Fulton Manor Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fulton, Missouri.
- Location
- 520 Manor Drive, Fulton, Missouri 65251
- CMS Provider Number
- 265760
- Inspections on file
- 15
- Latest survey
- April 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Fulton Manor Care Center during CMS and state inspections, most recent first.
Facility staff did not prevent the employment of a CNA who had a federal indicator for misconduct on the CNA Registry. Despite policies requiring background checks and registry reviews, the responsible staff member overlooked the federal marker and the administrator was unaware of the issue, resulting in the CNA being hired.
Facility staff failed to ensure call lights were within reach for several residents, leading to unmet needs for assistance. Observations showed residents with cognitive impairments and assistance needs were unable to access call lights, resulting in them calling out for help. Staff interviews revealed a lack of awareness and communication regarding the accessibility of call lights, with some staff acknowledging the issue of short call light strings.
Facility staff failed to provide written notification of the bed hold policy to residents or their representatives during hospital transfers or therapeutic leaves. This issue affected four residents, and the facility lacked a bed hold policy. Interviews revealed that the DON and administrator were unaware of the bed hold requirements and processes.
The facility failed to complete baseline care plans within 48 hours for several residents, as required by policy. The Care Plan Coordinator and DON were unclear about the timeframe, leading to delays. The administrator incorrectly stated that care plans should be completed within seven days, contributing to the deficiency.
Facility staff failed to follow professional standards by not obtaining physician's orders for water flushes during G-tube medication administration for a resident. Medications were administered without necessary water flushes, and Levothyroxine was not given separately as required. Unauthorized documentation by CMTs on the MAR was also noted, with a lack of oversight due to the absence of a DON.
Facility staff failed to meet basic hygiene needs for four residents, as observations and interviews revealed inconsistent shower offers and documentation. A resident with mild cognitive impairment was observed with greasy hair despite documented showers, while another cognitively intact resident reported not having a shower in weeks. A newly admitted resident had no documented showers, and staff interviews indicated a lack of consistent care due to a temporary absence of a DON.
The facility failed to obtain signed consents and conduct necessary side rail assessments for four residents, as required by policy. Observations showed residents with bed rails in the upright position without proper documentation. Interviews with staff revealed confusion about responsibilities, leading to non-compliance with procedures.
The facility failed to provide adequate staffing as per their Facility Assessment, resulting in unmet hygiene needs for several residents. Observations and interviews revealed that residents were not receiving regular showers or personal hygiene assistance due to understaffing. The facility's reliance on fire code regulations instead of the Facility Assessment for staffing contributed to this deficiency.
The facility failed to maintain the required RN coverage of eight consecutive hours per day, seven days a week, from July 2024 to January 2025. The RN staff schedule showed numerous days without adequate RN presence, and interviews with the DON and administrator revealed a lack of awareness of the regulatory requirements. Despite recognizing the importance of RN expertise, the facility did not ensure compliance with staffing regulations.
The facility failed to post required nurse staffing information, including the facility census and actual hours worked by licensed and unlicensed staff, in an accessible location. Observations and interviews revealed that the Director of Nursing and the administrator were unaware of the missing information, despite policy requirements. The responsibility for completing the daily staffing sheet was assigned to the charge nurses, but the deficiency persisted.
A resident in an LTC facility experienced a medication administration error, resulting in a 28.13% error rate. The LPN administered multiple medications via G-tube over two hours late, contrary to the facility's policy of administering within one hour of the prescribed time. The resident expressed concern about the delay, and the LPN admitted to forgetting the scheduled administration.
The facility failed to ensure proper operation of the dishwashing machine, resulting in inadequate sanitization of kitchen wares due to low temperatures and insufficient sanitizer concentration. Manual warewashing also showed deficiencies, with improper sanitizer concentration and insufficient sanitization time. Additionally, the ice machine lacked a required air gap, indicating a failure to adhere to sanitation standards.
The facility failed to implement an effective QA/QAPI program, as there was no policy in place and no documentation of quarterly meetings held by department heads to discuss facility issues and resolutions. The administrator was unaware of the need for documentation, affecting a facility with a census of 43.
