Four Seasons Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sedalia, Missouri.
- Location
- 2800 Highway Tt, Sedalia, Missouri 65301
- CMS Provider Number
- 265149
- Inspections on file
- 34
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 34 (1 serious)
Citation history
Health deficiencies cited at Four Seasons Living Center during CMS and state inspections, most recent first.
Staff failed to report an allegation of physical abuse to the state survey agency within the required two-hour timeframe after a cognitively intact, ambulatory resident with schizoaffective disorder, bipolar type, ADHD, and an impulse disorder reported that a CNA grabbed the resident by the coat collar and pushed the resident against a wall. The allegation was communicated to the administrator by an LPN, and the administrator began but did not complete an online report to the Department of Health and Senior Services, resulting in no documented submission of the abuse allegation as required by facility policy.
Staff failed to monitor exit doors during a fire drill, resulting in a resident with psychiatric conditions eloping undetected for several hours, while two other residents also left the unit due to lack of supervision. In addition, medications were left unsecured and unattended in areas accessible to residents who wander, with staff confirming lapses in direct observation and medication security.
Staff failed to receive adequate training on behavioral health competencies and resident-specific interventions, resulting in multiple incidents where residents with mental health diagnoses engaged in verbal and physical altercations without timely or appropriate staff intervention. Staff were unsure how to access care plans or when to call behavioral crisis codes, and documentation of incidents was lacking. Residents and staff reported feeling unsafe due to the lack of effective behavioral health management.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes, as required. This lapse in communication was identified during the survey.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines. No further details about specific actions, staff, or residents are provided.
Facility staff did not notify a resident's guardian after the resident, who was moderately cognitively impaired, sustained a humeral fracture. Although the facility's policy and staff interviews confirmed the requirement to inform the responsible party of such changes, the guardian was not contacted following the injury.
Staff did not update care plans for two residents after each experienced unwitnessed falls, despite existing policies and staff knowledge that care plans should be revised following such incidents. One resident with cognitive impairment and another considered low risk for falls both had incident reports documenting falls, but no new interventions were added to their care plans. Staff interviews confirmed the expectation to update care plans, but this was not done due to other assignments.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines.
Facility staff did not consistently provide the number and type of nursing staff required by their own facility assessment, with staffing schedules showing shortfalls in NAs and the absence of an RCC on several days. The Staffing Coordinator was not trained to use the facility assessment for scheduling, and the administrator had not compared staffing schedules to assessment requirements. Staff interviews reflected mixed perceptions of staffing adequacy, with some noting a need for more crisis prevention education.
Staff failed to complete and document wound care treatments as ordered for two residents, with multiple missed entries on the TAR and no documentation of refusals, despite facility policy requiring timely and thorough documentation. Interviews with an LPN, the administrator, and the DON confirmed the expectation for documentation and revealed that audits were not consistently performed.
The facility staff failed to follow proper sanitation procedures, resulting in potential food contamination. Wet dishes were stacked without air drying, and unsanitary conditions were observed in the kitchens, including food debris and lime deposits. Staff interviews revealed a lack of awareness and enforcement of cleaning protocols, contributing to the deficiencies.
The facility failed to prevent the commingling of personal funds for 12 residents with the facility's operating funds, as identified in a review of records and staff interviews. The facility's policies require separate accounting for resident funds, but the Account Receivable Aging report showed residents' funds were held in the facility's operating account. Staff interviews confirmed the lack of written authorization to hold resident funds in the facility account.
The facility failed to refund personal funds to three residents within the required timeframe after discharge. Despite policies mandating refunds within 30 days of a resident's death and five days of discharge, credit balances remained unaddressed. Interviews revealed a lack of awareness and responsibility among staff, with the Business Office Manager and Corporate Account Receivable Manager acknowledging the issue but citing workload delays. The new administrator was unaware of the outstanding balances, highlighting a breakdown in communication and process adherence.
