that the SSD had taken their money, and law enforcement was notified; the facility’s investigation substantiated misappropriation of funds at the facility level. A second cognitively intact resident with COPD, morbid obesity, and cirrhosis had a documented history of willingly providing money to staff and others, with a care plan directing staff to provide protective oversight, financial safety review, and supervision of access to the resident’s lockbox. Despite this, the resident was able to give substantial sums of money and access to financial instruments to staff. The resident reported giving a CNA approximately $1,300 (including $1,000 in cash and additional amounts via debit card) to help with rent and utilities after receiving text messages about possible eviction, and also giving money for a staff member’s trip. Another resident, who was in a relationship with this resident, stated that they accessed the resident’s lockbox at the resident’s request, counted out $1,000 in cash, and handed it to a housekeeper for the CNA, and later handed the resident’s debit card to the CNA and housekeeper while stating the PIN aloud so staff could hear it. The resident explained in a written statement that they gave money because they felt unloved, had been abused all their life, and believed helping people made them nicer to them. Additional information from staff and residents corroborated that the second resident had given large sums of money to staff. A certified medication technician and an LPN both reported hearing the resident state that they had given the CNA $1,000–$1,300 for rent and that the resident was worried the CNA would get into trouble. Another resident reported being upset that the resident was giving money to staff and described witnessing the cash and debit card transactions. The facility’s Registered Nurse Investigation documented that the DON was notified that a resident had reported seeing the second resident give money to staff, that police were contacted, and that officers interviewed involved parties and confirmed the resident had voluntarily provided money to staff on multiple occasions. The facility concluded there was a strong possibility that the alleged misappropriation incidents involving the CNA, housekeeper, and activity assistant had occurred, and law enforcement reports described the situation as larceny involving staff taking approximately $1,000 from the resident.
Failure to Provide Ordered Laboratory Services
Penalty
Summary
The facility failed to ensure that laboratory services were provided as ordered by physicians for three residents. These residents had multiple physician orders for diagnostic blood tests, including Complete Metabolic Panel (CMP), Lipid Panel, Glyco-HbA1c, Thyroid Stimulating Hormone (TSH), Complete Blood Count (CBC), Vitamin D, and Iron studies, all scheduled to be drawn on specific dates. Upon review of the residents' electronic medical records, there were no results for these ordered lab tests, indicating that the tests were not completed as required. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and a Licensed Practical Nurse (LPN), revealed that the facility was experiencing ongoing issues with their contracted laboratory service. Staff reported that lab technicians sometimes did not come to the facility as scheduled, and in some cases, only a few lab orders were completed during visits. The facility's EMR system was integrated with the laboratory's system, and staff were responsible for entering lab orders, but despite this, the lab work for the affected residents was not performed. The laboratory's regional manager confirmed that there were no visible orders or completed results for the residents in question. The residents involved had significant medical histories, including diabetes mellitus, vascular dementia, pulmonary emphysema, quadriplegia, cerebral infarction, and paraplegia. The lack of completed laboratory testing was confirmed by both facility staff and the laboratory service, with staff acknowledging that the issue was known and ongoing. The deficiency was limited to the failure to provide ordered diagnostic testing and maintain appropriate documentation in the residents' medical records.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations, interviews, and record reviews. Housekeeping practices were inconsistent and insufficient, resulting in unsanitary conditions throughout the facility. Specific issues included unswept and unmopped dining room floors, uncleaned carpets in common areas, dirty resident rooms and bathrooms, and persistent urine odors. Observations revealed dust, debris, and grime in resident rooms, bathrooms, and hallways, as well as food, trash, and spills left unaddressed in the dining room. The courtyard and smoking area were also littered with cigarette butts, and several areas had visible build-up and stains that were not being regularly cleaned. Interviews with staff and residents confirmed these deficiencies. Family members and residents reported that rooms were not being cleaned regularly, with some unable to recall the last time their rooms had been cleaned. Staff interviews revealed that the housekeeping team was understaffed, with recent reductions in personnel and the elimination of the floor technician position. Housekeepers reported being unable to keep up with daily cleaning tasks, often prioritizing trash removal and smoke breaks over thorough cleaning. Deep cleaning was only performed when residents moved out, and some rooms were never deep cleaned. The Housekeeping Supervisor admitted to a lack of written cleaning schedules and infrequent monitoring of cleaning activities. The facility's own policies and job descriptions outlined clear expectations for daily and deep cleaning, including specific procedures for cleaning resident rooms, bathrooms, common areas, and carpets. However, these procedures were not being followed, and documentation of cleaning activities was lacking. The Environmental Services Director and Administrator acknowledged the unsanitary conditions, the absence of job descriptions in employee files, and the need for more thorough cleaning throughout the facility. Residents with medical conditions such as muscle weakness, chronic pain, and urinary retention were living in these unclean environments, with some rooms containing blood stains, urine, and feces that were not promptly addressed.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. During a scheduled smoke break, one resident touched another on the shoulder and then struck the resident on the buttocks twice, with the second strike being harder and causing pain. The affected resident immediately reported the incident to the charge nurse, stating that the contact was inappropriate and made them feel violated. The incident was witnessed on video footage, and the resident who committed the act was found to be intoxicated at the time. The resident who was abused had a history of borderline intellectual functioning and paranoid schizophrenia but was assessed as cognitively intact. The resident who committed the abuse had diagnoses of alcohol abuse and adjustment disorder and was also assessed as cognitively intact. The abused resident reported that the incident triggered memories of a previous sexual assault and described the contact as sexual in nature due to its inappropriateness. The resident also noted the smell of alcohol on the other resident's breath and observed signs of intoxication. The facility's abuse and neglect policy defines abuse as the willful infliction of injury or pain, including resident-to-resident altercations. The investigation determined that the incident constituted abuse, as the contact was both unwanted and caused physical pain and emotional distress to the resident. The facility's records and interviews confirmed the sequence of events and the impact on the resident involved.
