Fulton Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Fulton, Missouri.
- Location
- 1510 Bluff Street, Fulton, Missouri 65251
- CMS Provider Number
- 265663
- Inspections on file
- 21
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Fulton Nursing & Rehab during CMS and state inspections, most recent first.
Surveyors found that the facility failed to update and revise comprehensive care plans to address aggressive and disruptive behaviors and did not complete required quarterly care plan reviews in conjunction with the MDS. Several severely cognitively impaired residents had documented incidents of threatening, hitting, kicking, slapping, yelling, and cursing at peers, yet their care plans either lacked any behavioral interventions or were not revised to include new interventions after these events. Staff interviews with an LPN, the DON, and the MDS Coordinator confirmed that care plans were expected to be updated after behavioral incidents and at regular intervals, but this did not occur, partly because the MDS Coordinator was solely responsible for revisions and had been absent for an extended period.
Staff did not consistently separate residents who tested positive for COVID-19 from those who tested negative, resulting in both groups sharing rooms and common areas without masks. Several residents were not consulted about room changes despite their preferences, and staff interviews revealed confusion about which residents were COVID-positive and a lack of proper signage and PPE disposal. Leadership acknowledged that while a list of positive residents was available, not all staff were aware of it or following infection control protocols.
Facility staff did not ensure RN coverage for at least eight consecutive hours per day, seven days a week, as required. Staffing records showed multiple days without proper RN coverage, and interviews with the DON, administrator, and ADON revealed they were unaware of the specific lapses. The administrator attributed the deficiency to recent RN staff losses and challenges in scheduling, particularly on weekends.
Facility staff did not notify a resident's DPOA following a significant change in condition that led to a hospital transfer for psychiatric evaluation. Despite facility policy requiring immediate notification of family or legal representatives, the family only learned of the transfer after contacting the facility themselves. Staff interviews revealed confusion about responsibility for ensuring notification and documentation.
A resident with lower extremity impairment and using a manual wheelchair was subjected to physical abuse when a floor technician aggressively pulled the wheelchair, causing the resident to fall to the ground. Multiple staff witnessed the technician yelling and roughly handling the resident, who reported both physical pain and emotional distress as a result.
Two residents with impaired cognition were involved in an incident of inappropriate touching, where one resident raised their shirt and another touched their chest. The event was witnessed by a CMT and reported to an RN. Despite facility policies to prevent abuse, the incident highlights a lapse in monitoring and preventing inappropriate interactions between residents.
Facility staff failed to use appropriate infection control procedures during medication administration for two residents and did not ensure TB screening for three employees. Observations showed lapses in hand hygiene and handling of medications, and interviews confirmed non-compliance with facility guidelines. Additionally, the facility lacked a policy for catheter care, affecting the quality of care for residents with indwelling catheters.
Facility staff failed to maintain bathroom doorframes, sink counters, and floors in good repair, resulting in brown stains, broken sink counters, and rusted door frames in resident-occupied rooms. Staff were aware of the issues but cited difficulties in obtaining support for materials needed for repairs.
Facility staff failed to provide written information of the bed hold policy at the time of hospital transfer for three residents. Interviews revealed a lack of awareness among staff regarding the responsibility for completing bed hold notifications.
The facility staff failed to perform a significant change in status MDS assessment for two residents who experienced significant changes in their conditions. One resident elected hospice care, and another had a decline in their ability to perform ADLs. Despite the facility's policy requiring timely completion of these assessments, they were not done. Observations confirmed the residents' dependence on staff for care, and interviews revealed a lack of a full-time MDS nurse and unfamiliarity with the MDS process.
The facility staff failed to develop comprehensive care plans for four residents, leading to deficiencies in meeting their medical and nursing needs. Care plans were outdated and did not reflect significant changes in residents' conditions, such as the need for mechanical lifts, increased assistance, and hospice care. Interviews with staff confirmed that care plans should be comprehensive and updated regularly, but this was not adequately done.
Facility staff failed to obtain hydration orders for a resident with a gastric tube, did not complete required weight monitoring for multiple residents, and did not properly document falls and follow-up for a resident. These lapses indicate non-compliance with professional standards of care and facility policies.