The facility failed to maintain a clean and safe environment, with observations of unclean resident rooms, broken furniture, and inadequate maintenance. Residents reported unsanitary conditions, such as feces in bathrooms and issues with wheelchairs. Insufficient housekeeping staff and poor communication among staff contributed to the deficiency.
The facility failed to provide adequate weekend activities for residents, with only Bingo and church services offered, leading to boredom and disengagement. The activities calendar was inaccurate, listing events like Father's Day in October, causing confusion. Staff shortages on weekends limited the variety of activities, and the Director of Nursing acknowledged the need for scheduled activities and accurate calendars to prevent negative impacts on residents' moods.
The facility failed to serve hot food at safe temperatures, with observations showing food items like chicken paprikash and squash served below the required 135°F. Staff used room temperature plates and ineffective plate covers, leading to cold meals. Residents reported frequent cold food, and staff lacked awareness of proper serving temperatures. The dietary manager acknowledged the issue but did not routinely check food temperatures, and the administrator was unaware of the problem.
The facility failed to conduct required pre-employment screenings for four new employees, violating their policy. The Human Resources department did not complete necessary checks, such as the Family Care Safety Registry (FCSR) and Employee Disqualification List (EDL), before hiring. Interviews revealed that the Human Resources representative and the administrator were unaware of these oversights.
Facility staff failed to document medication and treatment administration for three residents, leading to a deficiency. A resident with a diabetic foot ulcer did not have documented wound treatments and pain assessments, while another with severe cognitive impairment had missing entries for wound treatment and barrier cream application. A third resident with a feeding tube had missing documentation for syringe kit changes and tube flushing. Interviews revealed that missing signatures were not reported, and the facility's tracking system was underutilized.
A resident with a history of inserting foreign objects into their colostomy bag and stoma was repeatedly hospitalized due to the facility's failure to implement and document interventions. Despite being cognitively intact, the resident's care plan lacked strategies to prevent access to potential objects, and staff did not attempt interventions after each incident.
Facility staff failed to update care plans for two residents regarding colostomy bag use and necessary interventions. One resident's care plan lacked directions for colostomy bag use, while another resident, with a history of inserting foreign objects into their colostomy bag, had no new interventions documented despite multiple hospitalizations. The DON and MDS Coordinator acknowledged these oversights.
A resident with a surgical wound and multiple diagnoses was transferred to the hospital from a wound care appointment without notifying the guardian. Facility staff, including an LPN, DON, and Resident Care Coordinator, failed to inform the guardian, despite the facility's policy requiring notification of significant changes or transfers.
The facility staff failed to maintain an infection prevention and control program, leading to potential COVID-19 spread. Staff did not isolate COVID-19 positive residents properly, wore inappropriate PPE, and disposed of contaminated PPE incorrectly. Observations and interviews confirmed these deficiencies.
Facility staff failed to complete 72-hour neurological checks and fall follow-up documentation for two residents who had un-witnessed falls. Interviews revealed inconsistencies in understanding and executing the facility's Post Fall Protocol, with confusion about responsibility for ensuring tasks were completed. The DON admitted some staff had trouble using the PCC system, leading to gaps in required documentation.
Failure to Timely Report Allegation of Physical Abuse to State Agency
Penalty
Summary
Facility staff failed to report an allegation of physical abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse and neglect policy, dated 06/12/24, defined physical abuse as handling a resident with more force than is reasonable and required that all alleged violations involving abuse be reported immediately, but no later than two hours after the allegation is made if the events involve abuse or result in serious bodily injury. The facility census was 227. Review of the DHSS complaint/facility self-report database showed no documentation that the facility reported the allegation of physical abuse involving one resident. During an interview, the administrator stated that all allegations of abuse should be reported to DHSS within two hours and acknowledged responsibility for submitting the report. The resident involved had an annual MDS dated 01/06/26 showing he/she was cognitively intact, independent with ambulation, and had diagnoses including unspecified impulse disorder, schizoaffective disorder bipolar type, and ADHD. In an interview on 02/18/26 at 12:18 P.M., the resident reported that on the previous night a CNA held him/her by the coat collar at the neck area with a fist and slammed him/her against a wall near a doorway; the resident reported no injury and was unsure if there were witnesses. The facility’s investigation documentation, dated 02/18/26, recorded that the resident reported on 02/17/26 at approximately 7:38 P.M. that the CNA grabbed and pushed him/her, and that there were no direct witnesses and no injuries. The administrator reported being notified of the allegation at approximately 8:00 P.M. on 02/17/26 by an LPN, began an online report to DHSS, but closed the computer without confirming that the report was successfully submitted, resulting in the failure to report the abuse allegation within the required timeframe.