Failure to Protect Resident from Verbal and Physical Abuse by Staff
Penalty
Summary
Facility staff failed to protect a resident from verbal and physical abuse by two staff members, an LPN and a CNA. The incident began when the resident, who had a history of intellectual disabilities, bipolar disorder, anxiety disorder, and major depressive disorder, requested a snack at the nurse's station. After being told there were no snacks, the LPN slammed the snack container, which escalated the resident's agitation. The LPN and the resident exchanged derogatory language, with the LPN telling the resident to "get your ass down there" and the resident responding in kind. The situation escalated further when the resident approached the LPN, and the LPN pushed the resident. Multiple staff members were present and observed the interaction but did not intervene. The CNA then physically intervened by grabbing the resident in a bear hug from behind and attempting to remove the resident from the area. The resident became more agitated, cursed at the CNA, and attempted to swing at the CNA. The CNA responded by swatting at the resident's fists and then struck the resident in the face. Video footage confirmed that both the LPN and CNA made physical contact with the resident, and that the altercation was witnessed by several staff members who did not take action to stop or report the abuse at the time. Interviews with staff and residents confirmed that the staff used inappropriate language and physical force against the resident. The resident reported being punched in the face and expressed distress over the incident. Witnesses described the staff's actions as abusive, with the DON and Nurse Practitioner both categorizing the incident as abuse. The staff failed to use appropriate de-escalation techniques and instead engaged in and escalated the confrontation, resulting in both verbal and physical abuse of the resident.
Failure to Report Staff-to-Resident Abuse Incident
Penalty
Summary
Facility staff failed to report an incident of abuse involving a resident who was cognitively intact and had a history of bipolar disorder, anxiety disorder, mild intellectual disabilities, cognitive communication deficit, and major depressive disorder. The incident, captured on video, occurred at the nurse's station and involved multiple staff members, including an LPN and several CNAs, who witnessed or participated in the altercation. The video showed the LPN using inappropriate language towards the resident, pushing the resident, and a CNA physically restraining and later engaging in a physical altercation with the resident. Other staff members were present and observed the incident but did not intervene or report the actions as abuse. Despite the facility's policy requiring immediate reporting of all allegations or suspicions of abuse, neglect, or exploitation to the Administrator and appropriate authorities, none of the staff involved reported the staff-to-resident altercation as abuse. Interviews revealed that staff either did not recognize the actions as abuse, assumed others would report, or believed that what was reported was sufficient. The DON and Administrator were not informed of the full extent of the incident, specifically that staff had physically engaged with the resident, until after reviewing video footage. The deficiency was further evidenced by staff interviews indicating a lack of understanding regarding what constitutes abuse and the proper reporting procedures. Staff reported only that the resident had hit a CNA, omitting the fact that staff had also physically engaged with the resident. The incident was not reported in accordance with facility policy or regulatory requirements, and the full details only came to light after administrative review of the video footage.
Failure to Train Staff on Behavioral Health Needs and De-escalation
Penalty
Summary
The facility failed to ensure that staff were adequately trained and competent to meet the behavioral health needs of a resident with known intellectual and mental health diagnoses. Staff training records revealed that while some CNAs had completed training related to challenging behaviors, several LPNs had no documentation of such training. Additionally, there was no evidence of staff in-services regarding the resident's behavioral history or direct training on behavioral interventions, such as recognizing triggers, redirection, and de-escalation, prior to a significant incident involving the resident. The resident involved had multiple diagnoses, including bipolar disorder, anxiety disorder, mild intellectual disabilities, and major depressive disorder. The care plan outlined specific interventions for managing behaviors related to these conditions, such as using calm and gentle approaches, providing positive reinforcement, and avoiding power struggles. Despite these documented interventions, staff responses during a behavioral incident did not align with the care plan or facility policy. Video footage and interviews showed that staff engaged in physical and verbal altercations with the resident, including pushing, hitting, and using inappropriate language, rather than employing non-physical, de-escalation techniques as required by policy. Interviews with staff and residents indicated a lack of understanding and consistency in managing the resident's behaviors. Several staff members were unsure of the resident's behavioral history or how to appropriately redirect or de-escalate situations. Some staff did not recognize repeated requests for snacks as a behavior requiring intervention, and there was confusion about what constituted appropriate redirection. The incident escalated due to staff actions that contradicted both the resident's care plan and facility policies, ultimately resulting in a physical confrontation.
Facility Van Operated Without Legal Licensing, Title, or Required Inspections
Penalty
Summary
The facility failed to ensure its van was legally licensed and properly maintained in accordance with Federal, State, and local laws, as well as accepted professional standards. Documentation revealed that the van's license tags had been expired for four years, and the title had not been transferred when the facility was purchased. Multiple emails between the Administrator, Director of Finance, Regional Nurse Consultant, and corporate legal representatives confirmed ongoing issues with obtaining a title and legal registration for the van. Despite these issues, the van continued to be used for resident transport, with invoices showing ongoing maintenance such as brake service, tire replacement, and air conditioner repairs, but no evidence of legal licensing or inspection was provided. Interviews with staff, including van drivers and the Administrator, indicated a lack of clarity and responsibility regarding the van's legal status, insurance, and maintenance records. One van driver stated the van had not been inspected, was not insured to their knowledge, and the lift had not been inspected as required every six months. The Administrator was unable to provide documentation for insurance or maintenance and acknowledged the van had not been legal for operation since their employment began. The Regional Nurse Consultant and Corporate Legal Representative confirmed the van was inherited from the previous owner without a title, and efforts to resolve the issue were ongoing but unresolved. A resident who was dependent on renal dialysis and had hemiplegia reported being transported in the facility van three times per week. Observations confirmed the van had expired license plates and lacked current inspection stickers. Staff expressed concerns about the safety and legality of the van, including the condition of the lift and illuminated engine and service lights. No legal documents for title, licensing, inspection, or insurance were found in the van, and maintenance documentation was limited to air conditioner service. The deficiency affected all residents requiring transport, as the van was in regular use despite its unresolved legal and safety status.
