Hillside Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 1265 Mclaran Avenue, Saint Louis, Missouri 63147
- CMS Provider Number
- 265585
- Inspections on file
- 32
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Hillside Health Care Center during CMS and state inspections, most recent first.
The facility did not ensure that an RN was on duty for at least 8 consecutive hours each day, as required by regulation and its own staffing policy. Staffing records for a review period showed multiple days with no RN scheduled despite a census of 147 residents. The DON reported serving as the on-call RN on those days and believed this counted as RN coverage, although she was not physically present in the building for 8 hours and did not clock in due to being salaried. The Administrator acknowledged awareness of the requirement for daily RN coverage.
The facility failed to report an allegation of abuse to DHSS within the required timeframe after a verbal dispute between two residents escalated into a physical altercation. One resident, with severe cognitive impairment and multiple neurologic and cardiac diagnoses, was separated by nursing staff but repeatedly returned to the shared room, where an LPN later found the other resident standing over this resident, yelling. Both residents stated they had hit each other, and one resident requested hospital evaluation and voiced suicidal ideation, while the other reported being hit in the chest. The facility’s abuse policy required immediate reporting of all alleged abuse, including resident-to-resident physical altercations, yet no report was submitted to the state, and one resident’s record lacked documentation of the incident. The DON expected policy compliance, while the Administrator stated she was initially informed there had been no physical contact and therefore did not report the event.
The facility failed to thoroughly investigate an alleged abuse incident involving a physical altercation between two residents sharing a room. One resident with severe cognitive impairment and multiple diagnoses and another resident with psychiatric and neurologic conditions both later reported that they hit each other, and an LPN found one resident standing over the other, yelling, after being alerted by another resident. Although the facility’s abuse policy required immediate reporting, comprehensive documentation, and an administrative investigation with statements from all involved parties, there was no incident documentation or care plan updates for either resident, key witnesses were not interviewed or asked for written statements, and the Administrator did not document interviews that were obtained, resulting in a deficient investigation of the abuse allegation.
Staff did not continue wound care treatments for a resident after hospitalization, resulting in the worsening of a sacral pressure injury and the development of two additional pressure ulcers. Staff also failed to document wound changes accurately, notify the physician, and obtain updated wound care orders. Additionally, timely dressing changes were not performed for another resident with saturated dressings.
Staff failed to ensure two residents received appropriate pain management, including not administering prescribed pain medications for a resident with metastatic cancer and not providing adequate pain relief during wound care for another resident, resulting in significant pain for both individuals.
A resident with diabetes and peripheral vascular disease developed a wound on the right heel that was not documented in progress notes, physician order sheets, or treatment records. Facility staff failed to follow wound management protocols, including assessment, documentation, and obtaining physician orders, resulting in a lack of appropriate monitoring and care for the wound.
Staff failed to follow wound care policies for two residents, resulting in the worsening of pressure injuries and the development of new wounds. One resident did not receive continued wound care after hospital discharge, with missed documentation, lack of physician notification, and no wound care orders in place. Another resident with multiple pressure ulcers did not have dressings changed as ordered, with saturated dressings left in place for days. There was a lack of accurate documentation, failure to obtain or follow wound care orders, and improper application of treatments by CNAs without orders.
Two residents experienced unmanaged pain due to staff failing to administer prescribed pain medications, notify the physician when medications were unavailable, and follow pain management protocols. One resident with metastatic cancer was not given ordered narcotics and was transferred to the hospital for uncontrolled pain, while another resident with multiple wounds suffered significant pain during dressing changes and was given an over-the-counter spray without a physician order. Staff did not consistently assess, document, or communicate about pain as required.
A resident with diabetes and peripheral vascular disease developed a wound on the right heel that was not documented in progress notes, physician orders, or treatment records, despite being noted on a shift report. Staff were unaware of the wound, and required notifications and wound management procedures were not followed, resulting in a lack of physician orders and monitoring for the wound.
A resident with a legal guardian and multiple psychiatric diagnoses left the facility without authorization by disguising themselves as a visitor and exiting through a vulnerable front entrance. Staff failed to recognize or intervene, and there was confusion among staff regarding the difference between elopement and AMA, especially for residents with guardians. The facility's policies did not address this scenario, and required procedures for elopement were not followed, resulting in the resident's unauthorized departure.
Staff failed to ensure safe and appropriate oxygen administration for two residents, including not turning on oxygen for a resident with hypoxia and not following physician orders for oxygen flow rate and tubing changes for another resident. Observations showed improper setup, incorrect flow rates, and lack of proper labeling, contrary to facility policy and physician orders.
The facility failed to maintain handrails on resident halls, with observations revealing loose or missing handrails across multiple units. The Interim Regional Director of Maintenance was unaware of these issues, and the previous director noted that replacements were available but required a work order. The DON and Administrator were aware of missing but not damaged handrails, highlighting a gap in maintenance oversight.
The facility failed to provide a safe, clean, and homelike environment in two dining rooms and several common areas. The 300 main dining room had stained curtains, damaged chairs, and a trash bag on the floor. The 200 main dining room and day room had water leaks, with residents expressing concerns about slipping. The 200 hall had floor cracks, and the 100 hall had a soiled PPE container. Maintenance issues were not reported by staff, and the Interim Regional Director of Maintenance was unaware of the problems until the survey.
A resident receiving a bed bath in a shared room was left exposed to the hallway due to an open door and an unpulled privacy curtain. The resident, who required substantial assistance with personal hygiene, expressed a preference for the door to be closed during care. The ADON and DON confirmed that the door should have been closed and the privacy curtain pulled to ensure the resident's dignity and privacy.
The facility failed to follow physician orders for wound care for two residents, resulting in their hospitalization for wound conditions, including amputations. Despite having detailed orders, treatments were frequently missed, and the residents' conditions worsened. One resident, with a complex medical history, was found in distress with untreated wounds and was eventually hospitalized with infections. Interviews revealed systemic issues in treatment administration and documentation, with staffing problems cited as a reason for missed care.
A facility failed to administer enteral nutrition correctly for a resident dependent on a g-tube, leading to severe vomiting and hospitalization. The feeding machine was incorrectly set to 140 ml/hour instead of the prescribed 40 ml/hour. Additionally, g-tube site treatments were not completed as ordered for another resident, and staff failed to complete necessary assessments for self-administration of medications. Interviews revealed a lack of training and procedural guidance, contributing to the deficiencies.
A resident with epilepsy did not receive prescribed Keppra, leading to a seizure and hospitalization, while another resident was given Ambien despite a documented allergy. The facility failed to ensure medication availability and adherence to allergy checks, resulting in significant medication errors.
A resident with multiple pressure ulcers, including a Stage IV ulcer, did not receive consistent wound care and antibiotics as prescribed. The facility failed to administer Santyl and Gentamycin ointments and did not notify the NP or physician about missed treatments. This led to the resident's condition worsening, requiring hospitalization for surgical debridement and treatment of a severe infection.