Failure to Supervise During Fire Drill and Inadequate Medication Security
Penalty
Summary
Facility staff failed to ensure the safety and supervision of residents in a secured unit during a fire alarm test, resulting in multiple incidents of elopement and inadequate monitoring. During the fire drill, staff did not monitor the doors on the Tiger Medical Unit, which allowed a resident with significant behavioral and psychiatric diagnoses to exit the facility undetected. Surveillance footage confirmed that the resident left the building and was not noticed missing until several hours later, despite missing dinner, smoke breaks, and scheduled medications. Hourly face checks were not completed as required, and documentation was inaccurate, with checks recorded after the resident had already eloped. Additionally, two other residents were able to leave the facility through an exit door and fence during the same fire drill, as no staff were assigned to monitor these points of egress. Staff interviews revealed a lack of clear assignments and communication regarding door monitoring during fire drills, and head counts conducted after the drill were incomplete and not systematically performed. The facility's fire drill policy did not address specific staffing assignments or door monitoring procedures for secured units during drills or emergencies. The facility also failed to properly store and secure medications for several residents. Observations found unattended medications in resident rooms and on medication carts, with residents who wander frequently present in these areas. Staff interviews confirmed that medications were sometimes left out and not always administered under direct supervision, contrary to facility policy. These lapses in medication security and supervision created opportunities for residents to access medications unsafely.
Failure to Train Staff on Behavioral Health Needs and Resident-Specific Interventions
Penalty
Summary
Facility staff failed to ensure that staff members possessed the necessary competencies and skills to meet the behavioral health needs of residents, as evidenced by multiple incidents involving residents with behavioral health diagnoses. Staff did not receive adequate training on resident-specific behaviors and interventions, and there was a lack of education on how to access and implement individualized care plans. This deficiency was observed through staff inaction during escalating resident-to-resident altercations, where staff did not intervene or utilize care planned interventions to de-escalate situations, resulting in physical altercations between residents. Additionally, staff interviews revealed uncertainty and lack of knowledge regarding when to call behavioral crisis codes and how to access or apply resident-specific interventions. Several residents with complex behavioral health needs, including diagnoses such as schizophrenia, bipolar disorder, PTSD, and impulse disorders, were involved in repeated incidents of aggression, verbal altercations, and physical assaults. In one instance, two residents engaged in a verbal and physical altercation while staff failed to intervene according to care plan interventions or call a behavioral crisis code in a timely manner. Staff members supervising the residents did not implement de-escalation techniques or follow the individualized interventions outlined in the residents' care plans. Documentation of these incidents was also lacking, with no investigation or nursing notes reflecting the altercations. Interviews with staff and residents further highlighted the deficiency, with staff expressing fear and lack of preparedness to manage residents with severe behavioral health needs. Staff reported not being trained on mental health interventions, de-escalation techniques, or how to access and apply care plan interventions. Residents reported feeling unsafe and stated that staff did not intervene until altercations became physical. The facility's failure to provide adequate training and education for staff on behavioral health needs and individualized interventions contributed directly to the incidents and ongoing unsafe environment for both residents and staff.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions leading to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as required by regulation.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report does not provide specific details about the actions or inactions of staff, the events leading to the deficiency, or information about any residents involved at the time of the incident.