Facility staff failed to provide appropriate personal hygiene for three dependent residents. One resident was observed with long facial hair and disheveled hair despite preferring to be clean-shaven. Another resident was observed with long facial hair multiple times, and a third resident reported having only one bath in a month and was observed with disheveled hair and food crumbs on clothing. Staff interviews confirmed that personal hygiene practices were not consistently followed.
Facility staff failed to ensure a safe environment by not using foot pedals during wheelchair propulsion, improperly using mechanical lifts, and not safely storing medications in a resident's room. These actions were confirmed through observations and staff interviews, highlighting a lack of adherence to safety protocols.
Facility staff failed to ensure residents' drug regimens were free from unnecessary drugs by not attempting GDR for psychotropic medications for four residents. Despite pharmacy recommendations, the medical records lacked completed GDRs, and the process for handling these recommendations was not followed.
Facility staff failed to monitor and store medication safely, resulting in expired medications in the storage room and unsecured medication on top of the cart. Interviews confirmed that CMTs and nurses are responsible for monitoring medication storage, but expired medications were still found. Additionally, an unsecured plastic box with resident medications was left on top of the medication cart, posing a safety risk.
Facility staff failed to designate a qualified Dietary Manager (DM). The DM's personnel record lacked documentation of food service experience or certification. The DM admitted to not being certified and not knowing all requirements. Both the DON and the administrator confirmed the necessity of certification, with the DON highlighting potential risks to residents.
Facility staff failed to protect residents' personal information by leaving EHR screens unlocked and unattended in public hallways. Observations showed a CMT and a CNA leaving EHR screens with resident information visible while administering medication. Interviews with staff confirmed that EHR screens should always be locked when unattended to protect residents' privacy.
Facility staff failed to complete the required Comprehensive MDS within the mandated timeframe for two residents. The facility lacked a full-time MDS nurse, and efforts to fill the role temporarily with a corporate nurse and the DON were insufficient to meet the required assessment deadlines.
Facility staff failed to complete the required Quarterly MDS assessments within the mandated timeframe for two residents. The facility lacks a full-time MDS nurse, and the current staff, including a corporate nurse and the new DON, are trying to manage the MDS assessments until the position is filled. Staff are expected to use the RAI manual as a guide to complete and submit the MDS data timely.
Facility staff failed to correctly assess a resident receiving an anticoagulant and another resident for their preferences and oral/dental status. The facility lacked a full-time MDS nurse, and the DON was new and unfamiliar with the MDS process. The corporate nurse and DON were assisting with MDS assessments until a floor nurse could fill the role full-time.
Facility staff failed to ensure that the three most recent years of survey results were posted and readily accessible to residents, family members, or representatives. Observations on multiple dates confirmed the absence of the survey results, and an LPN and the administrator were unable to locate them.
The facility staff failed to complete required neurological checks and fall follow-up documentation for three residents who experienced falls and did not perform weekly skin assessments for two residents. Interviews revealed a lack of clarity and accountability among staff, exacerbated by the absence of a DON.
Failure to Update Behavioral Care Plans and Conduct Timely Quarterly Reviews
Penalty
Summary
The deficiency involves the facility’s failure to develop, update, and revise comprehensive, individualized care plans to address residents’ aggressive and behavioral symptoms, and to review and update care plans at least quarterly in conjunction with the MDS. Facility policy required an individualized comprehensive care plan with measurable goals and time frames, ongoing assessment with revisions as changes occur, and periodic review and updating by the interdisciplinary team when significant changes or other care-impacting changes occur. Despite this, three residents with severe cognitive impairment had documented aggressive or disruptive behaviors that were not reflected in their care plans, and two residents’ care plans were not updated on a quarterly basis as required. One resident, assessed on a quarterly MDS as severely cognitively impaired and without physical behavioral symptoms toward others during the look-back period, had no care plan directions or interventions for aggressive behaviors despite three documented altercations with other residents, including threats with a knife and hitting and slapping peers. A second resident, also severely cognitively impaired and assessed on a quarterly MDS as not exhibiting physical behavioral symptoms toward others, had no care plan guidance for aggressive behavior after kicking another resident in the dining room, and the care plan was not updated quarterly. A third severely cognitively impaired resident had a care plan listing multiple behaviors such as attempting to hit peers and staff, rummaging, making sexual comments, shouting, and refusing care, but no new intervention was added after an altercation involving yelling and cursing at another resident. In interviews, an LPN, the DON, and the MDS Coordinator each stated that new interventions should be added after behavioral incidents and that care plans should be updated quarterly, annually, and after significant changes, but acknowledged that care plans were not consistently updated, in part because the MDS Coordinator was the only person revising care plans and had been out sick for an extended period.
