Highland Rehabilitation & Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Missouri.
- Location
- 904 East 68th Street, Kansas City, Missouri 64131
- CMS Provider Number
- 265167
- Inspections on file
- 34
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Highland Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
A resident with schizophrenia, mood disorder, and a history of aggressive behavior was on 1:1 monitoring but was allowed to enter a shared bathroom unaccompanied, where another cognitively intact resident with schizophrenia and anxiety was already present and naked. The first resident crossed through the adjoining bathroom into the neighbor’s side and punched the second resident multiple times in the back and back of the head, while the assigned CNA remained seated in the hallway and did not follow into the bathroom. The assaulted resident later reported pain and fear, and another resident witnessed the punches before staff intervened. Nursing documentation showed no pain assessments or pain medication provided to the assaulted resident that day. This sequence of events reflects a failure to provide effective supervision and to protect a resident from abuse as required by the facility’s abuse prohibition policy.
A resident with severe cognitive impairment physically assaulted another resident after the latter grabbed a CNA's arm, resulting in a fractured jaw. Multiple staff and resident interviews confirmed that the incident involved deliberate kicking and punching, and the event was substantiated as abuse according to facility policy.
A resident with severe cognitive impairment and total dependence for mobility was transferred and repositioned in bed by a single CNA using a Hoyer lift, contrary to policy requiring two staff. The resident was left unsupervised on the edge of the bed and subsequently fell headfirst to the floor, sustaining multiple bruises and abrasions. Video evidence and staff interviews confirmed the policy violations and improper handling during and after the fall.
A resident with a history of mental illness, substance use, and prior elopement risk was left unsupervised during a smoke break, despite facility policy requiring supervision. The resident hid from view, climbed a second-floor fence, and jumped, resulting in a compound leg fracture that required surgery. Staff interviews confirmed that no one was monitoring the smoke deck at the time, and previous exit-seeking behaviors had been reported but not addressed with increased supervision.
The facility failed to meet food safety standards, as staff did not use hair restraints, and food items were improperly stored and labeled. Uncovered food and unlabeled personal items in the refrigerator were observed, with staff acknowledging the need for proper labeling and storage practices.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, as staff did not consistently use gowns and gloves during high-contact care activities. A CNA and an RN did not wear gowns while providing care involving a catheter and feeding tube, respectively. Additionally, an AC did not perform hand hygiene or wear PPE while assisting a resident. Observations also revealed a catheter drainage bag and tubing on the floor, contrary to facility policy.
A resident with a suprapubic catheter was observed in a common area without a privacy cover on the catheter drainage bag, compromising their dignity. Despite facility policies emphasizing privacy, the assigned LPN forgot to cover the bag, and the facility lacked a specific policy addressing this issue.
A resident dependent on tube feeding was found to have dried formula splatters on their feeding pump, pole, and floor, indicating a failure to maintain cleanliness. Despite the facility's housekeeping routine requiring spill management, the spills were not addressed. Interviews with staff confirmed the issue, highlighting unclear responsibilities for cleaning around the feeding equipment.
A resident with Huntington's disease was improperly restrained by a CMT who picked them up and carried them inside to prevent them from taking another resident's cigarette. This action violated the facility's restraint policy, which requires that restraints only be used in emergencies with proper authorization. The facility's leadership acknowledged the action as inappropriate, emphasizing the need for alternative de-escalation techniques.
A resident with a history of substance use disorder left the facility and did not return as expected. The facility failed to conduct a thorough investigation, as required by their policy, by not interviewing staff or submitting a follow-up report to the State Survey Agency. The resident returned after four days with no recollection of the absence, highlighting a deficiency in the facility's handling of the incident.
The facility failed to update PASRRs for two residents diagnosed with new mental disorders. One resident, initially diagnosed with schizophrenia, later developed major depressive disorder, while another resident developed major depressive disorder and psychotic disorder with delusions. Despite these new diagnoses, the facility did not complete new PASRRs, as confirmed by the Administrator and Interim DON.
A facility failed to develop a comprehensive care plan for a resident with PTSD, resulting in staff being unaware of the diagnosis and lacking guidance on managing the resident's mental health needs. The resident had a history of PTSD from childhood abuse and was on multiple psychiatric medications. The MDS RN admitted to relying on automated systems, leading to care plan omissions, while the DON and Administrator stressed the need for documented triggers and approaches.