Failure to Ensure Safe Transfer Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure the safety of a resident identified as a fall risk, resulting in a fall and a closed right-sided tibial fracture. The incident occurred when an Agency Certified Nursing Assistant (CNA) attempted to transfer the resident alone, despite the resident's care plan indicating the need for a sit-to-stand lift with two-person assistance. The resident, who was morbidly obese and had difficulty walking, was being transferred from a shower chair to a toilet when the fall occurred. The CNA was unaware of the resident's transfer orders and did not use the required equipment or assistance. The facility's policies on safe resident handling and fall prevention were not followed, as the CNA did not use a mechanical lift or have a second staff member present during the transfer. Additionally, the facility failed to complete a thorough fall investigation, as there was no documentation of witness statements or a root cause analysis. The resident's care plan did not clearly document the transfer technique, and there was a lack of communication between the therapy department and facility staff regarding the resident's transfer orders. Interviews with facility staff revealed inconsistencies in the understanding and communication of the resident's transfer needs. The Occupational Therapy Assistant and other staff members indicated that the resident required a sit-to-stand lift with two-person assistance, but this information was not effectively communicated or documented in the resident's care plan. The Director of Nursing and Regional Director of Operations acknowledged that the fall investigation was incomplete and that staff members, including agency staff, should have been educated on the resident's transfer orders.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management and storage, as observed during a survey. Medication carts were found unlocked and unattended, with non-medical items such as bleach wipes, isopropyl alcohol, used toenail clippers, a lighter, a box cutter, a computer mouse, and a stapler stored alongside residents' prescribed medications. Additionally, medication carts contained loose pills and debris, indicating a lack of cleanliness and organization. Staff interviews revealed that the responsibility for maintaining the cleanliness and security of the medication carts was not consistently upheld. The facility also failed to maintain accurate narcotic counts and documentation. Narcotics were not consistently counted at the beginning and end of each shift, resulting in numerous missing signatures and discrepancies in narcotic records for several residents. For instance, discrepancies were noted in the narcotic records of residents receiving Hydrocodone/Tylenol, Lorazepam, and Tramadol Hydrochloride, with incorrect counts and missing documentation. Staff interviews indicated a lack of adherence to the facility's policy requiring two nursing staff to verify narcotic counts, and the Director of Nursing (DON) was not notified of these discrepancies. Furthermore, the facility did not ensure that medication refrigerators were maintained within the required temperature range. Temperature logs showed multiple instances where temperatures were not recorded, and on one occasion, the refrigerator temperature was recorded below freezing, which could compromise medication integrity. There was no documentation of corrective actions taken, such as notifying maintenance or the pharmacy, when temperatures were out of range. Interviews with staff revealed a lack of understanding of the procedures to follow when medication storage temperatures were incorrect.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility was found to have multiple deficiencies related to food safety and sanitation during a survey. Observations revealed that the walk-in refrigerator and freezer floors were not clean, and there were no operable thermometers in these units to ensure proper temperature control. Additionally, the facility failed to safeguard against foreign materials entering food and beverages, as evidenced by a non-sealing gasket on an ice machine lid and paper debris on a can opener blade. The facility also did not maintain cutting boards and utensils in good condition, with cutting boards being excessively scored and a spatula having chips on its blade. Damaged foodstuffs, such as dented cans, were not properly separated, and some food items were not stored within acceptable temperature parameters or labeled correctly. Further issues included the failure to consistently measure and document hot food temperatures, which is crucial to prevent bacterial contamination. The facility also did not keep trash dumpsters properly lidded, as observed during multiple inspections. Interviews with the new Dietary Manager revealed expectations that were not met, such as ensuring food was free of foreign substances and that refrigerators and freezers had extra thermometers. The facility's census at the time was 74 residents, with a licensed capacity for 91, indicating that these deficiencies had the potential to affect a significant number of individuals consuming food from the kitchen.