The facility failed to follow its policy for TB testing, administering the second PPD test too soon for several employees. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) effectively, as staff were not educated or alerted about residents requiring EBP, and PPE was not readily available. Observations showed staff did not wear gowns during high-contact care activities, and interviews revealed a lack of awareness and training on EBP. The new DON acknowledged the oversight issues, but no corrective actions were taken at the time.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential entrapment risks for four residents. The facility's policies lacked a specific policy for Entrapment Risk Assessments, and the existing policy on the proper use of side rails was undated. Interviews with staff revealed a lack of awareness and adherence to regulations regarding bed rail safety, contributing to the deficiency in ensuring resident safety.
Facility staff failed to protect resident privacy by leaving computer screens with sensitive information open in public areas and not ensuring privacy during incontinence care. Two residents' medication information was exposed, and a resident was left visible to the parking lot during personal care. Staff interviews confirmed these actions were against facility policy.
The facility failed to complete the federally mandated MDS assessments within the required time frames for three residents. The MDS Coordinator was behind on completing assessments due to being pulled to work on the floor, and there was no system to ensure timely completion. The DON was unaware of the required time frames, contributing to the deficiency.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical and psychosocial needs. A resident on hospice care lacked hospice documentation in their care plan, another resident's use of bed rails was not documented, and a third resident with contractures had no interventions noted. Staff acknowledged these oversights, attributing them to the MDS/Care Plan Coordinator's responsibilities.
The facility failed to implement an Antibiotic Stewardship Program, lacking protocols and a system to monitor antibiotic use. The DON, new to the role, was unaware of any existing program, and the Corporate Nurse admitted that tracking and trending of antibiotic use had not been done. The administrator was unaware of the program's absence, indicating a lack of oversight.
A resident with a history of aggression grabbed another resident's arm, leading to a physical altercation. The aggressive resident was supposed to be monitored one-on-one after returning from the hospital, but was left unattended by an LPN who was not informed of the monitoring requirements. Surveillance footage showed no staff present during the incident, highlighting a failure in communication and supervision.
A CNA in a long-term care facility misappropriated $400 from a resident's checking account by cashing a check for personal use. The resident, who was moderately cognitively impaired, wrote the check after the CNA requested a loan to bail out a relative. The incident was reported over a month later, leading to an investigation and confirmation of the CNA's actions.
A facility failed to implement its abuse prevention policy when a PTA accused of inappropriate conduct was allowed to continue working with residents during an investigation. The policy requires immediate suspension and removal of alleged perpetrators, but the PTA remained unsupervised. The incident involved a cognitively intact resident with multiple diagnoses who reported feeling uncomfortable with the PTA's proximity and alleged inappropriate comments.
Failure to Screen and Prevent Employment of CNA with Federal Misconduct Indicator
Penalty
Summary
Facility staff failed to ensure that an employee with a federal indicator for misconduct on the Certified Nurse Aide (CNA) Registry was not hired or engaged to work. The facility's policies required screening of potential employees for any history of abuse, neglect, exploitation, or misappropriation of resident property, including checking the CNA Registry for federal indicators. Despite these policies, a review of one employee's personnel record showed that the individual was hired even though their CNA Registry indicated a federal marker for misconduct. Interviews revealed that the Social Service Director (SSD) was responsible for conducting background checks, including reviewing the CNA Registry. However, the SSD overlooked the section indicating the federal marker for misconduct, focusing instead on the active status of the CNA. The administrator was unaware of the federal indicator and acknowledged that no audits were being conducted to ensure compliance with hiring policies at the time.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility staff failed to provide reasonable accommodations to meet the needs of residents by not ensuring that call lights were within reach for four residents. The facility's policy requires that call lights be accessible to residents at all times, but observations showed that call lights were consistently out of reach for several residents. For instance, Resident #4, who has cognitive impairment and requires moderate assistance, was observed multiple times with the call light across the room, leading the resident to yell for help. Similarly, Resident #10, with severe cognitive impairment and needing maximal assistance, was found in situations where the call light was not within reach, causing the resident to express confusion and inability to call for help. Resident #48's call light was secured to a wall light pull-cord, making it difficult for the resident to reach, despite the resident's ability to use the call light if it were accessible. Interviews with staff confirmed that the call light string was too short, and the Maintenance Director was unaware of the issue until it was brought to their attention. Resident #295 also experienced issues with the call light being out of reach due to a short string. Interviews with staff, including CNAs, LPNs, and the Director of Nursing, revealed a lack of communication and awareness regarding the accessibility of call lights. The staff acknowledged the expectation that call lights should be within reach, but the deficiency persisted due to inadequate measures to ensure compliance with the facility's policy.