The facility failed to timely identify and address significant weight loss in several residents, leading to inadequate nutritional interventions. A resident experienced a weight loss of -24.93% over a short period, with the facility failing to provide appropriate therapeutic diets, supplemental food items, and feeding assistance. Another resident, diagnosed with quadriplegia and malnutrition, also experienced significant weight loss due to inconsistent provision of nutritional supplements and inadequate assistance during meals. A third resident experienced a significant weight loss of over 10% within a few months, with prescribed supplements not documented or consistently provided.
The facility failed to provide appropriate respiratory care for a resident with COPD, resulting in hospitalization due to a delay in medication administration and reporting of a STAT chest x-ray. Additionally, the facility did not obtain physician orders for CPAP machines for two residents with sleep apnea, leading to inadequate care. The lack of communication and documentation regarding respiratory care needs contributed to the deficiencies.
The facility did not maintain the required RN coverage for at least eight consecutive hours a day, seven days a week, as per their policy. Staffing sheets showed multiple dates without RN coverage, and interviews revealed reliance on agency staff and recruitment challenges. The Administrator expected the Staffing Coordinator to ensure compliance with RN coverage requirements.
The facility did not have a certified Director of Food and Nutrition Services, as the Dietary Manager lacked the necessary certification despite completing the course. The Registered Dietician only visits once a week and is not full-time, affecting all 151 residents consuming facility-prepared food.
The facility failed to conduct a thorough facility-wide assessment, missing critical details such as staffing ratios and the necessity for an RN for eight consecutive hours daily. The assessment also lacked documentation on the use of locked units for residents with cognitive impairments. Surveyors found insufficient nursing staff, missed treatments, and a lack of a restorative program, with no RN scheduled for the required hours.
The facility failed to implement an effective Antibiotic Stewardship Program (ASP) due to a lack of a current tracking system and surveillance for antibiotics. The newly appointed Infection Preventionist (IP) was unaware of previous tracking information, and staff interviews revealed a lack of awareness and implementation of the ASP. The Administrator and DON acknowledged the expectation of antibiotic stewardship, but the responsibility to establish and maintain the ASP was not being fulfilled.
The facility did not maintain a tracking system for the mandatory 12-hour training requirements for CNAs. Five CNAs' records showed signed in-service sheets without time durations, and no tracking documentation was provided. A CNA and the Administrator confirmed the lack of official tracking despite ongoing education.
The facility failed to accommodate resident needs by not maintaining wheelchairs, providing necessary side rails, ensuring call light accessibility, and granting access to community rooms. Residents experienced discomfort and limited social interaction due to these oversights, highlighting a lack of communication and timely maintenance within the facility.
The facility failed to maintain a safe and homelike environment, with issues such as a leaking dining room ceiling, broken furniture, and the use of plastic utensils for meals. Additionally, a clogged toilet, damaged walls, dusty AC units, and a missing closet door were observed, indicating a lack of effective maintenance and housekeeping procedures.
The facility failed to conduct criminal background checks on three newly hired employees before their start dates, as required by policy. The HR representative admitted to delays in running these checks due to hectic circumstances, and the Administrator confirmed the expectation for timely checks. This oversight was identified during a review of employee files.
The facility failed to provide adequate personal care, nail care, and facial hair hygiene for several residents requiring assistance with ADLs. Observations revealed missed showers, strong odors, and visible hygiene issues due to staffing shortages and resident resistance. One resident with severe cognitive impairment missed multiple showers, while another with cerebral palsy had long nails and unwashed hair. Additionally, a resident with dementia had soiled bed linens unchanged for days, attracting flies. These deficiencies highlight the facility's failure to adhere to its care and services policy.
The facility failed to implement a restorative therapy program for residents with limited mobility, affecting three residents. A resident's therapy was discontinued due to insurance issues, and no restorative services were recommended. Another resident with severe cognitive impairment and range of motion limitations did not receive therapy or restorative services. A third resident with quadriplegia and dementia also did not receive therapy. The facility lacked an active restorative program, and the restorative aide was often pulled to work as a CNA due to staffing shortages.
The facility failed to provide sufficient nursing staff, resulting in missed wound care for two residents with complex medical needs. Staff interviews revealed consistent understaffing, leading to incomplete tasks and inadequate care. Despite efforts to use agency staff, the facility struggled to maintain safe staffing levels, impacting resident care.
The facility failed to serve food at safe and appetizing temperatures for three residents. A resident reported that their food was often cold upon delivery, while another resident with moderately impaired cognition also experienced cold meals. Observations confirmed that food items like waffles, hash browns, and fried chicken were served below the required temperatures. Staff interviews indicated an expectation for food to be delivered at appropriate temperatures.
The facility failed to maintain kitchen cleanliness and staff compliance with hygiene standards. Observations revealed grease and debris build-up on equipment, trash in the walk-in freezer, and dust on fans blowing on clean dishes. A staff member with a beard was repeatedly seen preparing food without a beard net, violating hygiene protocols.
A resident self-administered medications via a g-tube without a physician's order, contrary to facility policy. An LPN observed but did not educate the resident on safe administration techniques, leading to the injection of air into the stomach. The resident had a history of refusing staff-administered medications, and the DON was unaware of improper medication handling.
The facility failed to update resident inventory records, resulting in missing clothing for two residents. Issues in the laundry department, including staff changes and poor communication, contributed to the problem. Residents expressed dissatisfaction, with one washing clothes by hand to avoid further losses. The social worker and administrator were not fully aware of the missing items, highlighting a breakdown in the reporting process.
A resident with severe cognitive impairment repeatedly pulled the call light out of the wall, but this behavior was not documented in their care plan. Observations showed the call light unplugged with no audible alert at the nurse's station. Staff interviews revealed a lack of awareness and communication about the issue, contributing to the deficiency.
A resident with a history of stroke and bilateral leg amputations was transferred to another facility at their request, but the LTC facility failed to document the resident's involvement in the discharge planning process. Despite the Social Services Director's involvement, there was no record of the resident's decision or a Discharge Planning Assessment in the medical record.
A facility failed to complete a discharge summary for a resident transferred to another facility. The resident, with a history of stroke and bilateral leg amputations, was moved with medications and personal belongings, but there was no documentation of the transfer reason or a comprehensive discharge summary. Interviews revealed that the SSD did not document conversations or complete the summary, and the MDS nurse noted the discharge order but was not responsible for the process. The Administrator confirmed the SSD's responsibility for the summary, which was not completed as per policy.
A resident's room was found to contain hazardous chemicals, including Raid bug spray and Odoban and Febreeze sprays, despite staff expectations to keep rooms free from such items. The resident, with schizoaffective disorder and moderate cognitive impairment, had these items on their nightstand over several days. Staff interviews confirmed the expectation to monitor and remove harmful chemicals, highlighting a lapse in supervision and safety protocols.
A resident with dementia and depression did not receive prescribed cognition-enhancing medications due to the facility's failure to transcribe psychiatric NP recommendations into physician orders. The resident exhibited frequent crying episodes, and there was no Social Services documentation of behaviors or interventions. Staff interviews revealed a breakdown in the process of handling psychiatric recommendations, with LPNs unaware of new orders and the DON acknowledging issues in the transcription process.