Failure to Cohort and Isolate COVID-19 Positive Residents
Penalty
Summary
Facility staff failed to maintain an effective infection prevention and control program, specifically in the management of residents who tested positive for COVID-19. Despite having a policy that directs staff to isolate or cohort residents with confirmed or suspected SARS-CoV-2 infection, staff did not consistently separate residents who tested positive from those who tested negative. Multiple observations showed that residents with positive COVID-19 test results were housed in the same rooms as residents with negative results, and neither group consistently wore masks. Additionally, COVID-positive residents were observed in common areas, such as hallways and dining rooms, in close proximity to other residents and staff. Interviews with residents and their representatives revealed that several residents were not asked if they wanted to move rooms when their roommate tested positive for COVID-19, despite expressing a preference not to share a room with an infected individual. Staff interviews indicated a lack of clear communication and awareness regarding which residents were COVID-positive. Some staff members, including a Certified Medication Technician and the Assistant Director of Nursing, were unaware of the COVID status of residents or the absence of appropriate signage and PPE disposal materials in affected rooms. The Infection Preventionist acknowledged that interventions such as room trays, some room changes, and mask usage had been implemented, but also noted that many residents refused to wear masks outside their rooms. Leadership interviews highlighted inconsistencies in staff education and communication regarding infection control protocols. While a list of COVID-positive residents was reportedly posted at the nurse's station, several staff members were unaware of it or did not know which residents required isolation or specific PPE. The Director of Nursing and Infection Preventionist were identified as responsible for ensuring compliance, but gaps in implementation and staff knowledge were evident throughout the facility.
Failure to Provide Required RN Coverage
Penalty
Summary
Facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. Record review showed that the facility did not have a policy regarding RN services, and the Facility Assessment indicated the need for at least one RN for eight hours daily. Staffing assignment records for September and October revealed multiple days where there was no documentation of RN coverage for the required period. Specifically, there was no RN coverage for eight consecutive hours on several dates in both months. Interviews with the Director of Nursing (DON), administrator, and Assistant Director of Nursing (ADON) confirmed awareness of the requirement but also revealed a lack of awareness regarding the specific days when coverage was not met. The administrator cited recent RN staff losses and difficulty in providing daily RN coverage, especially on weekends, and stated that efforts to hire more RNs were ongoing. The ADON, who had recently taken over scheduling, was also unaware of the missed coverage on the identified dates.
Failure to Notify Responsible Party of Resident Transfer
Penalty
Summary
Facility staff failed to notify a resident's responsible party following a significant change in the resident's condition that resulted in a hospital transfer. The facility's policy requires immediate notification of the resident, physician, and legal representative or family member when there is a significant change in the resident's status or a decision to transfer or discharge. In this case, a resident with severe cognitive impairment, multiple psychiatric diagnoses, and an active Durable Power of Attorney (DPOA) was transferred to a psychiatric center for evaluation due to agitation and physical behaviors. Documentation showed that the family was not informed of the transfer at the time it occurred. The resident's family member, who was the active DPOA, only learned of the transfer after calling the facility the following morning. Interviews with facility staff, including the Social Service Director, DON, and administrator, confirmed that nurses are expected to notify families and document such notifications, but there was uncertainty and lack of clarity regarding responsibility for ensuring this process was completed. The LPN involved stated that they may have forgotten to document the notification, and the DON acknowledged responsibility for oversight of this process.