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility staff failed to provide written notification to residents or their representatives regarding the bed hold policy during transfers to hospitals or therapeutic leaves. This deficiency was identified for four residents out of a sample of four, with the facility's census being 43. The facility's policies did not include a bed hold policy, and the medical records of the affected residents lacked documentation of notification about the bed hold policy at the time of their discharge and readmission. Interviews with the Director of Nursing (DON) and the administrator revealed a lack of awareness and understanding of the bed hold requirements and processes. The DON was unaware of the bed hold requirement, while the administrator acknowledged the existence of bed hold paperwork in the admission packet but was not familiar with the requirement or process for bed hold at the time of residents' transfer and discharge.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to complete baseline care plans within 48 hours of admission for five residents out of a sample of 16, as required by their policy. The policy, dated December 2016, mandates that a baseline care plan should be developed to meet the resident's immediate needs within 48 hours of admission. However, the electronic medical records (EMRs) for Residents #20, #43, #45, #46, and #48 did not contain documentation of a completed baseline care plan within the specified timeframe. Interviews with the Care Plan Coordinator revealed uncertainty and delays in completing these plans, with attempts to gather information extending beyond the 48-hour requirement. The Care Plan Coordinator admitted to trying to complete the baseline care plans within the first week rather than the required 48 hours. The Director of Nursing (DON) was unaware of the specific timeframe for completing baseline care plans and acknowledged that there was no system in place to ensure timely completion. The facility administrator stated that the initial nurse should initiate the care plan, and the Care Plan Coordinator should complete it within seven days, contrary to the policy. This lack of clarity and oversight contributed to the deficiency in meeting the residents' immediate needs upon admission.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility staff failed to adhere to professional standards of practice by not obtaining physician's orders for water flushes during medication administration via G-tube for a resident. The facility's policy required a physician's order for such procedures, but the resident's Physician's Order Sheet did not include this order. Despite this, medications were administered without the necessary water flushes, as observed on multiple occasions. Interviews with staff revealed a lack of awareness and communication regarding the need for such orders, indicating a breakdown in protocol adherence. Additionally, the facility staff did not administer medications as directed by the physician and the Medication Administration Record (MAR). Specifically, Levothyroxine, which was ordered to be given on an empty stomach and separately from other medications, was administered alongside other medications. This was contrary to the instructions on the MAR and the facility's policy, which emphasized the importance of timing and separation of medication administration to enhance therapeutic effects. Staff interviews highlighted a lack of attention to these instructions, with one LPN admitting to not following the MAR directions. Furthermore, the facility staff failed to ensure that only licensed personnel documented medication administration via G-tube. The MAR showed documentation by Certified Medication Technicians (CMTs), who were not authorized to administer medications via G-tube. Interviews with staff, including the Director of Nursing (DON) and the facility administrator, revealed a lack of monitoring and auditing of MARs, leading to unauthorized documentation. This issue was compounded by the absence of a DON for a period, resulting in lapses in oversight and adherence to physician orders.
Failure to Provide Adequate Hygiene Care
Penalty
Summary
The facility staff failed to provide adequate hygiene care for four residents, resulting in unmet basic hygiene needs. The facility's Bath, Shower/Tub Policy, dated February 2018, requires staff to promote cleanliness, document shower/bath occurrences, and notify supervisors of refusals. However, observations and interviews revealed that residents were not receiving showers as scheduled, and documentation was inconsistent or missing. For instance, Resident #24, with mild cognitive impairment, was observed with greasy hair despite documented showers, indicating a lack of adherence to the care plan. Resident #32, who is cognitively intact and requires supervision for bathing, reported not having a shower in several weeks and feeling neglected. The care plan lacked specific directions for assistance with ADLs, and the shower sheets showed infrequent showers with no recent offers. Similarly, Resident #35, also cognitively intact, was observed with greasy hair and unclean fingernails, suggesting infrequent bathing despite documented showers. The care plan did not provide clear instructions for ADL assistance, contributing to the deficiency. Resident #48, newly admitted, had no documented showers since admission, and observations showed poor hygiene, including greasy hair and food debris on teeth. The resident expressed a need for assistance with bathing, which was not provided. Interviews with staff, including CNAs and an LPN, revealed a lack of consistent shower offers and documentation, partly due to the absence of a Director of Nursing (DON) for a period. The facility administrator acknowledged the expectation for regular showers and the lapse in monitoring during the DON vacancy.
