Hill Crest Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Hamilton, Missouri.
- Location
- 801 South Colby, Hamilton, Missouri 64644
- CMS Provider Number
- 265665
- Inspections on file
- 22
- Latest survey
- June 27, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Hill Crest Manor during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering exited the facility through a door with a malfunctioning alarm system, which reset after the door closed instead of alerting staff continuously. Staff were unaware of the resident's absence until notified by another resident, and the individual was found and returned by a former employee after traveling a significant distance. The incident was attributed to the disengaged door/alarm system and lack of immediate staff supervision.
The facility failed to respect residents' rights to privacy and dignity, with staff entering rooms without knocking and discussing residents' conditions openly. A visually impaired resident did not receive necessary verbal cues during meals, and another resident's grooming needs were neglected due to the absence of a beautician.
The facility failed to honor resident choice for showers and dietary preferences. A resident with a history of stroke and another with diabetes and depression received fewer showers than preferred, while a third resident with multiple diagnoses was not provided with preferred food items like fresh fruit and yogurt. Staff interviews confirmed inconsistencies in providing showers and dietary options.
The facility did not address or resolve grievances raised by residents during council meetings, such as dietary issues, staff behavior, and missing laundry. Despite policy requirements for investigation and corrective action, no follow-up or communication was provided to residents, leading to a deficiency in honoring their rights.
The facility did not maintain a surety bond equal to or greater than 1.5 times the average monthly balance for the residents' trust fund (RTF) account over the past year. The bond amount was reduced from $65,000 to $58,000, which was insufficient given the average monthly balance of $39,259.28, requiring a bond of at least $58,500. This affected all residents with funds in the RTF account.
The facility did not annually inform residents of their rights, affecting all 11 residents in a group interview. The policy requires informing residents of their rights, but resident council minutes showed the rights section was left blank for three consecutive months. During a group meeting, residents confirmed their rights were not discussed. The Activity Director was unaware of the required frequency for providing notice of rights, and the Administrator acknowledged the oversight.
The facility did not effectively communicate information about the State Long-Term Care Ombudsman program to residents. During a group meeting, all residents were unaware of the Ombudsman's role or contact information. The Activity Director admitted to not recently discussing this information, and the Administrator confirmed that staff should inform residents about the Ombudsman, highlighting a communication lapse.
The facility did not distribute mail to residents on Saturdays, despite mail being delivered to the facility. During a resident group meeting, all attendees confirmed the lack of Saturday mail distribution. The facility's policy ensures residents' access to mail, but this was not followed. Interviews revealed that the responsibility for distributing mail on Saturdays fell to on-call managers, but this was not being done.
The facility failed to inform residents about the grievance process, as 11 residents expressed uncertainty about filing grievances. The facility's policy outlines the grievance process, but it was not communicated to residents, as shown by the lack of documentation in meeting minutes. Staff interviews revealed that the grievance process was not discussed with residents, leading to confusion and a violation of their rights.
The facility did not conduct timely Employee Disqualification List (EDL) checks for five employees and failed to verify the CNA Registry for a Registered Nurse, contrary to its Abuse and Neglect policy. Interviews revealed that EDL checks were not routinely performed, and the Administrator expected these checks to be completed per policy.
The facility failed to conduct care plan meetings quarterly or upon significant changes in residents' conditions, affecting five residents. Residents and their representatives were not involved in the care planning process, contrary to the facility's policy. Interviews revealed a lack of documentation and coordination in scheduling and conducting these meetings.
Facility staff failed to follow safety protocols during resident transfers and wheelchair use, leading to potential accident hazards. A resident was transferred using a mechanical lift without spreading the lift's legs for stability, and two residents were pushed in wheelchairs without foot pedals, contrary to facility policy.
The facility did not ensure that nurse aides met the required qualifications, as three aides lacked documentation of certification within four months of hire. The Administrator confirmed the requirement for certification but the facility lacked a policy on hiring and training nurse aides.
The facility failed to manage and store medications properly, with expired medications found in the medication cart and room, and loose pills in the carts. An opened vial of tuberculin lacked a date, and insulin pens were unlabeled. Staff left medications at a resident's bedside, contrary to policy. A CMT and the DON confirmed these practices were incorrect.