The facility failed to properly label and store medications, with issues such as wet medication boxes in a refrigerator, expired medications on carts, and improper storage of Nystatin Powder. Staff interviews revealed a lack of awareness and adherence to policies, including temperature monitoring and removal of expired medications.
Two residents with cognitive impairments and swallowing difficulties did not receive mechanically altered diets as ordered by their physicians. Observations showed them being served whole foods, leading to difficulties in chewing and spitting out food. Staff interviews revealed inconsistencies in meal preparation and delivery, with dietary staff sending incorrect food textures and nursing staff having to intervene. The facility's care plans and diet cards were not updated to reflect the prescribed diets, contributing to the deficiency.
A facility failed to maintain accurate medical records and properly supervise a resident's medication administration. The MDS Coordinator revised a previous assessment instead of generating a new one, violating facility policy. The resident, with multiple diagnoses and using a feeding tube, self-administered medication without proper guidance from the LPN, who failed to educate on the risks of injecting air into the stomach. The DON and Administrator confirmed the need for accurate assessments and physician orders for self-administration.
The facility failed to implement Enhanced Barrier Precautions for a resident with a feeding tube, as staff did not wear protective gowns during high-contact care. Additionally, proper infection control techniques were not followed during blood glucose monitoring and insulin administration for a diabetic resident, as hand hygiene and equipment cleaning were neglected. Interviews revealed staff were unaware of EBP protocols and infection control practices.
The facility failed to provide privacy curtains in three shared rooms, affecting residents' visual privacy. A resident with Alzheimer's and another with dementia were observed without privacy curtains, exposing them during personal care. Staff interviews revealed a lack of communication and awareness about the missing curtains, with the facility acknowledging a shortage and pending orders for replacements.
The facility did not post daily nurse staffing information as required, failing to include the facility name on staffing sheets and not posting them on certain days. The Staffing Coordinator, responsible for filling out and posting the sheets, was unaware of the daily posting requirement and the need to include the facility name. The Administrator expected the sheets to be completed and posted daily, highlighting a lapse in policy adherence.
Failure to Ensure Required Daily RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required by regulation and by its own Sufficient Staffing Policy dated February 2023. The policy states that the facility must provide licensed nursing staff 24 hours a day, 7 days a week, and, except when waived, must use the services of an RN for at least 8 consecutive hours daily, 7 days a week, taking into account census, acuity, and resident diagnoses. Review of staffing sheets for March 2026 showed multiple days with no RN scheduled, specifically on 3/1, 3/7, 3/9, 3/14 through 3/17, 3/21, 3/22, and 3/25, despite a census of 147 residents and a sample of 8 residents reviewed. In interviews, the DON stated she was the on-call person for the days when no RN was scheduled and believed that on-call status would count as RN coverage, acknowledging she was in the building at times on those days but not for eight hours. The Administrator stated awareness that an RN needed to be scheduled for at least eight hours a day, seven days a week, and it was noted that the salaried DON does not clock in when on duty, contributing to the lack of documented RN coverage.
Failure to Timely Report Resident-to-Resident Physical Altercation as Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe following a physical altercation between two residents. The facility’s Abuse and Neglect policy required that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property be reported immediately to the Administrator and appropriate agencies within prescribed time frames, and defined abuse to include certain resident-to-resident altercations and physical abuse such as hitting and punching. Despite this policy, review of the DHSS reporting system showed no documentation that the facility submitted a report regarding the physical altercation between the two residents. Resident #1 had severe cognitive impairment and diagnoses including heart failure, cerebral palsy, and stroke. Nursing notes documented that a verbal disagreement between Resident #1 and his/her roommate, Resident #2, escalated, requiring the nurse to physically separate them and move Resident #1 to the hallway; however, Resident #1 repeatedly returned to the room, and staff were later called back for a “fight.” LPN A found Resident #2 standing over Resident #1, yelling, and both residents stated they had hit each other. Resident #1 later reported being hit and hitting back, and Resident #2 reported being hit in the chest. Resident #1 was kept near the nurse’s station for safety and expressed a desire to go to the hospital and voiced suicidal ideation. Resident #2’s record contained no documentation of the altercation. The DON stated she expected the Abuse and Neglect policy, including timely state reporting, to be followed and did not know why reporting did not occur. The Administrator stated she was initially told there was no physical contact and therefore did not believe the incident needed to be reported to DHSS.
Failure to Thoroughly Investigate Resident‑to‑Resident Physical Altercation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse arising from a physical altercation between two residents. The facility’s Abuse and Neglect policy requires that all allegations of abuse, including resident‑to‑resident altercations, be immediately reported to the Administrator and other appropriate agencies, and that an administrative investigation be completed with statements from all involved staff and residents, documentation of pertinent information, and identification of root cause. Despite this policy, the facility did not complete a comprehensive investigation after an incident in which two residents reported hitting each other. Resident #1, who had severe cognitive impairment and diagnoses including heart failure, cerebral palsy, and stroke, was documented in a nurse’s note as having an altercation with his/her roommate, Resident #2. The note described a verbal disagreement that escalated, with the nurse initially separating the residents and moving Resident #1 to the hallway, then later finding Resident #2 standing over Resident #1, yelling, after being called back because it was reported as a fight. Resident #1 requested hospital evaluation and voiced suicidal ideation, and management was notified. However, there was no care plan documentation regarding the altercation, and the medical record contained no evidence of a completed incident report or a documented administrative investigation as required by policy. In a later interview, Resident #1 stated that another resident hit him/her and he/she hit back. Resident #2, who had no documented cognitive impairment and diagnoses including hypertension, Alzheimer’s disease, seizure disorder, schizophrenia, and depression, also had no care plan or medical record documentation of the altercation. Resident #2 reported that Resident #1 hit him/her in the chest. Another resident, Resident #8, cognitively intact with anxiety and schizophrenia, reported hearing two residents arguing and notifying an LPN, but stated no one had asked him/her about the incident before the survey interview. The LPN reported finding Resident #2 standing over Resident #1, being told by both residents that they hit each other, separating them, and notifying the on‑call ADON, but was not asked to write a statement. The ADON stated he/she was only told there was an argument, not a physical altercation, and the Administrator acknowledged not interviewing Resident #1 and not documenting interviews obtained from others. The DON stated the Abuse and Neglect policy was expected to be followed, including accurate information and gathering statements, but could not explain why this did not occur, resulting in a failure to conduct the thorough investigation required by facility policy.
Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
Staff failed to follow the facility's wound care policy for a resident who returned from hospitalization with an identified sacral pressure injury. After discharge, wound care treatments were not continued as required, leading to the worsening of the existing sacral wound and the development of two additional pressure injuries. Staff did not ensure accurate documentation of the wounds, failed to notify the physician about the worsening condition since hospitalization, and did not obtain updated wound care orders. Additionally, for another resident, staff did not perform timely wound dressing changes for saturated dressings. These failures were identified through observation, interview, and record review, and involved a total facility census of 145 residents.