Failure to Obtain Consent and Conduct Bed Rail Assessments
Penalty
Summary
The facility failed to obtain signed consents for the use of bed rails and did not complete necessary side rail assessments for four residents. The facility's policy requires an assessment of the resident's risk from using bed rails, obtaining informed consent, and a physician's order before installation. However, these steps were not followed for Residents #3, #15, #20, and #46, as their medical records lacked signed informed consents and bed rail assessments. Resident #3, who was assessed with severe cognitive impairment and required substantial assistance with toileting and transfers, was observed with the left side rail in the upright position on multiple occasions. Similarly, Resident #15, who was cognitively intact and independent with bed mobility, was observed with bilateral side rails in the upright position over several days. Resident #20, who used side rails for bed mobility, and Resident #46 also had side rails in the upright position without the necessary consents or assessments. Interviews with facility staff, including an LPN and the Director of Nursing, revealed a lack of clarity and adherence to the facility's policy regarding bed rail assessments and consents. The staff were unsure about the responsibility for obtaining consents and completing assessments, leading to the deficiency in following the established procedures for bed rail use. The administrator acknowledged the oversight but was unsure why the assessments were not conducted quarterly as required.
Inadequate Staffing Leads to Unmet Hygiene Needs
Penalty
Summary
The facility failed to provide adequate staffing in accordance with their Facility Assessment, leading to unmet basic hygiene needs for several residents. The Facility Assessment outlined specific staffing requirements based on census numbers, but the employee schedules from August to December 2024 showed consistent understaffing across various shifts. This lack of sufficient staffing resulted in residents not receiving necessary care, such as showers and personal hygiene assistance, as documented in the observations and interviews with residents and staff. Resident #24, who was assessed with mild cognitive impairment and required partial assistance with personal hygiene, was observed with greasy hair on multiple occasions, indicating a lack of regular showers. Similarly, Resident #32, who was cognitively intact and required supervision for bathing, reported not being offered a shower for several weeks, leading to feelings of neglect. Resident #35, also cognitively intact and requiring assistance with personal hygiene, was observed with greasy hair and long, dirty fingernails, further highlighting the facility's failure to meet hygiene needs. Resident #48, who required assistance with ADLs, had not been documented as receiving a shower since admission, and was observed with greasy hair and food debris on teeth. Interviews with other residents and staff confirmed the perception of short staffing, with residents expressing dissatisfaction with the frequency of showers and staff acknowledging the lack of adequate assistance. The Director of Nursing and the administrator admitted to not following the Facility Assessment for staffing, instead relying on fire code regulations, which contributed to the deficiency in care.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required by their policy. The review of the facility's RN staff schedule from July 2024 to January 2025 revealed numerous instances where the facility did not have an RN on duty for the required hours. Specifically, there were multiple days each month where the facility lacked RN coverage for the mandated eight consecutive hours, indicating a consistent pattern of non-compliance with the staffing requirement. Interviews conducted with the Director of Nursing (DON) and the facility administrator highlighted a lack of awareness and understanding of the regulatory requirements for RN coverage. The DON admitted to being unsure of the regulation and acknowledged the importance of having an RN for their expertise and knowledge. Similarly, the administrator was aware of the deficiency in RN coverage and recognized the significance of having an RN present for their advanced nursing knowledge. Despite this awareness, the facility failed to ensure adequate RN staffing, leading to the identified deficiency.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility staff failed to complete the required nurse staffing information, which included the facility census and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, on a daily basis. The facility's policy, dated July 2016, mandates that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care should be posted in a prominent location accessible to residents and visitors. However, reviews of the facility's daily staffing sheets from November 2024 to January 2025 showed that they did not contain the facility census or actual hours worked for licensed and non-licensed staff. Observations on multiple dates in January 2025 confirmed that the facility staff postings did not include the required information and were not readily accessible to residents and visitors. Interviews with the Director of Nursing (DON) and the administrator revealed that they were unaware of the missing information on the daily staffing sheets. Both acknowledged that the daily staff postings should include the facility census and actual hours worked and should be accessible to all residents and visitors. The responsibility for completing the daily staffing sheet was attributed to the charge nurses, specifically the night charge nurse, but the deficiency persisted due to a lack of awareness and oversight.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than five percent, resulting in a 28.13% error rate during the observation period. Out of 32 medication administration opportunities, nine errors were identified, affecting one resident. The errors were primarily due to the late administration of medications, which were given two hours and twenty minutes past the scheduled time. The facility's policy mandates that medications should be administered within one hour of their prescribed time, and any administration beyond this window is considered a medication error. The deficiency involved a resident who was supposed to receive multiple medications via a gastric tube during the morning medication pass. The medications included Levothyroxine, Midodrine, Vitamin D, Cyclobenzaprine, Eliquis, Fludrocortisone, Gabapentin, Fluoxetine, and Prenatal vitamins. The resident expressed concern about not receiving medications as scheduled, and the LPN responsible admitted to forgetting to administer them on time. The LPN acknowledged the error and the need to notify the Director of Nursing and the resident's physician, although this had not been done at the time of the interview.