The facility exhibited deficiencies in food safety and hygiene practices, including improper labeling and storage of food, inadequate hand hygiene, and failure to monitor food and refrigerator temperatures. Staff did not label or seal opened food items, and dishes were improperly stored. Hand hygiene was neglected, with staff failing to wash hands between tasks. Additionally, food temperatures were not checked before serving, and refrigerator temperature logs were incomplete.
The facility failed to maintain safe operating conditions for wheelchairs, affecting three residents. One resident, who was moderately cognitively impaired, had a wheelchair arm taped on the left side. Another resident, cognitively intact and using a wheelchair for mobility, had armrests taped with white tape. A third resident, also cognitively intact and dependent on a wheelchair, had a left armrest wrapped in white tape. Interviews with staff revealed awareness of the issue, but wheelchairs were not maintained as expected.
The facility failed to transmit MDS assessments within the federally mandated timeframe for a resident. The resident was admitted and discharged without the discharge assessment being transmitted. The MDS/Care Plan Coordinator could not explain the delay, and the facility lacked a policy on MDS transmittals. The Administrator noted that MDS should be submitted timely and reviewed by an RN.
A facility failed to obtain routine PT/INR orders for a resident on Coumadin, continuing medication administration without monitoring its effects. The resident's care plan indicated a risk of bleeding and required regular lab tests, which were not scheduled or conducted. The resident expressed concern over the lack of monitoring, leading to refusal of medication. The DON confirmed the absence of necessary physician orders for PT/INR tests, highlighting a lapse in medication management procedures.
A resident with severe cognitive impairment and impaired vision did not have their missing prescription eyeglasses replaced for several weeks. The Social Services Director failed to ensure timely replacement and communication with the resident's representative, leading to a deficiency in quality care.
The facility failed to provide adequate personal hygiene care for residents, resulting in deficiencies in shaving, showering, and nail care. A resident with cognitive impairment did not receive regular shaving and was given only two showers in a month. Another resident had overgrown nails with a substance underneath, and the facility did not provide regular nail care. A third resident, requiring substantial assistance with bathing, reported receiving only two showers in a month. Staff interviews revealed challenges in adhering to the shower schedule due to low staffing levels.
A resident with moderate cognitive loss and mental health issues eloped from an LTC facility due to inadequate supervision and failure to identify elopement risk. Despite exhibiting exit-seeking behavior, the resident was not reassessed as an elopement risk, leading to their unsupervised departure. Staff interviews revealed communication gaps and lack of awareness regarding the resident's risk and necessary safety measures.
A resident with no cognitive loss and multiple health conditions felt disrespected when a CNA made a derogatory religious comment on Easter Sunday. The CNA admitted to the statement, while the DON was unaware and stated it was inappropriate, violating the facility's policies on resident rights and dignity.
Resident Elopement Due to Faulty Door Alarm and Inadequate Supervision
Penalty
Summary
A resident with diagnoses of dementia, depression, Alzheimer's disease, and stage 3 chronic kidney disease eloped from the facility through an unsecured and improperly alarmed exit door. The resident was able to exit the south exit door without staff observation, and the door alarm, which was intended to sound continuously until reset by staff, ceased once the door closed. This malfunction allowed the resident to leave the premises undetected by staff. The resident was not immediately noticed missing by staff; instead, another resident witnessed the elopement and alerted a CNA, who then informed an LPN to initiate a search. The resident was found and returned to the facility by a former employee approximately 20 minutes later, after having traveled about one third of a mile on foot. Upon return, a full physical and psychosocial assessment was conducted, and no concerns were noted. The facility's investigation determined that the root cause of the incident was the disengagement of the door/alarm system, which allowed the alarm to reset improperly. Staff interviews confirmed that the alarm system was old and not functioning as intended, and that staff were unaware of the resident's exit until notified by another resident. The resident was identified as an elopement risk with impaired safety awareness, and the care plan included monitoring and diversional interventions, but these were not sufficient to prevent the incident.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to honor residents' rights to privacy and dignity, as evidenced by multiple instances where staff entered residents' rooms without knocking or announcing themselves. This was observed with several residents, including one who expressed that staff never knocked and entered as if they owned the place. Additionally, staff were observed discussing residents' conditions openly in hallways, compromising their privacy and dignity. In one instance, a resident with visual impairments was not provided with necessary verbal cues during meals, leaving them with food on their hands without assistance. Staff failed to announce themselves or explain their actions to the resident, which was crucial given the resident's visual limitations. This lack of communication and respect for the resident's needs was a clear violation of their right to a dignified existence. Another resident's personal grooming needs were neglected, as their hair was left unmanaged and uncut for months due to the absence of a beautician. Despite the resident's family expressing concerns, the facility did not ensure regular haircuts or grooming, further compromising the resident's dignity. These deficiencies highlight a pattern of neglect in maintaining residents' rights to privacy, dignity, and personal care.