Resident Physically Abused During Wheelchair Transfer by Floor Technician
Penalty
Summary
Facility staff failed to protect a resident from physical abuse when a floor technician aggressively pulled the resident's wheelchair, resulting in the resident falling out of the wheelchair and onto the ground. The resident, who was cognitively intact but had impairment to both lower extremities and used a manual wheelchair, was involved in a verbal altercation with the floor technician. Multiple staff interviews confirmed that the floor technician yelled at the resident, refused to allow the resident to smoke, and then forcefully moved the wheelchair, causing the fall. The resident reported feeling hurt and emotionally distressed by the incident, stating it made them not want to go outside anymore. Witnesses, including a CNA, a housekeeper, and the dietary manager, observed the floor technician's rough handling and lack of assistance after the resident fell. The resident was assisted back into the wheelchair by other staff members. The incident was reported to the facility administrator, and the resident was assessed for injury. The floor technician stated that the resident was cursing and claimed the resident threw themselves to the ground, but this account was not supported by other staff interviews.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility staff failed to protect two residents from sexual abuse when one resident raised their shirt, and another resident touched their chest inappropriately. This incident occurred in a facility with a census of 34 residents. The event was witnessed by a Certified Medication Technician (CMT) who reported it to a Registered Nurse (RN). Both residents involved were assessed to have impaired cognition, with one resident having diagnoses of Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety, and the other having Unspecified Dementia, anxiety disorder, and Alzheimer's Disease. The facility's policy on abuse, neglect, and misappropriation emphasizes the prevention of abuse by providing information on reporting concerns and establishing a safe environment. However, the policy also requires staff to identify, assess, and monitor residents with behaviors that include sexually aggressive behavior. In this case, the staff observed one resident with their shirt raised and another resident touching them inappropriately, indicating a failure to adequately monitor and prevent such interactions between residents with cognitive impairments. The incident was documented in the facility's investigation summary, which noted that both residents had cognitive impairments and did not recall the incident. Interviews with staff members, including the administrator, Director of Nursing (DON), and the CMT who witnessed the event, confirmed the inappropriate touching and the immediate separation of the residents. Despite the facility's policies, the incident highlights a lapse in monitoring and preventing inappropriate interactions between residents with cognitive impairments.
Infection Control and TB Screening Deficiencies
Penalty
Summary
Facility staff failed to use appropriate infection control procedures during medication administration for two residents. Specifically, staff did not perform hand hygiene between administering medication to different residents, handling medication bottles, and administering eye drops. Observations showed that a Certified Medication Technician (CMT) did not perform hand hygiene after administering medication, using a keyboard, and preparing medication before administering it to another resident. Additionally, a Certified Nurses Aide (CNA) was observed removing Tylenol tablets from a bottle with bare hands and placing them into a medication cup, and the same CMT did not perform hand hygiene or wear gloves before administering eye drops to a resident. Interviews with the Director of Nursing (DON) and the administrator confirmed that these actions were against the facility's guidelines and infection control policies, which were found to be lacking in specific instructions for hand hygiene during medication administration and eye drop instillation. The facility also failed to ensure that all employees were screened for Tuberculosis (TB) as per policy and state law. Three employees, including a Dietary Aide, a CNA, and a CMT, did not have documented two-step purified protein derivative (PPD) tests completed and recorded in their personnel files. The facility's guidelines and Missouri state regulations require that all employees undergo a two-step TB test within one month prior to or after starting employment, with annual follow-up tests. Interviews revealed that the facility did not have a designated MDS coordinator responsible for overseeing the TB testing process, leading to lapses in documentation and compliance. Additionally, the facility did not provide a policy for catheter care, which is crucial for residents with indwelling catheters. One resident was assessed to have an indwelling catheter and a diagnosis of benign prostatic hyperplasia, which requires careful monitoring and management. The absence of a catheter care policy indicates a gap in the facility's infection prevention and control program, further compromising the quality of care provided to residents.