Failure to Notify Responsible Party After Resident's Change in Condition
Penalty
Summary
Facility staff failed to notify a resident's responsible party after the resident experienced a significant change in condition. According to the facility's Notification of Change policy, staff are required to promptly inform the resident, consult the resident's physician, and notify the resident's representative when there is a change requiring notification, such as accidents resulting in injury or those with the potential to require physician intervention. Review of the resident's records showed that the resident, who was assessed as moderately cognitively impaired, sustained a humeral fracture as confirmed by x-ray. The results were reviewed with the physician, but there was no documentation or evidence that the resident's guardian was notified of the fracture. Interviews with the resident's guardian confirmed that they were not informed about the injury. Further interviews with facility staff, including an LPN, the administrator, and the DON, all indicated that staff are directed to contact the resident's family or guardian in the event of a change in condition. Despite this policy and staff understanding, the required notification to the resident's guardian did not occur following the resident's fracture.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
Facility staff failed to review and revise the care plans for two residents following changes in their conditions, specifically after each experienced unwitnessed falls. For one resident, the care plan was last revised prior to a documented fall, and no new fall intervention was added after the incident. The resident was assessed as moderately cognitively impaired and at risk for falls due to confusion, incontinence, and psychoactive drug use. Despite an incident report documenting a fall, the care plan did not reflect any updated interventions addressing this event. For the second resident, the care plan was also not updated after two separate unwitnessed falls. The resident was assessed as cognitively intact and considered low risk for falls, with risk factors including psychoactive medications and extrapyramidal symptoms. Incident reports documented two falls, but the care plan did not include any new interventions following these events. Interviews with staff and administration confirmed that care plans are expected to be updated after such incidents, but this was not completed due to competing assignments and oversight.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the facility did not maintain the required level of care as expected by professional standards, but does not provide specific details about the actions or inactions of staff, nor does it mention any particular residents or their medical conditions at the time of the deficiency.
Failure to Provide Adequate Nursing Staff per Facility Assessment
Penalty
Summary
Facility staff failed to provide adequate nursing staff as determined by their own facility assessment, which was based on the resident population and their care needs. The facility assessment specified the required number of direct care staff for a 24-hour period, including LPNs, CMTs, CNAs, NAs, and an RCC. Review of staffing schedules over several days showed that the facility did not consistently meet these staffing requirements, with particular shortfalls in the number of NAs and the absence of an RCC on multiple days. The average daily census during this period was 235 residents, closely matching the assessment's basis. Interviews revealed that the Staffing Coordinator did not use the facility assessment to determine staffing needs and was not trained to do so. The administrator acknowledged not comparing the facility assessment to the staffing schedule and was unaware of the staffing shortfalls. The DON stated that the staffing schedule should reflect the facility assessment but believed no issues were found when recently reviewed. Staff interviews indicated a perception of adequate staffing, though some noted a need for more education in crisis prevention due to resident altercations.
Failure to Document and Complete Wound Care Treatments
Penalty
Summary
Facility staff failed to maintain professional standards of practice by not completing and documenting wound care treatments as ordered for two residents. For one resident, who was cognitively intact and had orders for multiple wound care treatments including barrier cream, Santyl ointment, and cleansing regimens, the Treatment Administration Record (TAR) showed multiple dates where treatments were not documented as completed. There was also no documentation indicating that the resident refused care on those dates. The physician orders required daily and shift-based wound care, but the records did not reflect that these were consistently provided or refused. Another resident, who was moderately cognitively impaired and had a surgical wound, had physician orders for daily application of xeroform and telfa dressings. The TAR for this resident also showed several dates where the wound care was not documented as completed, and again, there was no documentation of refusal of care. The facility's policy required wound treatments to be documented at the time of each treatment, with additional documentation if treatments were not due or if dressings were intact, as well as documentation of refusals and notifications to physicians or responsible parties. Interviews with staff, including an LPN, the administrator, and the DON, confirmed that treatments should be documented in the medical record and that refusals should be noted on the TAR. The DON acknowledged that missed treatments were identified when providing printed TARs to the surveyor and admitted that audits of the TARs had not been completed due to being too busy. The lack of documentation and failure to follow the facility's wound care policy led to the deficiency.