Failure to Honor Resident Choice in Showers and Dietary Preferences
Penalty
Summary
The facility failed to honor the right to self-determination and resident choice for three residents. Resident #12, who had a history of stroke and muscle weakness, was not provided with the preferred number of showers per week, receiving only one shower weekly over several weeks. The resident expressed dissatisfaction with the lack of choice regarding shower frequency, stating a preference for at least two showers per week. Similarly, Resident #25, diagnosed with diabetes, obesity, and depression, also received only one shower per week, despite expressing a desire for more frequent showers. Interviews with staff confirmed that showers were not consistently provided twice a week as preferred by the residents. Resident #42, with intact cognitive skills and multiple diagnoses including heart disease and diabetes, was not provided with preferred food items such as fresh fruit, yogurt, and cheese, despite these preferences being communicated to the dietician upon admission. The resident expressed frustration over the lack of healthy food options and the need to rely on family for preferred foods. The dietician confirmed that resident preferences were entered into the system, but the dietary manager indicated that residents needed to request specific foods from kitchen staff. The administrator acknowledged that the facility should have had the preferred food items available but admitted that fresh fruit was not always on hand.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to address and resolve grievances raised by residents during resident council meetings, as evidenced by the lack of documented actions or responsible parties in the council minutes. Issues such as dietary concerns, rude and rough behavior by staff, delayed response to call lights, and missing laundry items were repeatedly brought up by residents without any follow-up or communication on resolutions. The facility's policy on grievances requires investigation and corrective action, but this process was not followed, leaving residents' concerns unaddressed. During interviews, residents expressed that their concerns were not communicated back to them after being raised in meetings. The Activity Director confirmed that concerns were distributed to department heads and administration but did not receive feedback to report back to residents. The Administrator and DON were unaware of specific issues reported by the resident council, indicating a breakdown in communication and follow-up. This lack of action and communication led to a deficiency in honoring residents' rights to have their grievances addressed and resolved.
Facility Fails to Maintain Adequate Surety Bond for Resident Trust Funds
Penalty
Summary
The facility failed to maintain a surety bond that was equal to or greater than one and one-half times the average monthly balance for the residents' trust fund (RTF) account over the last 12 consecutive months, from January 2024 to December 2024. The facility's policy required that the bond amount should cover at least one and one-half times the annual average of the fund account, including any credit balances. However, the facility's current approved bond amount was $58,000, which was insufficient as the average monthly balance for the RTF account was $39,259.28, necessitating a bond of at least $58,500. The deficiency was identified during a record review and interviews with facility staff. The Business Office Manager acknowledged that the surety bond should be sufficient to cover 1.5 times the average amount held in accounts. Despite having a larger surety bond previously, the facility decreased the bond amount from $65,000 to $58,000 in December 2024. The Administrator also confirmed the expectation that the surety bond should equal 1.5 times the average monthly account total held in the resident trust accounts. This oversight had the potential to affect all residents with funds held in the RTF account, given the facility's census of 58.