Failure to Maintain a Homelike Environment
Penalty
Summary
Facility staff failed to provide a comfortable and homelike environment for residents by not maintaining bathroom doorframes, sink counters, and floors in good repair. Observations revealed multiple instances of brown stains, broken sink counters, rusted door frames, and excessive caulking around toilet bases in various resident-occupied rooms. The facility's policies did not include a specific policy regarding the environment, and the housekeeping and maintenance job descriptions, dated May 2006, outlined expectations for cleaning and minor repairs that were not met. Interviews with staff indicated awareness of the issues but highlighted a lack of timely action to address them. Housekeeping staff reported cleaning the bathrooms daily and notifying maintenance of needed repairs, while maintenance staff acknowledged the damage but cited difficulties in obtaining support for materials. The Director of Nursing confirmed that maintenance is responsible for repairs and emphasized that damage should be repaired quickly. Despite these acknowledgments, the deficiencies persisted, compromising the residents' right to a safe, clean, and comfortable environment.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
Facility staff failed to provide written information of the facility's bed hold policy at the time of transfer to the hospital to the resident and/or resident's representative for three residents. The facility's Bed Hold Guidelines state that notification should be given at the time of transfer, but this was not documented for Residents #14, #24, and #45. Resident #14 was transferred to the hospital and returned over a month later, Resident #24 was transferred and returned within a week, and Resident #45 was transferred and remained hospitalized at the time of the report. None of their medical records contained documentation that the bed hold policy was communicated at the time of discharge. Interviews with facility staff revealed a lack of awareness and clarity regarding the responsibility for completing bed hold notifications. The administrator indicated that the charge nurse is responsible for completing bed holds but believed that the licensed nursing staff were not aware of this requirement. An LPN confirmed that bed holds should be given to residents sent to the hospital but could not explain why they were not completed. The DON, who was new to the position, acknowledged knowing about the form but was unsure who was responsible for completing it.
Failure to Perform Significant Change in Status Assessments
Penalty
Summary
The facility staff failed to perform a significant change in status Minimum Data Set (MDS) assessment for two residents who experienced significant changes in their conditions. One resident elected hospice care, and another resident had a decline in their ability to feed themselves, transfer, and perform toilet hygiene. The facility's policy, based on the Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, mandates that a significant change in status assessment (SCSA) must be completed within 14 days of determining a significant change in a resident's condition. However, this was not done for the two residents in question. Resident #14, who was cognitively impaired and diagnosed with dementia, experienced a decline in their ability to perform activities of daily living (ADLs) such as eating, transferring, and toilet hygiene. The resident was discharged to the hospital and returned with orders for nothing by mouth (NPO) and artificial nutrition via a gastric tube. Despite these significant changes, the facility did not complete or submit an SCSA for this resident. Observations confirmed the resident's dependence on staff for transfers and hygiene, as well as the administration of nutrition through a gastric tube. Resident #37, who was cognitively impaired and diagnosed with dementia and stroke, was admitted to hospice care. The facility's records did not contain an order for hospice, a care plan for hospice, or a completed/submitted SCSA when the resident elected hospice services. Interviews with the facility's administrator and Director of Nursing (DON) revealed that the facility did not have a full-time MDS nurse, and the current staff were not familiar with the MDS process. The administrator acknowledged that the staff should use the RAI manual as a guide to complete and submit the MDS data timely.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility staff failed to develop a comprehensive person-centered care plan for four of six sampled residents, leading to deficiencies in meeting the residents' medical and nursing needs. Resident #14's care plan did not reflect significant changes, such as the need for a mechanical lift for transfers, increased assistance for toileting, and a change to gastric tube feeding. Despite physician orders and observations confirming these needs, the care plan remained outdated and incomplete. Resident #20's care plan lacked directions for fall risk, pressure injury risk, nutrition for pressure injury risk, and communication needs, despite the resident's history of falls, cognitive impairment, and other medical conditions. After an unwitnessed fall, the care plan was not updated with new interventions to prevent future falls. Similarly, Resident #35's care plan did not address facial hair preferences, contracture management, or changes to diet and required assistance, even though observations and physician orders indicated these needs. Resident #37's care plan did not include directions for hospice care, despite the resident being admitted to hospice. Interviews with facility staff, including the LPN assuming the role of MDS nurse and the Director of Nursing, confirmed that care plans should be comprehensive and updated regularly to reflect the residents' needs. However, the care plans for these residents were not adequately maintained, leading to deficiencies in their care.