Failure to Provide Effective Pain Management
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for two residents. For one resident with metastatic breast cancer and bone involvement, staff did not ensure the resident received prescribed pain medications as ordered by the physician and did not notify the primary physician when pain medications were not delivered from the pharmacy or when medications were available in the emergency kit. This resident experienced uncontrolled pain and was transferred to the hospital two days after admission. For another resident, staff did not provide effective pain relief during wound care, as wound dressings adhered to the wound sites were removed without adequate pain management, causing the resident to cry out in pain and request over-the-counter Bactine spray for relief. These deficiencies were identified through observation, interview, and record review, and involved a sample of 16 residents out of a census of 145.
Failure to Obtain Physician Orders and Monitor Wound
Penalty
Summary
Facility staff failed to obtain physician orders and monitor a wound identified on a resident's right heel. The resident, who had diagnoses of diabetes and peripheral vascular disease, was dependent on staff for personal hygiene and mobility. Although a wound was noted on the facility's 24-hour shift report, there was no documentation in the resident's progress notes, physician order sheet, or treatment administration record regarding the wound. Additionally, shower sheets did not reflect the presence of the wound, and some documentation was missing for the relevant period. The facility's wound management policy required licensed nurses to assess, document, and report wounds, obtain physician orders, and initiate appropriate treatment. It also required notification of the interdisciplinary team and responsible parties, as well as regular documentation of wound status and care. In this case, these procedures were not followed, as there was no evidence of wound assessment, physician notification, or initiation of treatment for the wound on the resident's right heel. Interviews with facility staff, including the CNA, ADON, and DON, revealed a lack of awareness and communication regarding the wound. The wound was only identified during a skin assessment conducted by the DON, ADON, and a wound care nurse practitioner, who described it as a diabetic ulcer secondary to pressure. Staff interviews confirmed that the expected documentation and notification processes were not carried out.
Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to follow its wound care policy for two residents, resulting in the worsening of existing pressure injuries and the development of new wounds. For one resident with quadriplegia, Parkinson's disease, diabetes, and reduced mobility, staff did not continue wound care treatments after a hospital discharge, despite clear hospital orders for wound care and nutritional supplements. The initial re-admission skin assessment and subsequent weekly assessments did not accurately document the presence or progression of wounds, and there was no evidence of physician notification or new wound care orders. The resident reported that no treatments were applied to his/her wounds after returning from the hospital, and staff interviews confirmed that wound care orders were missed and not carried over from the hospital. The resident's wounds worsened, with multiple open, bleeding areas observed, and a wound care specialist was not consulted until weeks later. Additionally, staff failed to ensure timely dressing changes for another resident with multiple pressure ulcers and severe protein malnutrition. Although wound care orders specified daily dressing changes and as needed for saturation, observations revealed saturated dressings that had not been changed for several days, and one wound was left uncovered. The resident and a CNA reported that wound dressings were not changed as ordered, and there was no documentation of wound care or dressing changes in the progress notes during the observed period. Throughout the incidents, there was a lack of accurate documentation, failure to notify physicians of worsening wounds, and failure to obtain or follow wound care orders. Staff also did not ensure the use of pressure-reducing devices for residents at risk, and CNAs applied treatments without proper orders. The facility did not have a dedicated wound care nurse, and floor nurses were expected to manage wound care, but failed to do so according to policy. These failures led to the worsening of wounds and the development of additional pressure injuries.
Failure to Provide Effective Pain Management for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents requiring such services. For one resident with metastatic breast cancer and severe pain, staff did not ensure that prescribed pain medications, including morphine and oxycodone, were administered as ordered. The resident's pain medications were not delivered from the pharmacy, and staff did not notify the primary physician about the delay or about the availability of pain medications in the emergency kit. Documentation showed that the resident experienced severe, uncontrolled pain, with pain scores as high as 10/10, and was ultimately transferred to the hospital two days after admission due to uncontrolled pain. Interviews revealed confusion among staff regarding the process for obtaining and administering pain medications from the emergency kit, and there was evidence that medications were marked as given in the records when they had not actually been administered. Another resident with quadriplegia, Parkinson's disease, and multiple wounds experienced significant pain during wound care. Staff removed wound dressings that were adhered to the wound sites, causing the resident to cry out in pain and request the use of an over-the-counter pain-relieving spray (Bactine) on the wounds. The aides applied the spray at the resident's request, despite there being no physician order for its use. There was no evidence that the nurse was notified of the resident's pain during the dressing change, nor was there documentation of a pain assessment or physician notification regarding the increased pain related to the wounds. The facility's own pain management policy required timely pain assessments, administration of pain medications as ordered, and physician notification if pain was not controlled or medications were unavailable. In both cases, these procedures were not followed. Staff failed to assess, document, and manage pain effectively, and did not communicate with the physician or utilize available resources to address the residents' pain, resulting in unmanaged pain and inappropriate administration of non-ordered medications.
Failure to Obtain Physician Orders and Monitor Wound for Resident with Diabetes and PVD
Penalty
Summary
Facility staff failed to obtain physician orders and monitor a wound identified on a resident with a history of diabetes and peripheral vascular disease. The resident required moderate to maximum assistance with activities of daily living and had no documented foot ulcers or wounds upon admission or in subsequent care plan updates. However, a wound to the right heel was noted on a 24-hour shift report, but there was no corresponding documentation in the resident's progress notes, physician order sheet, or treatment administration record for the period reviewed. Shower sheets for the resident did not document the presence of a wound on the right heel, and some shower sheets for the relevant week were missing. When the resident was assessed by the DON, ADON, and a wound care nurse practitioner, a wound was observed on the back of the right foot above the heel, described as a diabetic ulcer secondary to pressure. The wound measured 0.6 cm by 0.6 cm by 0.3 cm depth, with 90% granulation and 10% slough. Interviews with staff revealed a lack of awareness and communication regarding the wound. The CNA who assisted with the resident's shower was unaware of the wound, and the ADON had not been informed nor seen documentation of the wound. The DON stated that the expectation was for nurses to notify the physician, obtain treatment orders, and inform relevant parties when a wound is identified, but this process was not followed in this case.
Failure to Prevent Elopement and Ensure Staff Understanding of Policies for Residents with Guardians
Penalty
Summary
A deficiency occurred when a resident with a legal guardian, multiple psychiatric diagnoses, and a history of elopement risk left the facility without authorization or proper supervision. The resident, who was not permitted to leave the facility per the guardian's request, managed to exit the building by disguising themselves as a visitor and leaving through the front entrance, which had a known security vulnerability. Staff, including the receptionist, did not recognize the resident or intervene, and the resident was able to leave the premises and enter a waiting vehicle without staff knowledge or proper discharge procedures being followed. Facility staff demonstrated inconsistent understanding and application of policies regarding elopement, wandering, and discharge against medical advice (AMA). Interviews revealed confusion among staff about the distinction between elopement and AMA, particularly for residents with guardians who are not permitted to make independent medical decisions. Documentation showed that the resident was considered to have left AMA, and the guardian was contacted after the resident had already left. However, the facility's policies did not address the specific scenario of a resident with a guardian leaving without authorization, and staff failed to follow the established procedures for elopement, such as immediate intervention, thorough documentation, and care plan updates. The investigation further revealed gaps in staff training and policy implementation. Several staff members, including the ADON, LPN, and activity staff, provided conflicting accounts of the incident and the resident's risk status. The facility's documentation lacked statements from key staff involved, and there was no evidence that the required steps for managing elopement were followed. The resident's care plan did not document a history of wandering or elopement risk, despite information from staff that the resident had a known tendency to run off. The facility's failure to provide adequate supervision and to ensure staff understood and followed policies for residents with guardians led to the resident's unauthorized departure.