Sanitation Failures in Kitchen Lead to Potential Food Contamination
Penalty
Summary
The facility staff failed to adhere to proper sanitation procedures in the kitchen, leading to potential food contamination. Observations revealed that sanitized dishes were not allowed to air dry before being stacked, which can promote bacterial growth. Specifically, metal food service pans and plates were found stacked wet, with some containing food debris. Despite being aware of the issue, a dietary aide continued to use these wet dishes to serve food to residents, indicating a lapse in following the facility's policy on dish sanitation. Additionally, the facility's kitchens and kitchenette were not maintained in a clean and sanitary manner, as required by the facility's policies. Observations showed a build-up of food debris and other substances on kitchen equipment and surfaces, including steam tables, floors, and walls. The main kitchen lacked a visible cleaning schedule, and there was an accumulation of lime and calcium deposits on various surfaces. The dietary manager admitted to not having a routine schedule to check the sanitation of the kitchen and was unaware that staff were not following the cleaning schedules. Interviews with staff, including the dietary manager and the administrator, revealed a lack of awareness and enforcement of cleaning protocols. The dietary manager acknowledged responsibility for ensuring cleanliness but was unaware of the extent of the issues. The administrator also admitted to not being aware of the problems and stated that dietary staff should be trained on cleaning schedules and that routine inspections should be conducted. The facility's failure to maintain a sanitary environment and adhere to its own policies resulted in unsanitary conditions that could lead to food contamination.
Commingling of Resident Funds with Facility Operating Funds
Penalty
Summary
The facility failed to prevent the commingling of personal funds for 12 residents with the facility's operating funds, as identified in a review of the facility's records and interviews with staff. The facility's policies, including the Resident Rights policy and the Resident Trust policy, both revised in 2023, clearly state that resident funds must be kept separate from facility funds. However, the Account Receivable Aging report dated October 22, 2024, showed that residents' personal funds were held in the facility's operating account, with credit balances ranging from $184.00 to $6,651.61 for various residents. Interviews with the Business Office Manager and the Corporate Account Receivable manager revealed that the facility did not have written authorization to hold resident funds in the facility account, and both acknowledged that resident funds should not be commingled with facility funds. The Corporate Administrator, who had been overseeing the facility since June 2024, also confirmed that the facility lacked written permission to hold these credits and emphasized the importance of reviewing Account Receivable and billing weekly. The new administrator, who started the week of the survey, was informed of these responsibilities.
Failure to Refund Resident Funds Timely
Penalty
Summary
The facility failed to provide refunds of personal funds to residents from the facility operating account within 30 days for three residents who were discharged. The facility's policy requires that upon the death of a resident, the facility must convey resident funds and a financial accounting of those funds within 30 days to the individual or probate jurisdiction administering the resident's estate. Additionally, within five days of a resident's discharge, the facility is required to provide an up-to-date accounting of resident funds. However, the facility's Account Receivable Aging report showed that three residents had credit balances that were not refunded within the required timeframe. Interviews with facility staff revealed a lack of awareness and responsibility for the outstanding refunds. The Business Office Manager was unaware of why the refunds had not been processed, while the Corporate Account Receivable Manager acknowledged the issue but cited being behind on work as the reason for the delay. The new administrator, who started at the facility recently, was also unaware of the outstanding balances and stated that the business office and administrator are responsible for reviewing accounts receivable and billing. The Corporate Administrator, who had been at the facility since June, was also unaware of the outstanding credit balances until informed during the survey.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by numerous observations of unclean and poorly maintained resident rooms and common areas. Observations included black scuff marks, sticky floors, broken furniture, and debris in various resident rooms and common areas. Additionally, there were reports of feces in a resident's bathroom that had not been cleaned, leading to an unpleasant and unsanitary environment. Interviews with residents and staff revealed dissatisfaction with the cleanliness and maintenance of the facility, with some residents expressing that their rooms were not cleaned after previous occupants moved out. The facility's housekeeping and maintenance policies were not consistently followed, as evidenced by the lack of deep cleaning and maintenance in resident rooms and common areas. Staff interviews indicated that there were often insufficient housekeeping staff on weekends, leading to inadequate cleaning and maintenance. The housekeeping supervisor admitted to not conducting regular checks for cleanliness, and the maintenance director was unaware of certain maintenance issues until they were pointed out by surveyors. Residents reported issues with their wheelchairs, such as missing armrests and built-up debris, which were not addressed despite being reported to staff. The facility's failure to maintain clean and functional assistive devices further contributed to the deficiency. The lack of coordination and communication among staff, as well as insufficient staffing levels, were significant factors in the facility's inability to provide a safe and comfortable environment for its residents.