Deficiencies in Hydration Orders, Weight Monitoring, and Fall Documentation
Penalty
Summary
Facility staff failed to meet professional standards of care in several instances. For Resident #14, the nursing staff did not obtain a physician's order for water flushes for the gastric tube, despite the resident receiving all hydration via the tube. The LPN administered water flushes based on instructions from another nurse, but there was no documented order for this procedure. The Director of Nursing (DON) confirmed that an order should have been obtained to prevent dehydration, but was unaware that the record lacked this order. The facility also failed to complete resident weights as required by their policy. Resident #6 had an order for weekly weights, but weights were only documented sporadically. Resident #29 had an order for monthly weights, but no weight was documented for April. Resident #35, who had a Stage III pressure wound, did not have weekly wound assessments or measurements documented for specific weeks, and weights were missing for several weeks following a hospital readmission. The Restorative Aide responsible for obtaining and documenting weights was unaware of the missing entries, and the DON acknowledged that missing weights could lead to negative outcomes for residents. Additionally, the facility did not properly document falls and follow-up for Resident #2. The resident experienced falls on two occasions, but staff did not complete the required Event Report forms. The DON and the administrator both confirmed that an Event Report should be filled out for each fall, and a 72-hour neuro check should be initiated if the fall is unwitnessed. These deficiencies indicate lapses in adherence to facility policies and procedures, potentially compromising resident care and safety.
Failure to Provide Appropriate Personal Hygiene
Penalty
Summary
Facility staff failed to provide appropriate personal hygiene for three residents who were dependent on staff for their daily care needs. Resident #28, who was moderately cognitively impaired and diagnosed with debility, heart disease, lung disease, and dementia, was observed multiple times with long facial hair, disheveled hair, and an unkempt appearance. Despite the resident's preference to be clean-shaven and clean-looking, staff did not provide the necessary grooming. Similarly, Resident #35, who was cognitively impaired and dependent on staff for personal hygiene, was observed with long facial hair on multiple occasions. The care plan for Resident #35 did not include facial hair preferences, and staff interviews revealed that dependent residents should be shaved on bath/shower days and in between if noticed, but this was not consistently done. Resident #251, who had diagnoses including cancer, hypertension, benign prostatic hyperplasia, dementia, and schizophrenia, was observed with disheveled hair and food crumbs on clothing on multiple occasions. The resident reported having only one bath in a month and feeling unclean. Staff interviews indicated that residents are scheduled to get showers twice a week, and personal hygiene should be documented in progress notes and shower sheets. However, the observations and resident's statements indicated that these practices were not consistently followed. The Director of Nursing and the administrator confirmed that dependent residents should be showered twice a week and that refusals should be documented, but this was not reflected in the care provided to Resident #251.
Failure to Ensure Safe Environment and Proper Medication Storage
Penalty
Summary
Facility staff failed to ensure a safe environment for residents by not adhering to proper wheelchair propulsion protocols. Specifically, three residents were observed being propelled in wheelchairs without foot pedals, causing their heels to touch the floor. This was confirmed through interviews with staff, who acknowledged that residents should never be pushed without foot pedals as it could cause injury. The Director of Nursing and the administrator both confirmed that staff are trained to use foot pedals during wheelchair propulsion, and there are no exceptions to this rule. Additionally, the facility staff did not follow proper procedures for mechanical transfers. Two residents were observed being transferred using a mechanical lift with the legs of the lift closed, contrary to the facility's policy that requires the legs to be open for stability. Interviews with the staff involved revealed that they were trained incorrectly, and the Director of Nursing and the administrator confirmed that the legs of the lift should remain open during transfers to prevent potential injuries. Furthermore, the facility failed to safely store medications in a resident's room. One resident was found to have various medications, including nasal spray, an inhaler, and tablets, in their room without a physician's order or proper assessment for self-administration. The resident admitted that other residents sometimes enter their room and access their belongings. Interviews with staff and the Director of Nursing confirmed that residents should be assessed for safety and have a physician's order to keep medications at bedside. The lack of proper assessment and storage poses a risk of medication misuse or access by other residents.
Failure to Attempt Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
Facility staff failed to ensure all residents' drug regimens were free from unnecessary drugs by not attempting gradual dose reductions (GDR) for psychotropic medications for four residents. The facility's Drug Review guidelines require monthly medication reviews, interdisciplinary care plans, and physician consultations for GDR attempts. However, the medical records for the four residents did not contain completed GDRs despite pharmacy recommendations for review and reduction of psychotropic medications. These residents had various diagnoses, including depression, anxiety, Alzheimer's Disease, psychosis, schizophrenia, bipolar disorder, and dementia, and were on multiple high-risk medications such as Fluoxetine, Buspirone, Quetiapine, Haloperidol, Divalproex, Trazodone, Phenytoin, Sertraline, and Clonazepam. Interviews with the Director of Nursing (DON) and the administrator revealed that the process for handling pharmacy recommendations was not followed. The DON stated that physicians should review and document their agreement or disagreement with the recommendations, sign the pharmacy recommendation sheet, and have the nurse document the review and decision. However, this process was not adhered to, as evidenced by the lack of completed GDRs in the residents' medical records. The administrator confirmed that pharmacy recommendations should be reviewed and signed by the physician, with documentation of the reasoning if the physician disagrees, but this was not done in these cases.