Failure to Ensure Safe and Appropriate Oxygen Administration
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care for two residents requiring oxygen therapy. In one instance, a resident with a history of COPD, asthma, and dementia returned from a canceled medical procedure exhibiting shortness of breath and low oxygen saturation levels. Staff placed the resident on supplemental oxygen, but Emergency Medical Services (EMS) later found that the oxygen was not turned on, resulting in continued hypoxia. Upon EMS intervention, the resident's oxygen saturation improved after the oxygen was properly administered. In another case, a resident with multiple diagnoses, including heart failure, respiratory failure, and mild cognitive impairment, was observed with oxygen tubing and a nasal cannula on the floor, and the oxygen flow rate set significantly higher than the physician's order. The tubing was not properly labeled or dated as required by facility policy, and the oxygen was set at 7 to 8 liters per minute, despite orders for 2 liters per nasal cannula as needed for shortness of breath. Staff interviews confirmed that the oxygen should have been set at the prescribed rate and that any changes should be communicated to nursing leadership and the physician. The facility's own oxygen administration policy requires verification of physician orders, correct setup and flow rate, proper labeling and dating of tubing, and regular monitoring and documentation. Observations and interviews revealed that these procedures were not consistently followed, resulting in deficiencies in respiratory care for residents requiring oxygen therapy.
Deficient Handrail Maintenance in Facility
Penalty
Summary
The facility failed to ensure that handrails on each resident hall were properly maintained, which had the potential to affect all residents. Observations on various units revealed multiple instances of loose or missing handrails. On the 100 South unit, several handrails were either detached, missing screws, or completely absent between rooms and outside key areas such as the soiled utility room and shower room. Similar issues were noted on the 100 Main, 200 Main, 300 Main, and 300 South units, with missing end caps and loose handrails being common problems. Interviews with facility staff revealed a lack of awareness and communication regarding the state of the handrails. The Interim Regional Director of Maintenance, who had just started, was unaware of the issues and had not yet assessed the equipment. The previous maintenance director acknowledged the problem and mentioned that replacement handrails were available but required a work order through the TELs system. The Director of Nursing and Administrator were aware of the missing handrails but not the damaged ones, indicating a gap in the facility's maintenance oversight and reporting processes.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in two of its three dining rooms and several common areas. In the 300 main dining room, there were large brown stains on the curtains, a wet spot on the floor with a yellow substance, and chairs with torn or detached seats. Residents were observed sitting on damaged chairs, and a trash bag was placed directly on the floor for waste disposal. In the 200 main dining room, water was leaking onto the floor, and residents expressed concerns about the risk of falling due to the wet conditions. Staff occasionally placed towels to absorb the water but often did not take any action. In the 200 main day room, the carpet was wet, and residents, including those in wheelchairs, were sitting in the wet area. One resident's socks were wet from the carpet, and they expressed concern about slipping. The 200 hall had large cracks in the floor, and the 100 hall had a soiled PPE container. The Interim Regional Director of Maintenance, who started recently, was unaware of these issues until the survey and noted that the building had bad seals on the windows and roof, contributing to the leaks. Interviews with the Director of Nursing and Administrator revealed that they were not informed of the leaks or the condition of the chairs until the survey. Staff had not reported these issues through the facility's maintenance request system. The previous Regional Director of Maintenance was also unaware of the chair conditions and the extent of the water leaks. The facility lacked a policy to address maintenance duties, and there was no record of staff reporting the leaks or damaged equipment.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident during incontinence care. The incident involved a resident who was cognitively intact and had multiple diagnoses, including deep venous thrombosis, neurogenic bladder, septicemia, seizure disorder, and anxiety. The resident required substantial assistance with personal hygiene and was bedfast most of the time. During an observation, the resident was receiving a bed bath in a shared room with the door open and the privacy curtain not pulled, leaving the resident exposed to the hallway and visible to passersby. The resident expressed a preference for the door to be closed during care, although they were not concerned about the privacy curtain due to the same-gender roommates. The Assistant Director of Nursing (ADON) confirmed that it was inappropriate for the door to be open during personal care, and the Director of Nursing (DON) and Administrator agreed that personal care should be provided with the door closed and the privacy curtain pulled. The incident highlighted a failure to maintain the resident's right to privacy and dignity as outlined in the resident bill of rights.
Failure to Follow Wound Care Orders Leads to Hospitalization
Penalty
Summary
The facility failed to obtain and follow physician orders for wound care for two residents, leading to their hospitalization for wound conditions, including amputations. The facility's wound management policy outlines procedures for assessment, treatment, and documentation of wounds, but these were not consistently followed. For Resident #89, there were multiple instances of missed wound care treatments as documented in the Treatment Administration Record (TAR) and progress notes. Despite having detailed physician orders for wound care, including specific instructions for cleansing, applying medications, and dressing wounds, the TAR showed numerous blank entries where treatments were not administered. Notifications to the Nurse Practitioner (NP) about missed treatments were made, but no new orders were received, and the resident was eventually hospitalized with infections and wounds requiring further medical intervention. Resident #89 had a complex medical history, including heart failure, diabetes, and obesity, which contributed to their vulnerability to skin integrity issues. The resident was noted to be resistive to care, often removing dressings and scratching wounds, which exacerbated their condition. Despite this, the facility's staff failed to consistently document and follow up on the resident's refusal of care or missed treatments. Observations revealed the resident in distress, with actively bleeding wounds and an inability to call for help due to a malfunctioning call light. The resident reported not receiving treatments for several days, and the room was noted to have an odor of urine and feces, indicating neglect in care. Interviews with facility staff, including the DON and LPN responsible for wound care, revealed systemic issues in the administration of wound treatments. The DON acknowledged that treatments were not completed and emphasized the need for documentation and communication with physicians when residents refuse care. However, there was a lack of awareness and follow-through on missed treatments, and the facility's staffing issues were cited as a reason for the inability to carry out treatment orders. The resident's condition deteriorated to the point of requiring hospitalization, where they were found to have a blood infection and were placed on IV antibiotics.
Inappropriate Administration of Enteral Nutrition via G-Tube
Penalty
Summary
The facility failed to provide appropriate administration of enteral nutrition for a resident dependent on a gastrotomy tube (g-tube). The resident's physician's orders specified a continuous feeding rate of 40 ml/hour with water flushes of 175 ml every four hours. However, the tube feeding machine was not set in English and was incorrectly set to infuse at a rate of 140 ml/hour. This error resulted in the resident receiving approximately 400 cc of feeding in a short period, leading to severe vomiting and subsequent hospitalization. The facility also failed to ensure that g-tube site treatments were completed as ordered for another resident. Additionally, the staff did not complete a self-administration medication assessment and obtain physician's orders for self-administration of medications via g-tube. The facility's policies on feeding tube site care and physician's orders were not adequately followed, contributing to the deficiencies observed. Interviews with staff revealed a lack of awareness and training regarding the correct settings and operation of the g-tube machine. The DON and other nursing staff were not informed about the machine's incorrect settings in a timely manner, and there was no policy in place to guide staff on setting up the tube feeding pump or hanging the feeding container. This lack of communication and procedural guidance contributed to the failure in providing appropriate care for residents with feeding tubes.