A resident with a history of alcoholism left the facility without returning as expected, and the staff failed to follow the facility's policy for monitoring and reporting missing residents. The resident signed out to go to the library but did not fill out the anticipated return time. The staff did not initiate the required follow-up actions promptly, resulting in a delay in reporting the resident as missing. The resident was found wandering and returned to the facility four days later.
A resident in an LTC facility did not receive several physician-ordered medications due to miscommunication and improper handling. The medications were delivered but not administered, as they were misplaced in the nurses' room instead of the CMT's cart. Staff failed to reorder the medications or notify the physician, resulting in missed doses for the resident with a history of hypothyroidism, hyperlipidemia, hypertension, and bradycardia.
A resident with cerebral palsy did not receive proper bathing care due to the facility's failure to update the care plan and ensure the use of a specialized shower chair. The resident's bathing schedule was inconsistent, and staff were unaware of the resident's specific needs and the location of the specialized equipment. The specialized shower chair was found in a locked room, indicating a lack of communication and coordination among staff.
A resident with multiple medical conditions was transferred to another facility without belongings, medications, or necessary paperwork. The DON instructed not to send medications, and the facility lacked a policy for medication disposition during transfers.
Failure to Prevent Resident-on-Resident Physical Abuse in Shared Bathroom
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse when another resident physically assaulted him/her in a shared bathroom. Resident #3 had a history of behavior problems, restlessness, agitation, aggressive behavior, and pacing, with diagnoses including schizophrenia, schizoaffective disorder, mood disorder, personality disorder, anxiety disorder, and depression. Despite these conditions and the use of one-on-one monitoring, Resident #3 was allowed to go into the shared bathroom unaccompanied while the assigned CNA sat in the hallway outside the resident’s room. Resident #3 entered the bathroom that connected to Resident #4’s room, where Resident #4 was already present and naked, and then physically attacked Resident #4, striking him/her multiple times with a fist. Resident #4, who also had diagnoses of schizophrenia, anxiety, and depression but no documented negative behaviors, was cognitively intact and independent with most self-care. At the time of the incident, Resident #4 was in the bathroom without clothing when Resident #3 entered and began punching him/her in the back and the back of the head. Resident #4 later reported being hit three or four times, that it hurt, and that he/she was scared. Another resident in the room with Resident #4 witnessed Resident #3 throwing punches at the back of Resident #4’s head until staff intervened. The CNA assigned to one-on-one monitoring heard noises from the bathroom, then observed Resident #3 coming out of Resident #4’s side of the bathroom stating he/she had beaten the other resident up, and noted swelling and pain in Resident #3’s hand. Following the altercation, RN A documented that Resident #4 reported being hit on the back and back of the head but denied pain at that time, and the nurse’s assessment found no visible swelling, discoloration, bruising, or drainage. However, Resident #4 later stated that the incident hurt and that he/she was scared, and described praying for a reason to live afterward. The facility’s records showed no pain medication was administered to Resident #4 on the date of the incident and no pain assessments were documented in the EMR. Resident #3 refused a full assessment before being sent to the hospital, where his/her guardian was later informed that Resident #3 had a fractured right hand attributed to the altercation. The primary care physician for both residents stated that the incident of Resident #3 attacking and punching Resident #4 was abuse and noted that it would have been better if Resident #3 had not shared a bathroom with another resident. The facility’s abuse, prohibition, and intervention policy stated that each resident had the right to be free from abuse, defined as the willful infliction of injury with resulting physical harm, pain, or mental anguish. Despite this policy, Resident #3, who was on one-on-one monitoring due to unpredictable explosive behaviors, was not kept within immediate reach of staff when going into the shared bathroom, allowing access to Resident #4 while he/she was naked and vulnerable. CNA A acknowledged not following Resident #3 into the bathroom and remaining outside the doorway, and RN A reported that Resident #3 would not allow staff in his/her room, leading to one-on-one supervision being conducted from the hallway rather than in close proximity. These actions and inactions resulted in Resident #3 being able to physically assault Resident #4, causing fear, pain, and mental anguish, and constituted a failure to ensure the resident’s right to be free from abuse.