Infection Control and Employee Screening Deficiencies
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program, which included deficiencies in managing Legionella and other water-borne pathogens. The facility's water management program was incomplete, lacking a facility-specific risk management plan assessment and a completed CDC toolkit assessment. The Maintenance Supervisor was responsible for implementing the Legionella program but was only somewhat familiar with federal requirements. Additionally, the facility's disaster manual was not properly maintained, containing only residents' admission face sheets instead of relevant disaster management information. The facility also failed to properly screen new employees for tuberculosis, with eight out of nine new employees lacking completed Tuberculin Skin Tests (TSTs). The Human Resources Director and Director of Nursing were responsible for ensuring TSTs were completed, but there was a misunderstanding about where and when the tests were to be administered. This oversight had the potential to affect all residents, employees, and visitors to the facility. Furthermore, the facility did not ensure staff practiced Enhanced Barrier Precautions (EBP) for residents with specific medical conditions, such as a colostomy, supra pubic catheter, and pressure ulcers. Staff were not adequately educated on EBP, and there was a lack of signage and isolation carts with personal protective equipment outside residents' rooms. Hand hygiene practices were also insufficient, with staff failing to cleanse their hands during medication passes and after handling potentially contaminated items. The facility's infection prevention and control program lacked necessary policies, including those for hand washing and EBP, and there was no documentation of infection control training provided to staff.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) with the required primary professional training for its Infection Prevention and Control program. The facility, with a census of 74 residents, did not provide certifications for employees certified in the IP program at the time of the survey exit. The Minimum Data Set (MDS) Coordinator, who worked 15 hours a week as the IP, had only completed 15 of the 26 modules of the CDC's online IP course and was not certified. During interviews, the MDS Coordinator confirmed they had not finished the IP course and lacked certification. The Director of Nursing (DON) and the Administrator both stated they had completed the IP program training and were certified, but the MDS Coordinator had not completed the training or obtained certification.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, which is a violation of residents' rights. During an initial facility walk-through inspection, it was observed that a plumbing clean-out in the middle of the 300 Hall was missing its cover, creating a potential tripping hazard. Additionally, the 100, 200, and 300 Halls had room numbers in both Arabic and Braille, but the 400, 500, and 600 Halls only had regular numbers, lacking Braille, which did not meet ADA requirements. Further observations revealed various issues in resident rooms, including broken furniture, missing slats in window blinds, and a cracked bathroom door. Interviews with the Maintenance Supervisor (MS), Environmental Services Supervisor (EVS), and the Administrator highlighted a lack of prompt action in addressing these deficiencies. The MS acknowledged the need to change room numbers to include Braille, while the EVS and MS were responsible for reporting and ordering replacements for damaged mattresses, furniture, and blinds. However, they indicated that orders required approval from the corporate office, which could delay necessary repairs and replacements. The Administrator emphasized the importance of a hazard-free environment but confirmed that the process for ordering replacements involved waiting for corporate approval.
Deficiencies in Dental and Nutritional Assessments
Penalty
Summary
The facility failed to accurately assess the dental status of two residents, Resident #33 and Resident #51. Resident #33 had multiple dental issues, including missing and discolored teeth, which were not accurately reflected in the Minimum Data Set (MDS). Despite having teeth removed and needing further dental procedures, the resident's MDS inaccurately indicated no dental issues. Interviews with the resident and staff revealed a lack of proper documentation and assessment of the resident's dental condition, leading to a failure in care planning. Resident #51 also experienced a deficiency in dental assessment. The resident's MDS did not document missing teeth, and there was no dental care plan in place. Observations confirmed the resident had multiple missing teeth, yet this was not reflected in the MDS or care plan. Interviews with the MDS coordinator and the Director of Nursing (DON) highlighted a lack of awareness and documentation regarding the resident's dental status, indicating a failure to provide individualized care. Additionally, the facility failed to accurately assess and address unintended weight changes for Resident #19. The resident experienced significant weight fluctuations, with a 22.1% weight gain in 30 days followed by a 7.5% weight loss. Despite these changes, there were no notes addressing the weight fluctuations, and staff were unaware of the resident's weight issues. Interviews with the Registered Dietician (RD) and nursing staff revealed a lack of communication and follow-up on the resident's weight changes, leading to inadequate nutritional management and care planning.
Inadequate Care Planning for Residents
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for several residents, leading to deficiencies in addressing their specific needs. For Resident #33, the care plan did not include any interventions related to dental issues, despite multiple dental progress notes indicating the resident's interest in dentures and the removal of several teeth. The resident expressed a need to see a dentist, and observations confirmed poor dental condition, yet the care plan remained unchanged. The MDS Coordinator acknowledged the oversight and admitted that dental needs should have been included in the care plan. Resident #54's care plan was also found lacking, as it did not address the resident's diabetes, insulin use, depression, or anxiety, despite these being identified as high-risk areas in the resident's MDS assessments. The resident was receiving multiple high-risk medications, including insulin, antidepressants, and antianxiety medications, but these were not reflected in the care plan. The MDS Coordinator admitted to missing these critical areas when developing the care plan. Similarly, Resident #51's care plan did not include a dental care plan, even though the resident had multiple missing teeth and expressed a desire for dentures. The staff, including the MDS Coordinator and the DON, were unaware of the resident's dental issues, indicating a lack of communication and assessment. Additionally, Resident #20's care plan failed to include interventions for skin and wound care, despite the resident having a history of skin issues and a new open wound. The MDS Coordinator and nursing staff did not update the care plan to reflect these needs, resulting in inadequate care planning for the resident's condition.
Deficiencies in Care Plan Notifications and Updates
Penalty
Summary
The facility failed to notify a resident or their representative about care plan meetings, and did not update care plans for falls, pain, and infections for several residents. Resident #67, who was moderately cognitively impaired and diagnosed with anxiety disorder, depression, and schizophrenia, was not aware of what a care plan was and could not recall being invited to any care plan meetings. Interviews with staff revealed inconsistencies in the notification process for care plan meetings, with the MDS Coordinator admitting to not having time to conduct meetings with residents or their representatives. Resident #33 experienced multiple falls, including a fall that resulted in a hospital visit, yet their care plan did not include any interventions for falls or fall prevention. The MDS Coordinator acknowledged the oversight, and the DON confirmed that falls should have been included in the care plan. The responsibility for updating care plans was shared among the MDS Coordinator, DON, ADON, and charge nurses, but the care plan did not accurately reflect the resident's current status. Resident #14 had a history of recurrent urinary tract infections and was prescribed various antibiotics, but their care plan did not address these infections or the use of antibiotics. Similarly, Resident #51, who suffered from chronic pain and had a history of substance abuse, did not have a comprehensive pain management plan in their care plan. The MDS Coordinator and DON both emphasized the need for individualized care plans that address specific medical conditions and treatments, but these were not adequately reflected in the residents' care plans.