Medication Storage and Monitoring Deficiency
Penalty
Summary
Facility staff failed to monitor and store medication in a safe and effective manner, leading to the presence of expired medications and unsecured medication storage. Observations revealed that the medication room contained expired medications, including extra strength Acetaminophen/diphenhydramine HCI, Therma-M, mucus relief, Zinc, and Cranberry 450 mg. Interviews with Certified Medication Technicians (CMTs) and the Director of Nursing (DON) confirmed that out-of-date medications should be destroyed or returned to the pharmacy, and that CMTs and nurses are responsible for monitoring medication storage rooms and carts. Despite these protocols, expired medications were found in the medication storage room, indicating a lapse in adherence to the facility's Storage of Medications policy. Additionally, observations showed that a CMT left an unsecured box containing residents' medications on top of the medication cart while passing medications to residents. Another observation noted an unattended plastic container with multiple drawers of resident medication on top of the 100 hall medication cart. The plastic container could not be locked and was left on top of the cart at all times. Interviews with the CMTs and the administrator highlighted that the unsecured plastic box posed a risk to residents and should be removed for their safety. The administrator acknowledged that the box was used for regularly used medications and extra storage, but its unsecured state was a safety concern.
Unqualified Dietary Manager
Penalty
Summary
Facility staff failed to designate a person to serve as the Dietary Manager (DM) with the appropriate qualifications. The facility census was 44. Review of facility policies showed staff did not provide a policy related to the qualifications of kitchen staff. Review of the DM's personnel record showed the record did not contain documentation of when the DM assumed the DM role. The record did not contain documentation of previous food service experience or food service management certification. During an interview, the DM stated he/she was not certified yet but was currently working on the certification and was about halfway done. The DM also mentioned not knowing all of the requirements. The Director of Nursing (DON) and the administrator both confirmed that the DM should be certified, with the DON noting that lack of certification could lead to residents not receiving the correct food or having allergic reactions, which could cause harm.
Failure to Protect Residents' Personal Information
Penalty
Summary
Facility staff failed to ensure residents' personal information was protected when staff left residents' Electronic Health Records (EHR) open and unattended in public hallways. The facility census was 44. The facility's Medication Administration Guidelines did not contain directions for the protection of residents' privacy. Multiple observations on 04/30/24 showed a Certified Medical Technician (CMT) and a Certified Nursing Assistant (CNA) leaving EHR screens unlocked in the hallway with resident information visible while administering medication to residents in their rooms. Additionally, an unsecured box with drawers containing residents' medications was left on the medication cart. Interviews with staff, including a Registered Nurse (RN), the Director of Nursing (DON), and the facility administrator, confirmed that EHR screens should always be locked when unattended to protect residents' privacy. The CMT also acknowledged that screens on the carts should be locked when unattended to provide privacy. These actions and inactions led to a violation of residents' rights to privacy and confidentiality of their personal and medical records.