Inadequate Weekend Activities and Inaccurate Calendar
Penalty
Summary
The facility staff failed to provide an ongoing activity program designed to meet the residents' interests, mental, and psychosocial well-being on the weekends for six residents out of 35 sampled residents. The activities calendar posted on Tiger Lane was inaccurate, listing events such as Father's Day in October, which confused residents. Interviews with residents revealed dissatisfaction with the limited activities offered on weekends, primarily consisting of Bingo and church services, leading to boredom and a lack of engagement. Interviews with staff, including Certified Medication Technicians, Certified Nurse Aides, and the Activities Director, highlighted the challenges faced in providing adequate activities on weekends. The facility had only one activity staff member available on weekends, which limited the variety and frequency of activities. Staff expressed that more activities could prevent residents from becoming bored and potentially getting into conflicts with each other. The Activities Director acknowledged the inaccuracies in the posted calendar and the difficulty in arranging activities without sufficient staff support. The Director of Nursing and Corporate Administrator recognized the need for scheduled weekend activities and the importance of an accurate activity calendar. They noted that incorrect events, such as Father's Day in October, could negatively impact residents' moods, especially those with a history of trauma. The lack of diverse and engaging activities on weekends was a significant deficiency, affecting the residents' quality of life and psychosocial well-being.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility staff failed to ensure that hot food items were served at a safe and appetizing temperature, as observed during meal service on the 400 and 500 halls. The facility's Dietary Food Preparation policy requires hot foods to be served at temperatures greater than 135 degrees Fahrenheit, preferably between 160 to 170 degrees Fahrenheit. However, observations revealed that the internal temperatures of hot food items, such as chicken paprikash with pasta and squash, were significantly below the required temperature, measuring at 109.4 degrees Fahrenheit and 95.7 degrees Fahrenheit, respectively. The dietary manager acknowledged the temperature discrepancy but continued to serve the food without reheating it to the proper temperature. Further observations showed that the dietary aide prepared meal trays using room temperature plates and covered them with metal plate covers that had open holes, which did not retain heat effectively. The trays were then placed on an open wheeled bakery rack cart for delivery. Interviews with staff members revealed a lack of awareness regarding the correct serving temperatures for hot foods, with one staff member incorrectly believing that 72 degrees Fahrenheit was acceptable. Residents reported that their food was often served cold, indicating a recurring issue with maintaining appropriate food temperatures. The dietary manager admitted that the metal plate covers with holes were used due to storage limitations and acknowledged that this contributed to the problem of cold food. Additionally, the dietary manager did not routinely check the temperatures of foods served on carts in the unit, and there was no communication with the administrator regarding the need for different plate covers. The administrator was unaware of the issues with food temperatures and stated that the dietary manager was responsible for monitoring food temperatures, highlighting a lack of oversight and communication within the facility's management.