Medication Errors and Allergy Oversight in LTC Facility
Penalty
Summary
The facility failed to administer the prescribed medication, Keppra, to a resident with epilepsy, resulting in a significant medication error. The resident, who had a history of epilepsy, intellectual disability, dementia, schizophrenia, and anxiety, was admitted to the hospital after experiencing a grand mal seizure and sustaining a fracture of the right fibular shaft. The medication administration record indicated that the Keppra was not available on multiple occasions, and the resident did not receive the medication as ordered. Despite documentation indicating the medication was given, progress notes revealed that the medication was not available, leading to the resident's seizure and subsequent hospitalization. Another resident with known allergies to several medications, including Ambien, was administered Ambien despite the allergy being documented in the medical record. The resident's medical history included mild cognitive impairment, high blood pressure, wound infection, septicemia, hip fracture, anxiety, and depression. The medication administration record showed that Ambien was given on multiple occasions, and there was no documentation of any adverse reactions or symptoms following its administration. Interviews with staff revealed a lack of awareness and adherence to checking for allergies before administering medications. The facility's failure to ensure the availability and administration of prescribed medications, as well as the administration of a medication to which a resident was allergic, constituted significant medication errors. These errors were identified during a survey, and the facility was notified of the immediate jeopardy situation. The deficiency was initially determined to be at the immediate jeopardy level, indicating a serious threat to the health and safety of the residents involved.
Failure to Administer Wound Care and Antibiotics
Penalty
Summary
The facility failed to provide adequate care for a resident with pressure ulcers, resulting in a significant deficiency. The resident, who was cognitively intact and required substantial assistance for daily activities, had multiple pressure ulcers, including a Stage IV ulcer on the coccyx. The facility did not consistently administer prescribed wound treatments and antibiotics, as evidenced by multiple undocumented and missed applications of Santyl and Gentamycin ointments. Additionally, the facility failed to notify the attending wound Nurse Practitioner (NP) or the physician about these missed treatments. The resident's condition worsened, leading to a hospital admission for surgical debridement of the sacral wound. The hospital's infectious disease physician had prescribed a regimen of antibiotics, which the facility did not administer consistently. The facility's records showed numerous instances where the antibiotics were not given, and there was no documentation of physician notification regarding these omissions. Interviews with facility staff, including the Director of Nursing and the wound care NP, confirmed that the facility had significant issues with completing wound care and administering medications as ordered. The failure to provide consistent wound care and medication administration resulted in the resident developing a severe infection, requiring hospitalization. The facility's wound nurse and the specialty wound care NP both highlighted the importance of adhering to treatment orders and the risks associated with untreated wounds. Despite these concerns, the facility did not take appropriate action to ensure the resident received the necessary care, leading to the deficiency noted in the report.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to timely identify and address significant weight loss in several residents, leading to inadequate nutritional interventions. Resident #127 experienced a weight loss of -24.93% over a short period, with the facility failing to provide appropriate therapeutic diets, supplemental food items, and feeding assistance. The resident's medical history included malnutrition, dysphagia, and cognitive impairment, which contributed to poor food intake. Despite physician orders for nutritional supplements and ice cream, these were inconsistently provided, and the resident often refused facility food, preferring food brought by family. Observations showed the resident frequently spit out food, and staff did not consistently offer alternatives or encouragement during meals. Resident #123, diagnosed with quadriplegia and malnutrition, also experienced significant weight loss. The resident required maximum assistance for eating, but staff often left the resident unattended during meals, resulting in poor intake. Although the resident was prescribed nutritional supplements, these were not consistently provided with meals. The resident's family declined tube feeding, and the facility's dietary management failed to ensure the resident received the necessary nutritional support, contributing to ongoing weight loss. Resident #50, with diagnoses including malnutrition and schizophrenia, experienced a significant weight loss of over 10% within a few months. The resident was prescribed Boost supplements between meals, but there was no documentation of this order in the medication records. The facility's care plan did not address the resident's weight loss, and dietary staff failed to document the provision of supplements. Observations indicated that the resident's nutritional needs were not adequately met, contributing to the continued weight loss.
Deficiency in Respiratory Care and Equipment Orders
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with COPD, resulting in a deficiency. The resident, who had severe cognitive impairment and multiple diagnoses including COPD, experienced a change in condition and was sent to the hospital. The facility did not administer the ordered oral steroids in a timely manner, and there was a delay in obtaining and reporting the results of a STAT chest x-ray, which revealed pneumonia. The resident's condition worsened, leading to hospitalization where they were diagnosed with a COPD exacerbation and received necessary medications. Additionally, the facility failed to obtain physician orders for CPAP machines for two residents diagnosed with sleep apnea. One resident, who had no cognitive impairment and was diagnosed with heart failure and respiratory failure, used a CPAP machine during resting hours but lacked a physician's order for its use. The resident's CPAP mask was often found uncovered, and there was no documentation of the CPAP settings or diagnosis for its use. Another resident, with diagnoses including heart failure and COPD, also lacked physician orders for CPAP and oxygen therapy, despite using these devices. The resident's CPAP machine was reported broken, and there was no follow-up to obtain a replacement or notify the physician. The facility's failure to ensure proper medication administration and obtain necessary physician orders for respiratory equipment contributed to the deficiencies identified. The lack of communication and documentation regarding the residents' respiratory care needs and the unavailability of medications and equipment further exacerbated the situation, leading to inadequate care for the affected residents.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by their policy. The facility's staffing sheets from June 1 to July 9, 2024, revealed multiple dates with no RN coverage, specifically on June 1, 2, 15, 16, 17, 18, 19, 20, 21, 22, 23, 29, 30, and July 6, 7. During interviews, the Staffing Coordinator acknowledged the lack of RN coverage and mentioned the use of agency staff to fill the gaps. The Administrator expressed an expectation for the Staffing Coordinator to ensure RN coverage and noted ongoing recruitment efforts, including sign-on and referral bonuses, due to the difficulty in recruiting RNs.
Lack of Certified Dietary Manager
Penalty
Summary
The facility failed to designate a qualified individual to serve as the Director of Food and Nutrition Services, which is a requirement for ensuring the proper management of dietary services. The Dietary Manager, who was hired on September 29, 2022, did not possess the necessary certification from the Association of Nutrition and Food Service Professionals, as he had completed the course but had not taken the certification exam. This lack of certification was confirmed during an interview with the Dietary Manager. Additionally, the facility's Administrator acknowledged that the Registered Dietician only visits the facility once a week and is not employed full-time, further emphasizing the absence of a certified full-time dietary manager. This deficiency had the potential to impact all 151 residents who consumed food prepared by the facility.