Failure to Annually Inform Residents of Their Rights
Penalty
Summary
The facility failed to annually inform residents of their rights, affecting all 11 residents who participated in a group interview. The facility's policy, revised in February, mandates that employees treat residents with kindness, respect, and dignity, and that residents be informed of their rights and responsibilities as guaranteed by federal and state laws. However, a review of resident council minutes from November, December, and January showed that the section for resident rights was left blank. During a group meeting, all 11 residents confirmed that their rights were not discussed in their monthly resident council meetings. The Activity Director, who assisted in setting up these meetings, was unaware of the frequency with which the facility must provide a notice of rights and services. The Administrator acknowledged that resident rights should be discussed at these meetings.
Failure to Inform Residents About Ombudsman Program
Penalty
Summary
The facility failed to provide accessible information about the State Long-Term Care Ombudsman program to its residents. During a resident group meeting, all 11 residents present were unaware of what the Ombudsman was, their role, or where to find information about the program within the facility. An observation revealed that the Ombudsman information was located in the hall by the living room area, but it was not effectively communicated to the residents. The Activity Director acknowledged that while they had previously discussed the Ombudsman information, it had not been recently addressed with the residents. The Administrator confirmed that staff should inform residents about the Ombudsman, their role, and contact information, indicating a lapse in communication and education regarding resident rights and external advocacy resources.
Failure to Deliver Saturday Mail to Residents
Penalty
Summary
The facility failed to deliver Saturday mail to its residents, as revealed during a resident group meeting where all 11 attendees reported that mail was not distributed on Saturdays. The facility's policy on resident rights, revised in February 2024, guarantees residents access to mail, yet this was not adhered to. Interviews with the Activity Director and the Administrator confirmed that while mail is delivered to the facility on Saturdays, it is not distributed to residents until Monday. The Activity Director noted that a resident previously retrieved mail from the mailbox and placed it in the office, but this practice had ceased. The Administrator acknowledged that on-call managers are responsible for distributing mail on Saturdays, but this was not occurring.
Residents Uninformed About Grievance Process
Penalty
Summary
The facility failed to ensure that residents were informed about the grievance process, which is a violation of their rights. During a group meeting, 11 out of 11 residents expressed uncertainty about how to file a grievance, whether anonymously or in writing, and how to obtain a written decision regarding their grievances. The facility's policy on grievances, revised in April 2017, outlines the process for investigating and resolving grievances, including the roles of the grievance officer and the maintenance of a grievance log. However, the policy was not effectively communicated to the residents, as evidenced by the lack of documentation in the resident council meeting minutes from November 2024 to January 2025, which did not indicate whether residents were informed about the grievance process. Interviews with facility staff further highlighted the deficiency. The Activity Director admitted to not having discussed the grievance process with the residents, including where to find the necessary paperwork or whom to contact. Additionally, the Administrator mentioned that grievances would be addressed by the interdisciplinary team, but there was no indication that this information was communicated to the residents. This lack of communication and education regarding the grievance process led to the residents' confusion and uncertainty, thereby failing to uphold their rights to voice grievances without discrimination or reprisal.
Failure to Conduct Timely Background Checks
Penalty
Summary
The facility failed to adhere to its own Abuse and Neglect policy by not conducting Employee Disqualification List (EDL) checks prior to the hire dates for five out of eight employees. These employees included a Dietary Aide, two Nurse Aides, a Maintenance Director, and another staff member. Additionally, the facility did not verify the Certified Nurses' Assistant (CNA) Registry for one of the eight sampled staff, a Registered Nurse, to ensure they did not have a Federal Indicator for abuse or neglect. The facility's policy required EDL checks at the time of employment consideration, and any candidate on the list was not eligible for hire. However, the records showed that EDL checks were either not conducted or were completed after the employees had already been hired. Interviews with facility staff revealed inconsistencies in the implementation of the policy. The Business Office Manager admitted to only checking the EDL upon hire and not routinely, and acknowledged the oversight in checking the nurse aide registry for all employees. The Regional Accounting person stated that EDL checks were supposed to be completed quarterly for all employees, which was not being done. The Administrator confirmed that EDL and CNA registry checks were expected to be completed per facility policy and upon hire, indicating a lapse in following established procedures. This failure to implement the policy as intended led to the deficiency noted in the report.