Resident-to-Resident Physical Abuse Resulting in Jaw Fracture
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder and severe cognitive impairment physically assaulted another resident, resulting in a fractured jaw. The incident began when the cognitively intact resident, who also had schizoaffective disorder and anoxic brain damage, grabbed the arm of a CNA. The first resident, who was walking with the CNA, told the other to let go, but when the request was ignored, the first resident kicked and punched the other in the jaw, causing the resident to fall and sustain a fracture to the mandible. Multiple staff and resident interviews confirmed that the altercation involved deliberate physical contact, including kicking and punching, after an attempt to remove the resident's hand from the CNA's arm. The assaulted resident was sent to the emergency room, where an x-ray confirmed a fracture to the left jaw. The incident was witnessed by several staff members, including CNAs and an LPN, who described the sequence of events leading to the injury. Facility records and interviews with the DON, ADON, NP, and Administrator all acknowledged that the event constituted abuse as defined by facility policy and regulatory standards. The facility's abuse prevention policy specifically prohibits abuse by anyone, including other residents, and defines physical abuse as willful infliction of injury. The investigation substantiated that the physical altercation met the criteria for abuse, resulting in harm to the resident.
Failure to Provide Adequate Supervision and Safe Transfer Leading to Resident Fall
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate care and supervision to prevent an accident involving a resident with severe cognitive impairment and a history of falls. The resident, who was totally dependent on staff for mobility and required a two-person assist with a Hoyer lift for transfers, was transferred and repositioned in bed by a single CNA, contrary to facility policy and the resident's care plan. The CNA positioned the resident on the edge of the bed, with the resident's head and leg hanging over the side, and then turned away from the resident, leaving them unsupervised and unsupported. As a result of this improper positioning and lack of supervision, the resident rolled off the bed headfirst onto the floor, sustaining multiple bruises and abrasions to the left arm, face, and hip. Video footage provided by a family member confirmed that the CNA was alone during the transfer and that the resident was not combative or resistive at the time of the fall. The CNA admitted to transferring the resident alone with the Hoyer lift and acknowledged that this was against facility policy, citing difficulty in obtaining assistance from other staff. Interviews with other staff members and review of facility policies confirmed that the use of the Hoyer lift required two staff members at all times and that residents should be positioned in the center of the bed during care to prevent falls. Despite these policies, it was revealed that single-person Hoyer transfers had occurred previously due to staffing issues. After the fall, the resident was lifted from the floor by staff without the use of a lift or assistive device, which was also against policy. The incident was initially reported as a non-injury fall, but subsequent assessment and family-provided photos documented significant bruising and swelling.
Failure to Supervise High-Risk Resident During Smoke Break Results in Serious Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents, specifically for a resident with a known risk of elopement and a history of mental health and substance use disorders. The resident had previously demonstrated exit-seeking behaviors, including walking along the fence on the second-floor smoke deck and expressing intentions to jump the fence. These behaviors were reported by staff and documented in the care plan, which included interventions such as moving the resident to a secure unit and requiring supervision during smoke breaks. However, there was no documentation of exit-seeking behaviors in the medical record for the month prior to the incident, and no additional monitoring was implemented after staff were notified of the resident's statements and actions. On the day of the incident, the resident participated in a scheduled smoke break on the second-floor patio. Facility policy required that all residents be supervised during smoke breaks, but interviews and records revealed that no staff were present on the smoke deck at the time. The resident hid from view as other residents returned inside, then climbed the fence and jumped from the second-floor ledge, resulting in a compound fracture of the left tibia that required immediate surgery. Another resident witnessed the event and alerted staff, but by the time staff responded, the resident had already sustained significant injuries. Multiple staff interviews confirmed that supervision was not provided during the smoke break, despite facility policies and the resident's known elopement risk. Staff members were unclear about their responsibilities for supervising residents during smoke breaks, and some believed others were assigned to the task. The lack of supervision allowed the resident to act on previously expressed intentions to elope, leading to a serious injury that required hospitalization and surgical intervention.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure food safety standards were met in several areas, as observed during a survey. Staff were not adhering to the facility's policy on hair restraints, as evidenced by a Building Engineer entering the kitchen without covering their long hair and facial hair. This occurred in the presence of uncovered food items, such as oatmeal and scrambled eggs, which could lead to contamination. The Dietary Manager confirmed the expectation for staff to wear hair restraints, but the policy was not followed in this instance. Additionally, food storage practices were not in compliance with professional standards. Observations revealed that food items like sausage patties and chocolate chips were not stored in closed containers, leaving them exposed to air. Furthermore, several open food items, including preboiled eggs, diced pineapple, honey, and sausage gravy, were not labeled with dates to indicate when they were prepared or should be discarded. The Dietary Manager and staff acknowledged that these items should have been properly labeled according to the facility's policy. The facility also failed to manage residents' personal food items appropriately. In the fourth-floor dining room refrigerator, a pizza box was found without a label indicating ownership or date, and staff were unaware of its owner. A sandwich and a container with an unidentified substance were also found without proper labeling. The Assistant Director of Nursing noted that items should be labeled with a name and date, but there was confusion about who was responsible for maintaining the refrigerator contents.