Deficiency in CNA In-Service Training
Penalty
Summary
The facility failed to provide the required annual 12 hours of in-service training for Certified Nursing Assistants (CNAs), as mandated by their Nursing Assistant Training Program Policy. The policy specifies that each nursing assistant should receive at least 12 hours of in-service training annually, based on their employment date. However, a review of the facility's records showed that none of the five CNAs employed for the last 12 months or longer received the required training. The in-service and education sign-in sheets did not include necessary training topics such as dementia/Alzheimer care, misappropriation, and behavioral training. Additionally, the facility did not provide competency reviews for these CNAs during the previous 12 months. Interviews with CNAs and the Director of Nursing (DON) revealed inconsistencies in the training process. CNAs reported that in-service meetings were not held every month, and sometimes they were only given review sheets to read and sign. The DON acknowledged that CNAs should receive at least 12 hours of in-service training annually, which should include various topics like infection control and resident rights. However, the facility's records did not reflect this requirement, and the requested computer training records for the CNAs were not provided by the DON or the Administrator.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted correctly, including the total number and actual hours worked for RNs, LPNs, CNAs, and CMTs responsible for resident care per shift. Observations revealed that the staffing sheets posted in the common area near the 600-hall and the main nursing station for the 400, 500, and 600 halls did not include the number of hours worked for each staff member or the facility census. Additionally, the 100, 200, and 300 halls nursing station did not have any posted staffing information. Interviews with staff, including the Director of Nursing (DON), confirmed that the daily staffing sheets were posted in the glass bulletin board at the main nurses' station, showing the names of the staff working for each position. However, these sheets did not display the total number of hours worked for each position or the daily facility census. The whiteboard behind the main nursing station showed the number of hours for each staff position but also lacked the facility census. The DON acknowledged that the daily staffing should include the hours for each position and the facility census, and these should be posted on the 100, 200, and 300 hall side of the facility. The absence of this information could potentially affect all residents, staff, and visitors of the facility, as it is crucial for ensuring adequate staffing levels and transparency in care provision.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify residents and their representatives of transfers to a hospital, including the reasons for the transfer in writing, and did not provide the Ombudsman with a copy of the notification for three sampled residents. The facility's policy requires that any resident transferred or discharged under a facility-initiated transfer must be notified in writing, and a copy of the notice must be sent to the Ombudsman. However, for Residents #33, #73, and #40, there was no documentation of such notifications being made. Resident #33 was discharged to an acute hospital on two occasions, with no discharge notice documented in the medical records. The resident, who was moderately cognitively impaired, did not receive discharge notices for these hospitalizations. The facility's Administrator was unaware that notifications were not made to the Ombudsman, and the Social Services Director, who was responsible for these notifications, was not in position during the time of the discharges. Resident #73 was transferred to a hospital due to a physical decline, but there was no nursing or progress note documenting the transfer, and no discharge notice or Ombudsman notification was found. Similarly, Resident #40 was sent to the emergency room, but there was no documentation of a discharge notice or Ombudsman notification. The facility's staff, including the DON and RDO, acknowledged that the discharge notices and notifications were not completed as required.
Failure to Provide Bed Hold Notifications
Penalty
Summary
The facility failed to provide bed hold notifications to residents or their representatives upon transfer or discharge to a hospital for three residents out of a sample of 19. The facility's policy required that a bed hold policy be given to residents or their representatives when they were discharged to a hospital or went on therapeutic leave. However, for Resident #40, there was no documentation of a bed hold policy being provided when the resident was sent to the emergency room for slurred speech. Interviews with staff, including the LPN, ADON, DON, and RDO, revealed inconsistencies in the process of providing and documenting the bed hold policy. Resident #33 was discharged to an acute hospital with the return anticipated on two occasions, but there was no record of a bed hold policy notice being provided on either occasion. The resident confirmed not receiving the bed hold policies during hospitalizations. Interviews with the DON and RDO indicated that the charge nurse was responsible for sending the bed hold notice, and it should have been documented in the progress notes and scanned into the electronic health record. Resident #14 requested to be transported to the hospital, but there was no documentation of a bed hold policy notice being provided. Interviews with the RDO and MDS Coordinator indicated that the charge nurse was responsible for sending the bed hold policy, with the SSD following up if it was not sent at the time of transfer. The DON confirmed that the charge nurse should have provided the bed hold policy, with the SSD following up if necessary.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide the required Notice of Medicare Provider Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two residents who were discharged from Medicare Part A services. The NOMNC and SNF ABN are essential documents that inform residents or their representatives about the termination of Medicare coverage and potential financial liability for services not covered. The facility's policy did not include instructions to provide these notices at least two days before Medicare coverage ended, leading to the deficiency. For Resident #49, the last covered day for Medicare Part A services was August 23, 2024, and for Resident #14, it was August 30, 2024. In both cases, the facility initiated the discharge from Medicare Part A services before benefit days were exhausted, but failed to provide the necessary NOMNC and SNF ABN. The Social Services Director, who was responsible for providing these notices, was not in place during the time of the deficiency, and no other staff member was designated to fulfill this responsibility. Consequently, the required notices were not issued to the residents or their representatives.
Inaccurate MDS Assessment for Resident's Dental Health
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, which is a federally mandated assessment tool used for care planning. Upon admission, the resident's clinical assessment did not include an evaluation of dental status, despite the resident having missing teeth and experiencing difficulty chewing. The resident expressed a desire for dentures and had not seen a dentist since admission. The MDS inaccurately reported that the resident had no dental problems, missing teeth, or abnormal teeth issues, and the care plan did not address any dental concerns. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), revealed that a dental assessment should have been part of the initial clinical admission assessment. The MDS Coordinator expected to be informed of any missing teeth, which should have been documented in the MDS and care plan. The DON and Regional Director of Operations acknowledged that the MDS should be updated initially, quarterly, and upon any change in condition, and that dental issues should be reflected in the MDS. However, they were unaware of the resident's dental concerns and missing teeth.