Failure to Conduct Timely Care Plan Meetings and Involve Residents
Penalty
Summary
The facility failed to conduct care plan meetings on a quarterly basis or when a resident experienced a significant change in condition, as required by their Care Planning Policy. This deficiency affected five residents out of the 15 sampled, with a facility census of 58. The policy mandates that the interdisciplinary team, along with the resident and their family or legal representative, develop and implement a comprehensive, person-centered care plan. However, the facility did not adhere to this policy, resulting in residents and their representatives not being involved in the care planning process. Resident #24, who had intact cognitive skills and multiple diagnoses including kidney disease and diabetes, expressed frustration at not being involved in their care planning. Similarly, Resident #32, with severe cognitive impairment and diagnoses such as Alzheimer's disease, experienced a change in mobility from using a walker to a wheelchair without a care plan meeting to address this change. The Durable Power of Attorney for Resident #32 was informed of the change but noted the absence of a care plan meeting. Resident #42, with intact cognitive skills and various diagnoses including heart disease and diabetes, reported only being invited to one care plan meeting since admission. Resident #16 and Resident #21, both with intact or moderately impaired cognitive skills, also reported not being invited to or attending care plan meetings. Interviews with facility staff, including the MDS Coordinator and Social Services Director, revealed a lack of documentation and coordination regarding care plan meetings, contributing to the deficiency in involving residents and their representatives in the care planning process.
Failure to Follow Safety Protocols in Resident Transfers and Wheelchair Use
Penalty
Summary
The facility staff failed to ensure residents remained free from accident hazards by not adhering to the manufacturer's guidelines during resident transfers and wheelchair use. Specifically, Resident #8 was transferred using a mechanical lift without spreading the lift's legs for stability, contrary to the manufacturer's instructions. This oversight was observed during a transfer from a chair to a bed, where the lift's legs remained closed, posing a risk of instability. Interviews with staff revealed inconsistent understanding of the proper use of the mechanical lift, with some staff members incorrectly believing the legs should remain closed during transfers. Additionally, the facility staff did not ensure the safe transport of residents in wheelchairs by failing to use foot pedals. Resident #11 was observed being wheeled without foot pedals, which was only corrected after intervention by the Director of Nursing. Similarly, Resident #30 was pushed in a wheelchair with only one foot pedal, leaving one foot on the floor. Interviews with staff confirmed that pushing residents without foot pedals is against facility policy, as it could lead to injury. The facility's policies on resident handling and wheelchair use were not adequately followed, leading to these deficiencies. The policies require that resident transfer status be documented and reviewed, and that wheelchairs be used according to resident choice and safety needs. However, the observed practices did not align with these policies, indicating a lapse in adherence to established safety protocols.
Failure to Ensure Nurse Aide Certification
Penalty
Summary
The facility failed to ensure that nurse aides met the minimum qualifications required by not providing evidence of satisfactory participation in a State-approved nurse aide training and competency evaluation program within four months of hire. The facility's employee list revealed that three nurse aides, hired on different dates, lacked documentation of certification in their personnel files. Specifically, NA A, NA D, and NA E, who were hired on 6/5/24, 12/19/22, and 5/19/23 respectively, did not have records showing they were certified. During an interview, the Administrator acknowledged that nurse aides should obtain their certification within four months of their hire date, but the facility did not have a policy regarding the hiring and training of nurse aides.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications and biologicals, leading to several deficiencies. Observations revealed expired medications and biologicals in the medication cart and room, including an opened vial of tuberculin without a date, insulin pens without pharmacy labels, and various expired medications such as Tussin cough suppressant, liquid iron supplements, and Salonpas pain relieving patches. Additionally, loose pills were found in both the South and North medication carts, indicating a lack of proper medication management and storage practices. Furthermore, staff were observed leaving medications at the bedside of a resident, which is against the facility's policy. The resident reported that staff would leave pills for them to take later, which was confirmed by a Certified Medication Technician (CMT) and the Director of Nursing (DON), both of whom acknowledged that medications should not be left at the bedside and that staff should ensure residents take their medications. These actions and inactions demonstrate a failure to adhere to the facility's medication storage policy and ensure the safe administration of medications to residents.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of improper food handling and storage practices. Staff did not label or date opened food items, such as smoked sausage and bread, and failed to seal them properly. Additionally, food storage containers and dishes were not stored in a manner that prevents contamination, with items like measuring cups and butter bowls left uncovered. Interviews with the Dietary Manager, Dietician, and Administrator confirmed that these practices did not meet their expectations for food safety. Hand hygiene practices were also found to be lacking, with staff failing to wash or sanitize their hands between tasks, such as after touching a resident's wheelchair and before continuing to prepare food. Observations showed that staff did not wash their hands upon entering the kitchen or when transitioning between different food preparation tasks. The Administrator and Dietician both expressed that they expected staff to maintain proper hand hygiene to prevent cross-contamination. Furthermore, the facility did not have policies in place for monitoring food temperatures or recording refrigerator temperatures. Observations revealed that staff did not check the temperature of food items on the steam table before serving them to residents. Additionally, there were missing entries in the refrigerator temperature logs, indicating a lack of consistent monitoring. Interviews with the Dietary Manager, Dietician, and Administrator highlighted the expectation that these temperatures should be regularly checked and recorded to ensure food safety.