Infection Control Deficiencies in EBP Implementation
Penalty
Summary
The facility failed to adhere to infection control standards for two residents, specifically in implementing Enhanced Barrier Precautions (EBP). Observations revealed that staff did not consistently use personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. For instance, a Certified Nursing Assistant (CNA) did not wear a gown while emptying a catheter bag for a resident with an indwelling urinary catheter, and a Registered Nurse (RN) did not wear a gown while providing care involving a feeding tube. Additionally, the catheter drainage bag and tubing for one resident were found on the floor, contrary to facility policy. Resident #336, who had severe cognitive impairment and required a feeding tube and urinary catheter, was observed with their catheter drainage bag and tubing on the floor. Despite the presence of CDC signage indicating the need for EBP, staff failed to follow the required precautions. The CNA admitted to not wearing a gown and not performing hand hygiene after handling the catheter. Similarly, the RN acknowledged not wearing a gown while using the resident's feeding tube. Resident #103, who had a feeding tube and required EBP, was assisted by an Admissions Coordinator (AC) who did not perform hand hygiene or wear a gown and gloves while repositioning the resident. The AC admitted to not following the necessary infection control procedures. Interviews with the Assistant Director of Nursing (ADON) and the Interim Director of Nursing (IDON) confirmed that staff should have performed hand hygiene and worn appropriate PPE when providing care to residents requiring EBP.
Failure to Provide Privacy Cover for Catheter Drainage Bag
Penalty
Summary
The facility failed to provide a privacy cover for a urinary catheter drainage bag for Resident #63, compromising the resident's dignity. The facility's policy on resident rights emphasized the importance of privacy and confidentiality, yet there was no specific policy addressing the use of privacy covers for catheter drainage bags. On multiple occasions, Resident #63 was observed in a common area with the catheter drainage bag visible, containing approximately 100 cc of yellow urine, without a privacy cover. This visibility was noted by staff, residents, and visitors, indicating a lapse in maintaining the resident's dignity. Resident #63, who was admitted to the facility with a medical history of vascular dementia and obstructive and reflux uropathy, had a suprapubic catheter as part of their care plan. Despite the care plan's directive for catheter care every shift, the assigned LPN admitted to forgetting to place a privacy cover over the catheter drainage bag. The Interim Director of Nursing and the Administrator both acknowledged the importance of covering the catheter drainage bag to protect the resident's dignity, yet the oversight occurred, highlighting a gap in the facility's adherence to its own standards of resident care and dignity.
Failure to Maintain Cleanliness Around Tube Feeding Equipment
Penalty
Summary
The facility failed to maintain a clean and safe environment for Resident #103, who was dependent on tube feeding due to medical conditions including dysphagia and gastrostomy status. Observations revealed that the resident's feeding tube pump, pole, and the floor beneath them were splattered with dried tube feeding formula. These observations were made on multiple occasions, indicating a persistent issue with cleanliness in the resident's room. Interviews with facility staff, including a Registered Nurse and the Interim Director of Nursing, confirmed the presence of the spills. The facility's housekeeping routine required addressing spills and cleaning specific areas daily, yet the spills remained unaddressed. The Interim Director of Nursing stated that while nurses and CNAs should clean spills, housekeeping staff should not clean the tube feeding pump when in use, suggesting a lack of clarity in responsibilities for maintaining cleanliness around the resident's feeding equipment.