Incomplete Facility-Wide Assessment and Staffing Deficiencies
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment lacked critical details such as staffing ratios required per shift to meet resident needs, the necessity for a Registered Nurse (RN) to be present for at least eight consecutive hours a day, seven days a week, and the facility's use of locked units for residents with cognitive impairments and behaviors. The facility's assessment, updated on 12/13/23, was incomplete, missing documentation on direct care staff ratios, restorative therapy staff, social services staff, dietary staff, housekeeping, and laundry staff necessary for each shift. Additionally, there was no documentation regarding the need for an RN or the use of locked units for residents with specific needs. During the survey, it was identified that the facility had insufficient nursing staff to meet resident needs, as evidenced by staff interviews and reports of missed treatments and activities of daily living (ADL) care for residents. Furthermore, the facility did not schedule an RN for the required eight consecutive hours a day, seven days a week, and lacked a restorative program. The Administrator acknowledged that the facility assessment is developed by the Administrator and reviewed by the facility's Regional office and interdisciplinary team, and it is expected to accurately reflect staffing needs and resources, including the use of locked units.
Deficiency in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to establish an effective Antibiotic Stewardship Program (ASP) that included antibiotic use protocols and a system to monitor antibiotic use. The facility's ASP, revised on 10/24/22, outlined procedures for limiting antibiotic resistance, improving treatment efficacy, and reducing treatment-related costs. However, the facility did not have a current tracking system or surveillance for antibiotics. The Infection Preventionist (IP) and Medical Director were responsible for setting standards for antibiotic use, but the newly appointed IP was unaware of the previous tracking and surveillance information. The facility's Minimum Data Set (MDS) Nurse, who recently took over the ASP and IP role, did not have access to the previous tracking system, indicating a lapse in continuity and oversight. Interviews with facility staff revealed a lack of awareness and implementation of the ASP. The Wound Nurse expressed a need for an antibiotic log or tracking system to refine care plans for residents with infected wounds, but was unaware of the existence of a current ASP. The Administrator and Director of Nursing (DON) acknowledged that antibiotic stewardship was expected to be utilized to track and monitor residents with antibiotic orders, but the responsibility to establish and maintain the ASP was not being fulfilled. This deficiency highlights a significant gap in the facility's infection control practices, as evidenced by the absence of a functional ASP and the lack of a systematic approach to monitor antibiotic use among residents.
Failure to Track CNA Training Hours
Penalty
Summary
The facility failed to establish and maintain a tracking system for the mandatory 12-hour training requirements for Certified Nursing Assistants (CNAs). This deficiency was identified for five sampled CNAs out of a census of 151. The facility did not provide a policy related to the 12-hour training requirement. A review of the training records for the sampled CNAs showed multiple dated in-services and education sheets signed by the CNAs, but these documents did not list the duration of each in-service. Furthermore, there was no documentation provided by the facility to track the in-services for each CNA. During interviews, a CNA mentioned that the facility was always providing in-services and education but did not officially track the mandatory 12 hours. The Administrator acknowledged that while education and in-services were provided, there was a failure to organize and track the yearly mandatory training hours for the CNAs.
Facility Fails to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of several residents, leading to multiple deficiencies. Three residents were found to have wheelchairs in poor condition, with damaged armrests and improper fitting, causing discomfort and potential harm. Despite being aware of these issues, staff did not report them for repair in a timely manner. Additionally, one resident was not provided with side rails for bed mobility and positioning, despite having a physician's order and assessment indicating their necessity. The lack of communication and follow-through on maintenance requests contributed to these deficiencies. Another resident was found without access to a call light, which was stuck and unreachable, leaving the resident unable to call for assistance. This oversight was not addressed by staff, despite the resident's care plan emphasizing the importance of call light accessibility to prevent falls and ensure safety. The facility's failure to ensure the call light was within reach posed a significant risk to the resident's well-being. Furthermore, the facility restricted access to community rooms on the third floor, preventing residents from engaging in social activities and watching television. The rooms were locked due to excessive heat, and the television in one room was broken, yet these issues were not promptly addressed. This lack of access limited residents' ability to socialize and participate in preferred activities, impacting their quality of life. The facility's inaction in addressing these environmental concerns further exemplifies the failure to accommodate residents' needs and preferences.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple deficiencies observed during the survey. On the first floor, the dining room ceiling was leaking, with water collecting in a bucket on the floor, creating an unsafe and unhomelike environment for the 33 residents present. The issue had been ongoing since April, with significant damage noted by a roofing company, yet the problem persisted during the survey period. Additionally, the second floor common areas were found to have furniture in disrepair, including a loveseat missing a leg and a reclining chair with exposed stuffing, which residents and staff acknowledged had been in poor condition for an extended period. The facility also failed to provide a homelike dining experience on the second floor, where residents were served meals with plastic utensils, making it difficult for them to eat certain foods. This practice was attributed to concerns about regular utensils not being returned to the kitchen and a shortage of supply, despite the facility having enough silverware. The use of plastic utensils was not considered homelike, and residents expressed difficulty in eating their meals properly. Furthermore, the third floor shower room had a clogged toilet with fecal material and flies, which had been left unaddressed for weeks, indicating a lack of communication and reporting among staff. Additional deficiencies included a resident's bedroom wall being damaged and not reported for repair, AC units in several rooms being covered in dust and debris, and a resident's closet door missing, leading to concerns about privacy and security. These issues were not promptly reported or addressed by the staff, highlighting a breakdown in the facility's maintenance and housekeeping procedures. The facility's policies and procedures for maintaining a safe and operable environment were not effectively implemented, resulting in an environment that was not conducive to the residents' well-being.
Failure to Conduct Timely Background Checks on New Hires
Penalty
Summary
The facility failed to perform criminal background checks (CBC) on newly hired employees prior to their start date, as required by the facility's policy. This deficiency was identified for three out of ten employees hired since the last survey. The facility's Staff Screening policy, revised on October 24, 2022, mandates that criminal background screening and reference checks be conducted for prospective staff, contractors, consultants, registry/temporary staff, and volunteers before employment or contract commencement. However, the review of employee files revealed that CBCs were not requested or received for a Certified Nurse Aide, a Dietary Aide, and a Maintenance Assistant, all of whom were hired between November 2023 and March 2024. Instead, Family Care Safety Registry (FCSR) checks were run on July 10, 2024, well after their hire dates. Interviews with facility staff highlighted the oversight in conducting timely background checks. The Human Resources (HR) representative acknowledged her responsibility for running pre-employment background checks, including CBCs or FCSRs, before new hires start working. She admitted that due to hectic circumstances, background checks were sometimes delayed and not immediately saved in employee files. The Administrator confirmed the expectation that HR should complete these checks before employment begins and retain them in the employee files. This lapse in procedure led to the deficiency noted by the surveyors.