Facility Fails to Maintain Safe Wheelchair Conditions
Penalty
Summary
The facility failed to maintain resident wheelchairs in safe operating condition, as observed in the cases of three residents. Resident #11, who was moderately cognitively impaired and dependent on a wheelchair, was found with a wheelchair arm taped on the left side. Resident #57, who was cognitively intact and used a wheelchair for mobility outside their room, had wheelchair armrests taped with white tape. Resident #60, also cognitively intact and dependent on a wheelchair due to a lower extremity impairment, had a left wheelchair armrest wrapped in white tape. These observations indicate that the wheelchairs were not maintained in a safe and operable manner, as required by the facility's maintenance policy. Interviews with facility staff, including the Maintenance personnel, Director of Nursing, and Administrator, revealed an awareness of the issue, with the Maintenance staff acknowledging that several wheelchairs needed repairs. The Director of Nursing and Administrator both expressed expectations that residents' wheelchairs should be in good repair and free of torn armrests. Despite these expectations, the facility did not ensure that the wheelchairs were maintained in a condition that met the residents' rights to a safe and comfortable environment.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure the timely transmission of Minimum Data Set (MDS) assessments for one of the sampled residents, specifically Resident #49. The resident was admitted on July 27, 2024, and discharged on August 15, 2024. However, the discharge assessment was completed on August 15, 2024, with no transmission accepted date listed for the assessment. During interviews, the MDS/Care Plan Coordinator, who had been in the position for two years, was unable to explain why the MDS was marked as 'export ready' and could not print a transmission report. The Administrator acknowledged that MDS should be submitted timely and mentioned that a Registered Nurse (RN) would need to review it. The facility did not provide a policy regarding MDS assessment transmittals.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure routine orders for prothrombin time (PT) and international normalized ratio (INR) were obtained for a resident on anticoagulant medication, specifically Coumadin (Warfarin). Despite the absence of orders to monitor the medication's effect, staff continued to administer the anticoagulant. This oversight affected one resident, who was part of a sample of 15 residents, in a facility with a census of 58. The resident's PT/INR flow sheet showed several instances where the next PT/INR test date was left blank, indicating a lack of scheduled monitoring. The resident's care plan, revised in January 2025, highlighted the risk of bleeding due to anticoagulant therapy and the need for regular lab tests to monitor PT/INR levels. However, the resident reported not having a PT/INR test drawn in a long time, leading to their refusal to take Coumadin due to concerns about the lack of monitoring. Interviews with the Director of Nursing (DON) confirmed that there should have been a physician's order for regular PT/INR lab tests for residents on Coumadin. The DON acknowledged that if there was an order to recheck PT/INR in two weeks, it should have been completed. This deficiency in monitoring and documentation of PT/INR levels for a resident on anticoagulant therapy represents a significant lapse in the facility's adherence to its own policies and procedures for safe medication management.