Improper Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as evidenced by an incident involving a staff member and a resident identified as Resident #386. The resident, who had a medical history including Huntington's disease and anxiety disorder, was observed attempting to take a cigarette from another resident on the smoking patio. In response, a certified medication technician (CMT) physically picked up and carried the resident back inside the facility, thereby restricting the resident's freedom of movement. This action was not in line with the facility's policy on restraints, which requires that restraints only be used in emergencies to prevent harm and with proper authorization. The incident was reported by the resident, who claimed to have been manhandled by staff, resulting in bruises and scratches. Interviews with staff members provided varying accounts of the event, with some confirming that the CMT picked up the resident to prevent them from taking another resident's cigarette. The CMT and other staff members involved did not report any intention to harm the resident, but the action taken was deemed inappropriate as it restricted the resident's ability to move independently. The facility's Interim Director of Nursing and Administrator acknowledged that the CMT's actions were a poor choice and violated the resident's rights. The facility's policy defines a restraint as any method that restricts a resident's freedom of movement, and the action of picking up the resident met this definition. The staff involved were expected to use other de-escalation techniques, such as verbal redirection or seeking assistance from other staff members, rather than physically restraining the resident.
Failure to Investigate Missing Resident Incident
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a missing resident, identified as Resident #96. The resident, who had a history of substance use disorder related to alcoholism, left the facility and did not return as expected. The resident's care plan included interventions to address their substance use disorder, but on the day of the incident, the resident signed out to go to the library and did not return. The facility's policy required a thorough investigation of such incidents, including interviewing all staff on the relevant shift, but this was not completed. The resident's progress notes indicated that the facility was aware of the resident's absence and took steps to locate them, including notifying the police and local hospitals. However, the investigation folder provided by the facility lacked interviews from staff or residents and did not include a follow-up five-day final report submitted to the State Survey Agency. The administrator acknowledged the oversight in not conducting interviews and completing the required investigation documentation. The resident eventually returned to the facility with assistance from another person, who found them wandering and brought them back. Upon return, the resident was alert and not in distress, but had no recollection of being gone for four days. The facility's failure to conduct a thorough investigation and submit the necessary reports to the State Survey Agency constituted a deficiency in their handling of the incident.
Failure to Update PASRRs for Residents with New Mental Disorders
Penalty
Summary
The facility failed to ensure that Level I Preadmission Screening and Resident Reviews (PASRRs) were completed for two residents who were diagnosed with new mental disorders. Resident #45 was admitted with a diagnosis of paranoid schizophrenia, and later, a diagnosis of recurrent major depressive disorder was added. Despite this new diagnosis, there was no documented evidence that a new PASRR was completed. The resident's care plan indicated behaviors related to schizophrenia and a risk for depression, but the PASRR was not updated to reflect the new diagnosis. Similarly, Resident #23 was admitted without a major mental disorder diagnosis, but later developed major depressive disorder and psychotic disorder with delusions. Despite these new diagnoses, the facility did not complete a new PASRR. The resident's care plan included symptoms of depression, and psychiatric evaluations confirmed the new diagnoses, yet the PASRR remained outdated. Interviews with the Administrator and Interim Director of Nursing confirmed that the PASRRs for both residents should have been updated following the new diagnoses.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a diagnosis of PTSD, among other mental health conditions. The resident, who had a history of PTSD stemming from childhood abuse, was admitted to the facility with diagnoses including psychotic disorder, anxiety, insomnia, major depressive disorder with severe psychotic symptoms, and schizophrenia. Despite these diagnoses, the resident's care plan did not include a focus area related to PTSD, and staff members, including CNAs, were unaware of the resident's PTSD diagnosis. This lack of awareness and documentation led to a failure in addressing the resident's mental and psychosocial needs effectively. The MDS RN acknowledged the oversight in care planning, citing reliance on automated systems and input from others, which resulted in inaccuracies and omissions. The Interim Director of Nursing and the Administrator both emphasized the importance of having triggers and appropriate approaches documented in the care plan to prevent re-traumatization and manage behaviors effectively. However, the facility's current practices did not align with these expectations, as evidenced by the absence of a care plan addressing the resident's PTSD and the lack of staff awareness regarding the resident's specific needs.