Deficiencies in Dishwashing and Ice Machine Sanitation
Penalty
Summary
The facility staff failed to ensure the dishwashing machine operated according to the manufacturer's instructions, leading to inadequate sanitization of kitchen wares. Observations revealed that the dishwashing machine consistently failed to reach the required wash and rinse temperatures, with recorded temperatures as low as 90 degrees Fahrenheit for washing and 110 degrees Fahrenheit for rinsing. Additionally, the sanitizer concentration was below detection levels, as indicated by test strips that did not change color. Despite these issues, the Dietary Manager was unaware of the machine's failure to meet the necessary temperature and sanitizer concentration standards. The facility's manual warewashing process also demonstrated deficiencies. Staff were observed using a sanitizer concentration of 100 ppm, which was within the range stated by the Dietary Manager but not in accordance with the manufacturer's instructions, which required a concentration of 150-400 ppm. Furthermore, the sanitizing process was not consistently followed, with some items being removed from the sanitizer sink after only 30 seconds instead of the required one minute. The Dietary Manager admitted to not having read the sanitizer directions for use, indicating a lack of adherence to proper sanitization protocols. Additionally, the facility failed to maintain an air gap for the ice machine drain, which was directly connected to the floor drain without the necessary air gap. The maintenance director was unaware of this requirement, and the administrator confirmed that the maintenance director was responsible for the ice machine. This oversight further highlights the facility's failure to adhere to proper sanitation and safety standards, as the absence of an air gap can lead to potential contamination issues.
Lack of Effective QA/QAPI Program Documentation
Penalty
Summary
The facility staff failed to develop and implement an effective Quality Assurance (QA)/Quality Assurance Performance Improvement (QAPI) program. The facility's policies did not include a policy for the QA/QAPI program. During an interview, the administrator stated that department heads meet quarterly to discuss various items within the facility, but there was no documentation available regarding these meetings, issues discussed, or resolutions made. The administrator was unaware that such information needed to be documented and maintained. The facility census at the time was 43.
Deficiencies in TB Testing and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its own policy regarding the administration of the two-step purified protein derivative (PPD) skin test for tuberculosis (TB) for six employees. The policy required a second PPD test to be administered seven to 21 days after the first test if the initial result was negative. However, the second PPD tests for several employees were administered too soon, within five to six days after the first test, contrary to the policy. This discrepancy was attributed to the MDS Coordinator's misunderstanding of the policy and scheduling conflicts, as well as a lack of oversight from the Director of Nursing (DON) and the facility administrator. The facility also failed to implement its Enhanced Barrier Precautions (EBP) policy effectively. Staff were not educated or alerted about residents who required EBP, and appropriate personal protective equipment (PPE) was not placed in close proximity for residents with specific medical needs, such as feeding tubes and colostomies. Observations revealed that staff did not wear gowns when performing high-contact care activities, such as administering medications via G-tube or providing incontinence care, as required by the EBP policy. Interviews with staff indicated a lack of awareness and training regarding EBP requirements. The deficiencies in both TB testing and EBP implementation were compounded by inadequate communication and training from the facility's leadership. The new DON acknowledged the lack of oversight by the previous DON and the need for further education on EBP. The administrator also admitted that EBP precautions were not being followed and emphasized the importance of infection control. Despite these acknowledgments, the facility had not taken corrective actions to address these deficiencies at the time of the report.