Failure to Complete MDS Assessments Timely
Penalty
Summary
Facility staff failed to complete the required Comprehensive Minimum Data Set (MDS) within the mandated timeframe for two residents. The facility's policy, based on the Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, requires that an Admission (Comprehensive) MDS be completed no later than the 14th calendar day of the resident's admission and submitted within 14 calendar days from the care plan completion date. Additionally, an Annual (Comprehensive) MDS must be completed no later than 366 calendar days from the previous comprehensive assessment or 92 days following the previous OBRA quarterly assessment. However, the records for two residents showed that their Annual comprehensive assessments were not completed within the required timeframe. During interviews, the facility administrator and Director of Nursing (DON) revealed that the facility did not have a full-time MDS nurse. The administrator mentioned that a floor nurse was lined up for the MDS position once a floor nurse position was filled, and a corporate nurse was trying to fill in between their other duties. The DON, who was new and unfamiliar with the MDS process, stated that the MDS nurse would be trained by the corporate nurse once the position was filled full-time. The administrator confirmed that the corporate nurse and the DON would help complete the MDS assessments until the floor nurse could assume the role full-time. Despite these efforts, the required MDS assessments for the two residents were not completed on time, leading to the deficiency noted in the report.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
Facility staff failed to complete the required Quarterly Minimum Data Set (MDS) assessments within the mandated timeframe for two residents. The facility's policy, based on the Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, requires that Quarterly MDS assessments be completed no later than 14 calendar days after the Assessment Reference Date (ARD) and at least every 92 days following the previous OBRA assessment. However, for Resident #18, the record did not contain a completed Quarterly assessment on or before the required date. Similarly, for Resident #30, the record did not contain a completed Quarterly assessment on or before the required date. The facility census was 44 at the time of the survey. Interviews with the facility's administrator and Director of Nursing (DON) revealed that the facility does not currently have a full-time MDS nurse. The administrator mentioned that a floor nurse is lined up for the position once a floor nurse position is filled, and a corporate nurse is currently trying to fill in between their other duties. The DON, who is new and not familiar with the MDS process, stated that the MDS nurse would be trained by the corporate nurse once the position is filled full-time. The administrator also mentioned that the corporate nurse and the DON would help complete the MDS assessments until the floor nurse can assume the role full-time. Staff are expected to use the RAI manual as a guide to complete and submit the MDS data timely.
Failure to Accurately Assess Residents
Penalty
Summary
Facility staff failed to correctly assess one resident who was receiving an anticoagulant medication and another resident for their preferences and oral/dental status. Specifically, Resident #2, who had a diagnosis of atrial fibrillation and was prescribed Eliquis, an anticoagulant, was not assessed for taking a high-risk medication under the category of anticoagulant in their Quarterly MDS. Additionally, Resident #12's Quarterly MDS did not include assessments for Preferences for Customary Routine and Activities (Section F) and Oral/Dental Status (Section L). The facility census was 44 at the time of the survey. Interviews revealed that the facility did not have a full-time MDS nurse, and the Director of Nursing (DON) was new and unfamiliar with the MDS process. The administrator mentioned that a nurse from the corporate office was trying to fill in between their other duties, and the corporate nurse and DON would help complete the MDS assessments until a floor nurse could fill the role full-time. The facility's policy was to use the most current CMS MDS Resident Assessment Instrument (RAI) manual as a guide for completing and submitting MDS data timely.
Failure to Post Survey Results
Penalty
Summary
Facility staff failed to ensure that the three most recent years of survey results were posted and readily accessible to residents, family members, or representatives of residents. The facility census was 44. Review of the facility's policies showed that staff did not provide a policy for required postings or survey posting. Observations on multiple dates revealed that the facility did not have a copy of the federal survey results accessible to the residents, family members, or representatives of residents. During an interview, an LPN stated that they were not sure where the survey was posted. The administrator mentioned that the past survey results should be on the shelf by the front entrance door, but they were unable to locate them.
Failure to Complete Neurological Checks and Skin Assessments
Penalty
Summary
The facility staff failed to complete required neurological checks and fall follow-up documentation for three residents who experienced falls. Specifically, the medical records for these residents did not contain the necessary 72-hour follow-up documentation as mandated by the facility's Fall Champion Program. Interviews with various staff members, including the administrator, LPNs, and RNs, revealed a lack of clarity and accountability regarding who was responsible for ensuring these checks and documentation were completed. The absence of a Director of Nursing (DON) further contributed to this oversight, as staff were unsure about the location of necessary forms and who should oversee the process. Additionally, the facility staff failed to perform weekly skin assessments for two residents as required by the facility's wound care prevention strategies. The medical records for these residents showed incomplete documentation of weekly skin assessments over several months. Interviews with the new DON and nursing staff indicated that while there was an expectation for weekly skin assessments, these were not consistently performed due to staff being too busy and a lack of oversight. The deficiencies highlight significant lapses in the facility's adherence to its own protocols for fall follow-up and skin assessments. The lack of proper documentation and follow-up care for residents who experienced falls and those requiring skin assessments points to systemic issues in staff training, accountability, and resource management within the facility.
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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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