Failure to Assess Significant Change in Resident Condition
Penalty
Summary
The facility failed to comprehensively assess a resident who experienced a significant change in condition. Resident #33, who was moderately cognitively impaired and previously independent in most activities of daily living, experienced a decline in health status. The resident developed a blood infection requiring intravenous antibiotics and was moved from the independent side to the medical side of the building. Despite these changes, the facility did not complete a significant change assessment within the required 14 days as per their policy. Further review showed that the resident had a fall with altered mental status and experienced a weight loss of 7.21% over three months. The resident's care plan lacked a plan for falls, and the resident was later hospitalized for a nephrostomy. Observations indicated the resident was now using a wheelchair and required more assistance. Interviews with the MDS Coordinator and the Director of Nursing confirmed that a significant change MDS should have been initiated but was not completed.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly administer medications to a resident, leading to several deficiencies. The resident, who was cognitively intact and had multiple medical conditions including COPD, cancer, and chronic pain, was found to be self-administering inhalers and nebulizer treatments without a physician's order or evaluation. The resident reported that the physician had given permission for self-administration, but no documentation was found to support this claim. Additionally, the resident's care plan did not address self-administration of medications, and the facility's staff confirmed the absence of necessary orders and evaluations. The resident experienced delays in receiving medications, with some being administered outside the prescribed time frame. The facility's policy required medications to be administered within 60 minutes before or after the scheduled time, but records showed instances where medications were given late. The resident expressed a preference for receiving medications after breakfast, but often received them closer to noon. Staff interviews confirmed that medications were sometimes administered late, and the facility's open time frame for morning medications was not adhered to. Furthermore, the facility ran out of the resident's pain medication, Hydrocodone, which led the resident to call 911 for pain control. Despite the facility receiving two pharmacy deliveries a day, the resident was without some medications for a couple of days. The pharmacy indicated that a physician's signature was needed to fill the order, and the facility had recently changed physicians, which may have contributed to the delay. The resident's medications were discontinued after testing positive for cocaine use at the hospital, but there was no documentation from the hospital or the facility regarding this incident.
Failure to Follow Physician's Orders for Anticoagulation Monitoring
Penalty
Summary
The facility failed to adhere to physician's orders for obtaining Prothrombin Time (PT) and International Normalized Ratio (INR) labs for a resident on anticoagulation therapy with Coumadin. The resident, who had a history of deep vein thrombosis, transient ischemic attack, and cerebral infarction, was supposed to have PT/INR labs drawn every Monday and Thursday. However, a review of the resident's lab results from April to September revealed 23 missing lab results, indicating a significant lapse in following the prescribed schedule for monitoring the resident's anticoagulation therapy. Interviews with the resident and facility staff, including an LPN and the Director of Nursing (DON), highlighted a lack of awareness and communication regarding the resident's lab schedule. The resident reported inconsistent lab draws and had informed staff about the issue, though could not recall specific individuals. The LPN was unaware of the frequency of the lab draws and had not noticed any missing results. The DON and Regional Director of Operations acknowledged the expectation for labs to be drawn and communicated to the physician as ordered, but the missing labs were assumed not to have been done if not documented in the electronic medical record.
Failure to Provide Podiatry Care for Resident
Penalty
Summary
The facility failed to provide appropriate toenail care or arrange a podiatrist appointment for a resident, despite multiple requests and awareness among staff. The resident, who was admitted with diagnoses of morbid obesity and dysfunction of the lower extremity, was cognitively intact and required substantial assistance with personal hygiene. The resident reported having requested podiatrist care from both the previous social worker and the current administrator, experiencing pain due to long toenails, and being assured by the administrator that an appointment would be arranged. However, the resident had not seen a podiatrist since admission. Interviews with various staff members, including CNAs, an LPN, the DON, and the Social Services Director, revealed that the need for podiatrist care was known but not acted upon. The CNAs and LPN reported the resident's need to the charge nurse and the DON, who believed the resident was already on the list to see a podiatrist. The Social Services Director, responsible for setting appointments, was unaware of the resident's need and expected such information to be communicated through nursing notes, which were absent. The facility lacked documentation, such as podiatry or nursing notes, to support the resident's need for podiatrist care.
Deficiency in Dialysis Care Communication and Assessment
Penalty
Summary
The facility failed to ensure proper communication and assessment protocols for a resident requiring dialysis, leading to a deficiency in care. Resident #38, who has End Stage Renal Disease and requires dialysis three times a week, was not properly monitored for signs of infection or assessed for thrill and bruit at the dialysis access site. The resident's care plan and physician's orders lacked specific instructions for these assessments, and the facility did not maintain a consistent communication process with the dialysis center. Observations and interviews revealed that the facility's staff, including agency nurses, were unaware of the necessary post-dialysis assessments and the location of the dialysis communication binder. The binder, which was supposed to contain communication forms from the dialysis center, was missing for an unspecified period, and a new one was only created after the issue was identified. The lack of communication forms and missing binder indicated a breakdown in the facility's process for ensuring continuity of care for the resident. The Director of Nursing and Regional Director of Operations acknowledged the expectations for communication and assessment but were unaware of the missing binder. They confirmed that the nursing staff should have completed and documented assessments for thrill, bruit, and infection after each dialysis session. The absence of these assessments and communication forms highlights the facility's failure to implement and maintain essential care protocols for the resident.