Inadequate Supervision Leads to Resident Absence
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as Resident #96, who was reviewed for accidents. The resident, who had a history of substance use disorder related to alcoholism, left the facility and did not return as expected. The facility's policy required residents to sign out when leaving and to provide an anticipated return time. However, Resident #96 did not fill out the anticipated return time on the sign-out sheet, and the facility did not initiate the required follow-up actions in a timely manner. On the day of the incident, Resident #96 signed out to go to the library but did not return by the expected time. The facility staff, including a Certified Medical Technician (CMT) and a Licensed Practical Nurse (LPN), were aware of the resident's absence but did not follow the facility's policy to initiate a search or notify the appropriate authorities promptly. The Administrator was informed the following day, and only then were the police and other relevant parties contacted. The resident was eventually found wandering and returned to the facility four days later. The facility's failure to adhere to its own policy for monitoring residents who leave the premises resulted in a lack of timely action when Resident #96 did not return. The staff did not adequately check the sign-out logs or follow the procedure for contacting the resident or their designated contacts. This oversight led to a delay in reporting the resident as missing and in taking steps to ensure their safety, highlighting a deficiency in the facility's supervision and accident prevention measures.
Medication Administration Failure in LTC Facility
Penalty
Summary
The facility failed to provide physician-ordered medications to a resident, resulting in significant medication errors. The resident, who was admitted with a medical history of hypothyroidism, hyperlipidemia, hypertension, and bradycardia, did not receive several prescribed medications, including amlodipine, levothyroxine, lovastatin, and metoprolol, for multiple days following their admission. The medications were delivered to the facility, but due to miscommunication and improper handling, they were not administered as required. The Clinical Liaison received the medications and placed them in the nurses' room instead of the CMT's cart, leading to confusion about their availability. The CMTs documented the unavailability of medications in the MAR and informed the nurses, but the medications were not retrieved from the nurses' room or the emergency kit. The nurses failed to reorder the medications or notify the physician about the missing doses, resulting in the resident missing critical doses of their prescribed medications. Interviews with staff revealed a lack of clarity and communication regarding the handling and administration of medications. The CMTs and nurses did not follow the facility's policies for medication administration and reordering, leading to the oversight. Despite the medications being delivered and available, they were not administered to the resident, highlighting a breakdown in the facility's medication management process.
Failure to Provide Adequate Bathing Care and Use of Specialized Equipment
Penalty
Summary
The facility failed to ensure that a resident with cerebral palsy received proper bathing care and the use of a specialized shower chair. The resident, who was dependent on staff for activities of daily living, including bathing, was admitted to the facility and had a care plan that did not document the need for a specialized shower chair. The resident's bathing schedule was inconsistent, with missed baths and showers, and there was no documentation of bathing assistance on several occasions. The resident expressed a preference for showers over bed baths, yet reported having only one shower since admission. Observations and interviews revealed that the specialized shower chair, necessary for the resident's comfort and safety, was not readily available or used. Staff members, including CNAs and the Director of Nursing, were unaware of the resident's specific needs and the location of the specialized shower chair. The chair was eventually found in a locked room, indicating a lack of communication and coordination among staff regarding the resident's care requirements. The facility's failure to update the resident's care plan to include the need for a specialized shower chair and to ensure its use resulted in inadequate care. The Director of Nursing acknowledged the oversight in the resident's bathing schedule and the lack of documentation. The facility did not provide a policy for bathing or activities of daily living upon request, further highlighting the deficiency in care planning and execution.
Failure to Arrange Safe and Orderly Discharge
Penalty
Summary
The facility failed to arrange a safe and orderly discharge for a resident, who was cognitively intact and had multiple medical conditions including stroke, hypertension, muscle spasms, depression, and hyperlipidemia. The resident was on several medications, including anti-depressants, anti-coagulants, and anti-platelet medications. Upon discharge, the resident was transferred to another facility without any belongings, medications, or necessary paperwork. The receiving facility reported that the resident arrived without a report being called in, and the Director of Nursing (DON) had instructed not to send the resident's medications. Interviews with the DON and other staff revealed that it was not the usual practice to send medications with residents during transfers. The DON had emailed the resident's medication list to the receiving facility but did not ensure the physical transfer of medications. The Administrator was unaware of the situation and later arranged for the medications to be delivered to the receiving facility. The facility also lacked a policy for the disposition of medications when transferring residents to another facility, contributing to the oversight in this case.
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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