Failure to Conduct Pre-Employment Screenings
Penalty
Summary
The facility staff failed to conduct necessary pre-employment screenings for four out of ten new employees, which is a violation of their policy. The policy requires the Human Resources department to perform pre-employment checks to ensure applicants have not committed disqualifying crimes, are not excluded from federal or state healthcare programs, and are eligible to work in the United States. Specifically, the checks should include a Criminal Background Check (CBC) through the Missouri Highway Patrol or a Family Care Safety Registry (FCSR) check, and an Employee Disqualification List (EDL) check. However, the records showed that these checks were either requested or completed after the employees were hired, which is against the facility's policy. The personnel records revealed that Dietary Aide S, [NAME] Y, Housekeeper N, and Activity Aide K were hired before the completion of the required checks. For instance, Dietary Aide S was hired on 09/25/23, but the FCSR check was requested on 09/27/23. Similarly, [NAME] Y was hired on 12/04/23, with checks completed on 12/06/23. Housekeeper N and Activity Aide K also had their checks completed after their respective hire dates. During interviews, the Human Resources representative acknowledged the oversight, stating that the expectation is for all checks to be completed before hiring. The administrator also expressed that they were unaware of the incomplete checks prior to the hiring dates.
Documentation Lapses in Medication and Treatment Administration
Penalty
Summary
The facility staff failed to document the administration of medications and treatments for three residents, leading to a deficiency in meeting professional standards of quality. Resident #115, who had intact cognition and a diabetic foot ulcer, did not have documented wound treatments and pain assessments on multiple occasions in September and October 2024. The resident reported that the wound clinic recommended daily bandage changes, but facility staff changed it every three to four days, indicating a discrepancy in care. Resident #132, with severe cognitive impairment and a venous ulcer, also experienced lapses in documentation. The Treatment Administration Record (TAR) lacked entries for wound treatment and the application of barrier cream after incontinence on several days in October 2024. This lack of documentation suggests that the necessary treatments may not have been administered as prescribed. Resident #219, who had moderate cognitive impairment and a feeding tube, had missing documentation for changing the syringe kit, cleansing the feeding tube site, and flushing the feeding tube with water. These omissions occurred throughout August, September, and October 2024. Interviews with the Resident Care Coordinator (RCC) and the Director of Nursing (DON) revealed that missing signatures on the TARs and MARs were not reported, and the facility's dashboard for tracking missed medications was not effectively utilized.
Failure to Supervise Resident with Risky Behavior
Penalty
Summary
The facility staff failed to provide adequate supervision for a resident with a history of inserting foreign objects into their colostomy bag and stoma, leading to multiple hospitalizations. The resident, who was assessed as cognitively intact, had documented incidents of inserting objects such as a paperclip, fork, spoon, and other foreign items into their colostomy bag and stoma. Despite these repeated incidents, the resident's care plan did not include specific interventions to address this behavior, and staff did not implement or document any corrective actions following each occurrence. Interviews with facility staff, including the Charge Nurse and Director of Nursing (DON), revealed that there were no interventions attempted after each incident, and the care plan lacked strategies to prevent the resident from accessing silverware or other potential objects. The DON acknowledged that if interventions had been attempted, it might have prevented future incidents. The facility's failure to implement and document appropriate interventions and supervision measures contributed to the resident's repeated hospitalizations due to the insertion of foreign objects.
Failure to Update Care Plans for Colostomy Bag Use and Interventions
Penalty
Summary
The facility staff failed to document and update care plans for two residents regarding the use of colostomy bags and necessary interventions. Resident #2, who was cognitively intact and used an ostomy bag, had a care plan that did not include directions for the use of the colostomy bag, despite having a physician's order for it. The Director of Nursing (DON) and the MDS Coordinator acknowledged the oversight and admitted that the care plan should have been updated to include this information. Resident #1, also cognitively intact and using a colostomy bag, had a history of inserting foreign objects into the colostomy bag and stoma, leading to multiple hospitalizations. Despite these incidents, the care plan had not been updated with new interventions since February 2024. Interviews with the Charge Nurse, DON, and the administrator revealed that no new interventions were attempted or documented after each incident, although they agreed that such actions should have been taken and recorded in the care plan.