Failure to Address Pharmacist Recommendations in Medication Regimen Review
Penalty
Summary
The facility failed to ensure that the Medication Regimen Review (MRR) completed by the pharmacist was reviewed and responded to by the facility physician for two residents. Resident #19, diagnosed with type 2 diabetes, major depressive disorder, and gout, had a recommendation from the pharmacist to evaluate the need for a scheduled uric acid level due to the resident's Allopurinol prescription. However, there was no physician's response to this recommendation, and the resident's Physician's Order Sheet (POS) lacked an order for monitoring uric acid levels. Similarly, Resident #45, who was moderately cognitively impaired and diagnosed with type 2 diabetes and epilepsy, had pharmacist recommendations documented in the Electronic Health Record (EHR) that were not addressed by the physician. Interviews revealed that the Director of Nursing (DON) received pharmacist recommendations via email but was unaware they were available in the EHR. The consultant pharmacist noted that sometimes recommendations were not addressed for up to six months, requiring them to be redone. The facility's failure to document physician responses to pharmacist recommendations led to the deficiency.
Failure to Provide Dental Services to Residents
Penalty
Summary
The facility failed to provide necessary dental services to two residents, leading to deficiencies in their care. Resident #33's baseline care plan did not address dental needs, despite multiple dental issues being documented over time, including missing and discolored teeth. The resident expressed a need for dental care, including tooth extractions, which were recommended by a dentist but not scheduled. The MDS Coordinator acknowledged inaccuracies in the resident's assessments and care plan, and the Social Services Director admitted to not following up on dental recommendations. Resident #51 also did not receive appropriate dental services. Despite having missing teeth and expressing a desire for dentures, the resident's dental needs were not documented in the MDS assessments. The Social Services Director and nursing staff were unaware of the resident's dental condition and had not arranged for a dental appointment since the resident's admission. The facility had a dental provider available, but the necessary steps to ensure the resident received care were not taken. Interviews with facility staff, including the Director of Nursing, revealed a lack of awareness and follow-up regarding the residents' dental needs. The facility's policy required dental needs to be identified and addressed, but this was not effectively implemented for the two residents. The failure to provide dental services as needed resulted in unmet care requirements for both residents, highlighting deficiencies in the facility's dental care processes.
Deficiency in Hospice Care Documentation and Monitoring
Penalty
Summary
The facility failed to ensure proper documentation and monitoring of hospice care services for a resident who was admitted to hospice care. The resident, diagnosed with dementia, Alzheimer's disease, and senile degeneration of the brain, was admitted to hospice care on September 11, 2024. However, the facility did not maintain adequate records of hospice staff visits or communication with hospice staff. The hospice communication book lacked documentation of hospice staff visits after the resident's admission, a care plan, and the name of the resident's physician. Additionally, there was a discrepancy in the resident's code status between the hospice coordination form and the physician's order summary. Interviews with facility staff revealed a lack of awareness and communication regarding hospice care visits and documentation. A CNA was unaware of the hospice nurse or aide visits, and the Director of Nursing acknowledged that all hospice care information should be documented in the resident's hospice book. The DON stated that hospice staff should inform the facility of any changes to the resident's care both verbally and in writing, but this was not reflected in the documentation. The absence of proper documentation and communication led to a deficiency in the facility's management of hospice care for the resident.
Failure to Document and Educate on Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that two residents received or were provided education regarding pneumococcal vaccinations. The facility's policy required that residents be offered the pneumococcal vaccines recommended by the CDC upon admission, unless contraindicated or previously received. Additionally, education on the benefits and potential side effects of the immunizations was to be provided to residents or their representatives before offering the vaccines. Documentation was required to reflect the education provided and whether the resident received the immunizations. However, for two sampled residents, there was no documentation regarding their pneumococcal vaccine status in their medical records. Interviews with facility staff revealed that the Director of Nursing (DON) was responsible for ensuring immunizations were administered, and documentation should have been recorded in the electronic health record (EHR). The MDS Coordinator stated that the pneumococcal vaccine should be offered and administered during the resident's first week at the facility if they were over 65 or immunocompromised. The DON confirmed that charge nurses were supposed to offer the vaccines within 72 hours of admission and document the process in the EHR. Despite these procedures, the facility's process for offering and administering the pneumococcal vaccines was acknowledged to need improvement.
Failure to Document COVID-19 Vaccine Offer and Status
Penalty
Summary
The facility failed to ensure that two residents, out of a sample of five, were offered the COVID-19 vaccine as per the facility's policy. The policy required that all residents be offered the vaccine unless medically contraindicated or already vaccinated, with documentation of the vaccination status maintained in the resident's medical records. However, for Residents #24 and #325, there was no documentation regarding their COVID-19 vaccine status in their medical records, indicating a lapse in following the established protocol. Interviews with facility staff, including the MDS Coordinator and the DON, revealed that the responsibility for ensuring immunizations were done lay with the DON, and documentation should be recorded in the electronic health record. The COVID-19 vaccine was to be offered and administered within the first week of a resident's admission, with any declination documented in the resident's progress notes. Despite these procedures, the facility's process for offering and administering the COVID-19 vaccine was acknowledged by the DON as needing improvement, as evidenced by the lack of documentation for the two residents in question.