Failure to Conduct Regular Bed Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential entrapment risks for four residents. The facility's policies lacked a specific policy for Entrapment Risk Assessments, and the existing policy on the proper use of side rails was undated. The policy required regular checks to ensure bed rails and mattresses were appropriately secured and did not pose entrapment risks. However, the facility did not adhere to these guidelines, as evidenced by the absence of entrapment risk assessments and maintenance inspections in the electronic medical records of the sampled residents. Resident #3, who had severe cognitive impairment and required substantial assistance with toileting and transfers, was observed multiple times with the left side rail in the upright position without any documented entrapment risk assessment or maintenance inspection. Similarly, Resident #15, who was cognitively intact and independent with bed mobility, was observed with bilateral side rails in the upright position on several occasions, again without any documented assessments or inspections. Residents #20 and #46 also had side rails in the upright position without any documented entrapment risk assessments or maintenance inspections. Interviews with facility staff revealed a lack of awareness and adherence to regulations regarding bed rail safety. The Maintenance Director admitted to not conducting regular measurements of bed rails once installed and was unaware of any regulations requiring such measurements. The DON believed that the MDS coordinator was responsible for bed rail measurements but was not aware of specific regulations. The facility administrator was also unaware that entrapment assessments were not being conducted quarterly, as they believed was necessary. This lack of compliance with safety protocols and inadequate staff awareness contributed to the deficiency in ensuring resident safety.
Privacy Breaches in Resident Care and Information Handling
Penalty
Summary
The facility staff failed to protect the privacy and confidentiality of residents' personal and medical information. On two separate occasions, computer screens on medication carts were left open and unattended in public hallways, displaying sensitive medication information for two residents. This occurred despite the facility's policy requiring staff to lock or minimize computer screens when unattended. Interviews with staff, including the Care Plan Coordinator and an LPN, confirmed that the screens should have been secured to protect resident privacy. Additionally, during incontinence care for a resident, a CNA did not close the privacy curtain or window blinds, leaving the resident exposed to view from the parking lot. The resident expressed discomfort with the lack of privacy, and the CNA acknowledged the oversight, attributing it to nervousness. Interviews with the LPN and the Director of Nursing confirmed that staff are expected to ensure privacy by closing curtains and blinds during personal care activities.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility staff failed to complete the federally mandated Minimum Data Set (MDS) assessments within the required time frames for three residents out of a sample of six, with a total facility census of 43. The facility's policy, dated July 2017, outlines that the Assessment Coordinator or designee is responsible for ensuring timely submission of resident assessments to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation Service (QIES) Assessment Submission and Processing (ASAP) system. However, the review of the MDS records for Residents #20, #24, and #48 revealed that the required assessments were not completed or submitted within the specified time frames as per the Resident Assessment Instrument (RAI) Manual guidelines. Interviews with the MDS Coordinator and the Director of Nursing (DON) highlighted issues contributing to the deficiency. The MDS Coordinator admitted to being behind on completing MDSs due to being frequently pulled to work on the floor, and acknowledged that there was no system in place to double-check the timely completion of MDSs. The DON, who was new to the facility, was unaware of the required time frames for MDS submissions. The administrator confirmed that the MDS Coordinator was responsible for completing the MDSs within the required time frames, while the DON was responsible for monitoring their completion. This lack of adherence to the required assessment time frames resulted in the deficiency noted by the surveyors.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility staff failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in meeting their medical, nursing, mental, and psychosocial needs. Resident #1, who was admitted on hospice care, did not have hospice services documented in their care plan, despite the facility's policy requiring such documentation. The Social Services Director and the MDS/Care Plan Coordinator acknowledged the oversight, noting that hospice directions should have been included in the resident's care plan. Resident #15, assessed as cognitively intact and independent in certain activities, had bed rails in use that were not documented in their care plan. Observations over several days confirmed the presence of bilateral U-Bars in the resident's bed, yet the MDS/Care Plan Coordinator mistakenly believed this was already included in the care plan. The absence of this information in the care plan was acknowledged as an oversight by the staff. Resident #16, with severe cognitive impairment and multiple diagnoses, had contractures in both upper and lower extremities that were not addressed in their care plan. Observations showed the resident in a broda chair with contracted hands, lacking any interventions. The MDS/Care Plan Coordinator admitted that interventions, such as placing washcloths in the resident's hands, were supposed to be documented but were not. The Director of Nursing and the facility administrator confirmed that the responsibility for these omissions lay with the MDS/Care Plan Coordinator, who was expected to update care plans regularly.