Failure to Replace Missing Prescription Eyeglasses
Penalty
Summary
The facility failed to provide quality care by not assisting a resident in replacing their prescription eyeglasses, which had been reported missing for several weeks. The resident, who had severe cognitive impairment and required corrective lenses, was observed without eyeglasses. The resident's representative reported the loss to the Social Services Director, who initially found reading glasses that did not belong to the resident. Despite being informed of the issue, the Social Services Director did not ensure the replacement of the prescription eyeglasses in a timely manner. Interviews revealed a lack of communication and follow-through regarding the scheduling of an appointment for the replacement of the eyeglasses. The Social Services Director was unsure of who was responsible for notifying the resident's representative about the appointment, and there was no documentation of such communication in the resident's medical record. The facility's Administrator confirmed that the Social Services Director should have notified the resident's representative and documented the communication, highlighting a breakdown in the process of addressing the resident's needs.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide necessary services for activities of daily living (ADLs) to dependent residents, resulting in deficiencies in personal hygiene care. Resident #1, who had moderate cognitive impairment and severe vision impairment, did not receive regular shaving and was only given two showers in a month, despite being scheduled for twice-weekly showers. The resident expressed dissatisfaction with the infrequent showers and the presence of chin hairs, which were bothersome. The facility's records showed inconsistencies in documenting the showers and shaving services provided to the resident. Resident #2, who was cognitively intact but required assistance with personal hygiene, had overgrown nails with a brown/black substance underneath. The resident expressed a preference for having their nails cut, but the facility failed to provide regular nail care. The Director of Nursing acknowledged the need for nail care but had not ensured it was performed. The facility's documentation did not reflect consistent nail care, and the resident received only four of the nine scheduled showers in the past month. Resident #3, also cognitively intact, required substantial assistance with bathing but reported receiving only two showers in the past month. The resident felt unclean due to the infrequent showers and noted that staff sometimes offered showers at inconvenient times, such as late at night. The facility's records showed discrepancies in the number of showers documented, and the resident's care plan lacked specific preferences for bathing. Interviews with staff revealed challenges in adhering to the shower schedule, particularly when staffing levels were low, impacting the delivery of care.
Resident Elopement Due to Inadequate Supervision and Risk Assessment
Penalty
Summary
The facility failed to provide adequate supervision and identify an elopement risk, resulting in a resident eloping from the facility. The resident, who had a history of moderate cognitive loss and various mental health diagnoses, was initially assessed as not being an elopement risk. However, subsequent notes indicated the resident exhibited exit-seeking behavior and wandering, yet these behaviors were not adequately addressed in a timely manner. On multiple occasions, the resident demonstrated behaviors consistent with an elopement risk, such as exit-seeking and verbalizing intentions to leave the facility. Despite these indicators, the resident was not immediately reassessed as an elopement risk, and the necessary safety measures were not implemented. The resident eventually left the facility unsupervised and was missing for approximately one hour before being returned by a neighbor. Interviews with staff revealed a lack of communication and awareness regarding the resident's elopement risk and the implementation of 15-minute checks. The Director of Nursing and other staff members were not fully informed or did not act upon the resident's behaviors and the need for increased supervision, leading to the resident's unsupervised departure from the facility.
Resident Rights Violation Due to Derogatory Religious Comment
Penalty
Summary
The facility failed to uphold resident rights and dignity when a staff member made a derogatory religious statement to a resident. The incident involved a resident with no cognitive loss, as indicated by a Brief Interview of Mental Status (BIMS) score of 15, who was dependent on a wheelchair and required varying levels of assistance for daily activities. The resident, who had diagnoses including heart attack, obesity, and anxiety disorder, reported feeling hurt and disrespected when a staff member greeted them with 'happy zombie Jesus day' on Easter Sunday. The staff member, a Certified Nurse Aide (CNA), admitted to making the statement, believing it was not offensive. However, the Director of Nursing was unaware of the incident and stated that such comments were inappropriate and not in line with the facility's expectations for respectful communication. The facility's policies on resident rights and dignity emphasize treating residents with respect and ensuring they can exercise their rights without interference or discrimination.
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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