Misappropriation of Resident Funds
Penalty
Summary
The facility failed to prevent the misappropriation of approximately $1100 in cash from a resident's wallet, which was initially found in the laundry by the Environmental Services (EVS) manager. The wallet, containing a substantial amount of cash, was handed over to the social worker, who then placed it in the facility's safe without counting the money. The resident, who was cognitively intact and responsible for their own finances, later requested the return of their wallet, only to find the money missing. The incident involved multiple staff members, including the Director of Nursing (DON), the social worker, the business office manager, and the Administrator. Conflicting reports about the amount of money in the wallet were given by various staff members, with estimates ranging from $500 to $1860. The resident was unable to provide ATM receipts or bank statements to verify the exact amount, but bank records confirmed withdrawals totaling $1100, which the resident agreed was the correct amount. The facility's policies on resident rights and abuse and neglect were not adequately followed, as the money was not counted or properly safeguarded. The lack of clear procedures for handling resident funds and the failure to verify the amount of money in the wallet contributed to the misappropriation. The police were notified, but due to the wallet's material, fingerprinting was not possible, and no further investigation was conducted by law enforcement.
Resident Dignity Compromised During Care
Penalty
Summary
The facility failed to preserve a resident's dignity when an agency CNA slapped the resident's hand and made inappropriate comments during incontinence care. The incident involved a resident with multiple mental health diagnoses, including schizoaffective disorder, paranoid schizophrenia, and anxiety disorder. The resident was not cognitively intact and was dependent on facility staff for various daily needs, including toileting and hygiene. The resident's care plan emphasized the need for staff to treat the resident with dignity and respect, to explain procedures before starting them, and to protect the resident's rights and safety. On the day of the incident, Agency CNA A reported to the Facility Administrator that Agency CNA B had slapped the resident's hand and told the resident not to touch them. The resident confirmed the incident, stating that they were slapped and responded by telling the CNA not to hit them. The resident expressed that they were not hurt or scared by the incident. Agency CNA A witnessed the event and reported that Agency CNA B appeared upset about the mess in the resident's room and had a negative attitude during the care process. Agency CNA B denied slapping the resident, claiming that they blocked the resident's hand, which may have caused a slapping sound. The Facility Administrator expected all staff to maintain residents' dignity and make no derogatory comments. The incident highlights a failure to uphold the resident's rights to dignity and respect during care, as outlined in the facility's policy.
Resident Elopement Due to Inadequate Monitoring and Protocol Adherence
Penalty
Summary
The facility failed to ensure the safety and protective oversight of a resident who eloped from the facility without staff knowledge. The resident, diagnosed with paranoid schizophrenia, disorganized schizophrenia, and seizures, left the facility around 5:02 P.M. and was gone overnight. The facility staff did not notice the resident's absence until the following morning when the resident's guardian informed them that the resident had shown up at a family member's house the previous night. The facility's video surveillance showed the resident walking towards the exit door, entering a code, and leaving the building. The staff responsible for monitoring the resident did not perform the required face checks or notify the charge nurse of the resident's absence. Additionally, the facility did not change the door codes weekly as per policy, which allowed the resident to exit the building without detection. Interviews with staff revealed that there was a lack of communication and proper handover between shifts. The staff did not complete the necessary rounds to ensure all residents were accounted for, and the night shift staff did not perform the midnight census checks. The facility's failure to follow its elopement protocol and monitoring procedures directly led to the resident's elopement and the subsequent deficiency.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure that Resident #3 remained free from abuse, resulting in an incident where Resident #2 struck Resident #3 on the head. Resident #2, who had a history of severe mental illness and aggressive behavior, was admitted with diagnoses including Paranoid Schizophrenia, Anxiety Disorder, and various personality disorders. Despite showing signs of increased agitation and delusional behavior, Resident #2 was not sent for a psychiatric evaluation prior to the assault on Resident #3. On the day of the incident, Resident #2, who believed Resident #3 owed them a large sum of money, approached and struck Resident #3, causing physical harm and necessitating a visit to the emergency room for evaluation and treatment. Resident #2's care plan indicated a need for 24-hour supervision and ongoing evaluation of mood and behavior due to their chronic mental illness. However, the facility's staff did not take appropriate action to address Resident #2's escalating behavior, which included delusions and confrontations with other residents. The MDS Coordinator acknowledged that Resident #2 should have been sent for a psychiatric evaluation due to the change in behavior, which might have prevented the assault. The facility's failure to act on these warning signs directly led to the incident of abuse. Interviews with staff and residents confirmed that Resident #2's behavior had been problematic and that staff had to intervene on multiple occasions. Despite these interventions, the facility did not take sufficient steps to protect Resident #3 from harm. The Administrator and other staff members recognized the incident as abuse, highlighting a significant lapse in the facility's responsibility to ensure the safety and well-being of its residents.
Failure to Address Resident's Mental Health Needs and Ensure Safety
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with multiple mental disorders, including paranoid schizophrenia and anxiety disorder, who consistently refused psychoactive medications. This resident, who had a history of non-compliance with medications and aggressive behavior, struck another resident on the head, causing physical harm and necessitating a transfer to the emergency room. Despite the resident's refusal of medications being well-documented, the facility did not take adequate steps to address the escalating behaviors or ensure the safety of other residents. The resident's care plan indicated a need for protective oversight and monitoring for behaviors, but the facility staff did not effectively implement these measures. The resident had been refusing medications since September, and staff were aware of the increasing delusions and aggressive behavior, including calling 911 with grandiose allegations. However, the facility did not send the resident for a psychiatric evaluation or take other preventive actions before the assault occurred. Interviews with facility staff revealed a lack of communication and appropriate response to the resident's deteriorating mental status. The MDS Coordinator and Regional Nurse Consultant acknowledged the resident's medication refusal and increasing behaviors but felt limited in their ability to act due to the resident being their own responsible party. The Nurse Practitioner was not promptly informed of the resident's medication refusals or the specific targeting of another resident, which could have prompted earlier intervention. The facility's failure to act on these warning signs and provide necessary treatment and oversight led to the incident of physical abuse.
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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