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility staff failed to implement an Antibiotic Stewardship Program, which includes protocols and a system to monitor and track antibiotic use. The facility, with a census of 43, did not have a policy for antibiotic stewardship, and there was no process in place to track and trend antibiotic usage. Interviews revealed that the Director of Nursing (DON), who had been employed for only eight days, was unaware of any existing program. The Corporate Nurse admitted that the previous DON did not track and trend antibiotic use, and no one had been doing it. The administrator stated that the Infection Preventionist, who was the previous DON, was responsible for the program, but oversight was lacking, and she was unaware of the program's absence.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident, who had a history of physical aggression, grabbed the resident's arm. The incident involved two residents, one of whom was cognitively impaired and the other cognitively intact but with a history of aggressive behavior. The facility's policy defines abuse as the willful infliction of injury or intimidation resulting in harm, which includes resident-to-resident altercations. Resident #1, who was cognitively impaired, was involved in an altercation with Resident #2, who had a documented history of aggression and was assessed as cognitively intact. The care plan for Resident #2 included measures to reduce stimuli, monitor interactions, and intervene before agitation escalated. Despite these measures, Resident #2 was left unattended by LPN A, who was responsible for monitoring the resident one-on-one after returning from the hospital following a previous altercation. The incident occurred when Resident #1 propelled their wheelchair near Resident #2, who then grabbed Resident #1's arm. Surveillance footage showed no staff present at the time of the incident. Interviews revealed that LPN A was not informed of the need for continuous one-on-one monitoring, and there was a lack of communication among staff regarding the monitoring requirements for Resident #2. This failure to ensure proper supervision and adherence to the care plan led to the physical altercation between the residents.
Misappropriation of Resident Funds by CNA
Penalty
Summary
Facility staff failed to prevent the misappropriation of money from a resident's checking account when a Certified Nurse Assistant (CNA) cashed a check from the resident for personal use. The incident involved a resident who was assessed as moderately cognitively impaired with no behaviors. On June 22, 2024, the resident wrote a check for $400.00 to the CNA, who had asked to borrow the money to bail a relative out of jail, with the promise of repayment on the next payday. The resident kept the checkbook in their room and reported the incident to another CNA on July 27, 2024, after not being repaid. Upon discovery of the incident, the facility staff initiated an investigation and reported the misappropriation to the Department of Health and Senior Services, the local police department, and the resident's physician. The administrator conducted interviews with facility staff and residents, and it was confirmed that the CNA admitted to taking and depositing the check. The resident had also filed a grievance about the incident, and it was noted that a dental bill check had bounced around the same time the money was given to the CNA. The facility's policy on abuse, neglect, and exploitation mandates protection for residents' health, welfare, and rights, including the prevention of misappropriation of property. The policy requires immediate investigation of such allegations and reporting to the appropriate authorities. Staff are educated on these policies upon hire and annually, with additional training provided as needed. Despite these measures, the CNA involved in the incident admitted to knowing that accepting money from a resident was against policy.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its abuse prevention policy effectively, resulting in a deficiency related to resident safety. The policy, dated November 2017, mandates that any alleged perpetrator of abuse, neglect, or misappropriation of resident funds be immediately suspended from employment and removed from the property until the investigation is complete. However, the facility did not adhere to this policy when a Physical Therapy Assistant (PTA) accused of inappropriate conduct with a resident was allowed to continue working with other residents during the investigation. The administrator was aware of the allegation but did not suspend the PTA or ensure constant supervision as required by the policy. The incident involved a resident who was cognitively intact and had multiple diagnoses, including hypertension, end-stage renal failure, anxiety disorder, and a fracture. The resident reported feeling uncomfortable with the PTA's proximity and alleged that the PTA made inappropriate comments of a sexual nature. Despite these allegations, the PTA was observed in the facility without supervision, and the administrator admitted to not knowing if contracted staff should be treated the same as facility staff in such situations. This inaction led to a failure in protecting the resident and potentially others from further exposure to the alleged perpetrator.
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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