Failure to Notify Guardian of Resident's Hospital Transfer
Penalty
Summary
Facility staff failed to notify a resident's responsible party when the resident was transferred to the hospital from a wound care appointment. The facility's policy requires staff to inform the resident, consult the resident's physician, and notify the resident's representative of significant changes in the resident's condition or when a transfer occurs. However, in this case, the staff did not document any notification to the resident's guardian about the transfer. The resident, who was cognitively intact, had a surgical wound on the right foot and several diagnoses, including metabolic encephalopathy and diabetes with circulatory complications. The resident's care plan included a left below-the-knee amputation and a right transverse foot amputation. Interviews with facility staff, including an LPN, the DON, and the Resident Care Coordinator, revealed that there was an expectation to notify the guardian, but it was not done. The guardian was unaware of the transfer until contacted by the hospital for permission to treat the resident.
Failure to Maintain Infection Control Program
Penalty
Summary
The facility staff failed to maintain an infection prevention and control program to provide a safe and sanitary environment, leading to the potential spread of COVID-19 and other infections. Staff did not follow acceptable infection control practices, such as separating residents who tested positive for COVID-19 from those who tested negative or had only been exposed. This failure increased the risk of contracting COVID-19 for several residents due to prolonged exposure. Additionally, staff did not consistently wear the appropriate Personal Protective Equipment (PPE) when interacting with COVID-19 positive residents, nor did they remove and dispose of contaminated PPE appropriately. Observations revealed multiple instances where COVID-19 positive residents were not isolated properly. For example, the door to a room with two COVID-19 positive residents was left open, and a Certified Nurse Aide (CNA) was observed sitting close to one of the residents with only an N95 respirator on, lacking gloves, face shield, or gown. Other observations showed COVID-19 positive residents without masks, doors to their rooms open, and no PPE stations outside the rooms. Staff, including maintenance workers and the assistant administrator, entered rooms of COVID-19 positive residents without full PPE and continued to wear the same N95 masks after exiting the contaminated areas. Further observations indicated improper PPE removal and disposal practices. Staff were seen removing PPE in hallways and placing contaminated PPE in regular trash bags instead of bio-hazard bags. Interviews with staff, including CNAs, housekeepers, and the Director of Nursing (DON), confirmed that there was confusion and inconsistency regarding the proper use and disposal of PPE. The DON acknowledged that staff should wear full PPE when entering COVID-19 positive rooms and should remove PPE inside the room, placing it in red bio-hazard bags, not regular trash bags.
Failure to Complete Neurological Checks and Documentation After Un-witnessed Falls
Penalty
Summary
Facility staff failed to complete 72-hour neurological checks and fall follow-up documentation for two residents who had un-witnessed falls. The facility's Post Fall Protocol requires neurological assessments and detailed documentation following an un-witnessed fall, but these were not completed for the residents in question. Resident #1, who was cognitively intact and independent for mobility, had un-witnessed falls on two separate occasions, but the required neurological checks and documentation were not found in the medical record. Similarly, Resident #2, who was cognitively intact and used a wheelchair for mobility, also experienced an un-witnessed fall, and the necessary follow-up was not documented in the medical record. Interviews with various staff members, including LPNs, CMTs, RCCs, and the DON, revealed inconsistencies in the understanding and execution of the facility's Post Fall Protocol. Staff members acknowledged that neurological checks should be initiated and documented in Point Click Care (PCC) for 72 hours following an un-witnessed fall. However, there was confusion about who was responsible for ensuring these tasks were completed, with some staff indicating that the DON or RCCs were ultimately responsible. Despite this, the required documentation was not completed for the residents involved. The DON admitted that some staff had trouble using the PCC system and occasionally resorted to paper documentation, which was then scanned into PCC. However, this process was not consistently followed, leading to gaps in the required neurological checks and follow-up documentation. The failure to adhere to the facility's Post Fall Protocol resulted in incomplete assessments and documentation for the residents who experienced un-witnessed falls.
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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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