Deficiencies in Resident Hygiene and Care
Penalty
Summary
The facility failed to provide adequate personal care, nail care, and facial hair hygiene for five residents who required assistance with activities of daily living (ADL). Observations and interviews revealed that residents were not receiving showers as scheduled, and there were instances of missed showers, resulting in residents emitting strong odors and having visible hygiene issues. For example, one resident with severe cognitive impairment and a fungal infection was noted to have missed approximately seven showers, and staff reported difficulties in providing showers due to staffing shortages and resident resistance. Another resident with severe cognitive impairment and multiple diagnoses, including cerebral palsy and quadriplegia, was observed with long nails and a buildup of dirt, as well as white flakes in their hair, indicating a lack of regular hygiene care. The resident's care plan required substantial assistance for personal hygiene, but there was no documentation of showers being provided in July 2024. Staff interviews indicated that nail care and hair washing were not consistently performed, and the resident's hygiene needs were not adequately met. Additionally, a resident with moderate cognitive impairment and diagnoses of schizoaffective disorder and dementia was found with soiled bed linens that had not been changed for at least three days, attracting flies. Staff interviews confirmed that bedding should be changed daily or as needed, but this was not consistently done. The facility's failure to adhere to its care and services policy, which mandates sufficient staffing and individualized care plans, contributed to these deficiencies in resident care.
Failure to Implement Restorative Therapy Program
Penalty
Summary
The facility failed to fully implement the restorative therapy program for residents with limited mobility, affecting three residents. Resident #88's therapy was discontinued due to insurance issues, and no restorative services were recommended. The resident had a hand contracture, and although therapy recommended a hand splint, it was not ordered. Observations showed the resident lying in bed with contracted hands and no hand splint worn. The resident reported not receiving therapy or restorative services and required staff assistance for mobility. Resident #4 had severe cognitive impairment and functional range of motion limitations but did not receive therapy or restorative services. The care plan indicated a need for assistance with transfers and maintaining mobility, but no restorative program was established. The resident reported not receiving therapy services and had a contracted right hand, requiring full care assistance from staff. Resident #123, with quadriplegia and dementia, also did not receive physical, occupational, or restorative therapy. The care plan focused on maintaining the current level of function, but no restorative program was established. Observations showed the resident with contractures to the hands and upper arms. Interviews revealed that the facility did not have an active restorative program, and the restorative aide was often pulled to work as a CNA due to staffing shortages.
Inadequate Staffing Leads to Missed Wound Care in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of its residents, resulting in inadequate wound care for two residents. Resident #89, with a history of cellulitis, diabetic foot ulcer, and multiple other conditions, had several wound care orders that were not carried out due to the nurse-to-patient ratio being too high. Similarly, Resident #2, who had multiple pressure ulcers and infections, also did not receive the necessary wound treatments. The lack of adequate staffing was documented by LPN L, who reported being unable to complete wound treatments due to being the only nurse on the floor. Interviews with various staff members, including LPNs, CNAs, and the Staffing Coordinator, revealed a consistent theme of understaffing across all shifts. Staff members reported having to prioritize tasks, often leaving wound care and other essential duties incomplete. The facility's staffing sheets showed multiple days without RN coverage, further exacerbating the issue. The DON and Administrator acknowledged the staffing challenges but noted that they had not been made fully aware of the extent of the problem by the staff. The facility's staffing policy aimed to ensure adequate nursing personnel, but the actual staffing levels did not meet the needs of the residents, particularly those requiring wound care. The facility's census exceeded the average daily census, increasing the demand for nursing care. Despite efforts to use agency staff and adjust schedules, the facility struggled to maintain safe staffing levels, impacting the quality of care provided to residents.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to provide food at a safe and appetizing temperature for three residents, as observed during a survey. Resident #30, who is cognitively intact, reported that their food was cold most of the time when delivered to their room. Resident #58, with moderately impaired cognition, also stated that their food was usually delivered cold. Resident #111, who is cognitively intact, mentioned that their food was almost always cold upon delivery. These observations were made during interviews conducted on July 8, 2024. Further observations on July 11 and July 15, 2024, revealed that food items served on the second floor were below the acceptable serving temperatures as per the facility's policy. For instance, waffles, hash browns, and fried chicken were served at temperatures significantly lower than the required 135 degrees Fahrenheit. Similarly, breakfast items such as sausage patties, eggs, and oatmeal were also served at inadequate temperatures. Interviews with staff, including the Dietary Manager and the Administrator, confirmed that there was an expectation for food to be delivered at appropriate temperatures to ensure residents received hot meals.
Kitchen Hygiene and Staff Compliance Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and hygiene standards in the kitchen, as observed over several days. The kitchen equipment, including the deep fryer and tilt skillet, had significant grease and debris build-up. The walk-in freezer was found with trash and food debris on the floor, and the flour and sugar bulk bins had lids caked with a white powder substance. Additionally, a fan in the dishwashing room was observed with dust build-up, blowing on clean dishes and silverware. These observations were made on multiple occasions, indicating a consistent lack of adherence to the facility's cleaning protocols. Furthermore, staff failed to comply with personal hygiene standards during food preparation. A staff member with a beard approximately 3/4 of an inch long was observed preparing food without wearing a beard net on multiple occasions. This was noted during both breakfast and lunch preparations, where the staff member handled cooked eggs, chicken, and mixed veggies without the required protective gear. Interviews with the dietary staff and management confirmed that all dietary staff are responsible for cleaning duties and that beard nets are mandatory during food preparation to prevent contamination.
Failure to Ensure Safe Self-Administration of Medications via G-Tube
Penalty
Summary
The facility failed to ensure a resident was properly assessed and demonstrated the ability to safely self-administer medications via a gastric tube. The resident, who was cognitively intact and had a history of severe protein-calorie malnutrition, bipolar disorder, depression, PTSD, and anxiety, self-administered medications without a physician's order to do so. The facility's policy required an assessment and a physician's order for self-administration, which was not obtained in this case. During an observation, an LPN prepared the resident's medication, including crushing a Protonix tablet, which should not have been crushed, and handed it to the resident to self-administer through the g-tube. The resident injected the medication with a large amount of air into the stomach, which was not in accordance with safe medication administration practices. The LPN did not provide necessary education or cues to the resident about the risks of injecting air or the proper technique for administering medication via gravity. Interviews with staff revealed that the resident had a history of refusing medications if staff attempted to administer them, and the resident needed constant reminders about the correct procedure. The DON stated that a resident should have an order to self-administer medication and fluids through a g-tube, and staff should document refusals and notify management and the doctor. The DON was unaware that the Protonix was being crushed, indicating a lack of communication and oversight in the medication administration process.
Failure to Update Resident Inventory Leads to Missing Clothing
Penalty
Summary
The facility failed to update the records of residents' personal possessions according to its policy, resulting in missing clothing items for two residents. Resident #42 had purchased dresses and socks that were not documented on the inventory sheet and were missing after being sent to the laundry. Similarly, Resident #39 had purchased shirts and pants that were not documented and were also missing after laundry service. The facility's policy requires that items brought into the facility after admission be added to the resident inventory at the request of the resident or their representative, but this was not adhered to in these cases. Interviews and observations revealed that the facility's laundry services were experiencing significant issues, including a lack of communication between nursing staff and laundry staff, leading to misplaced or lost clothing. The laundry aides reported that they had to reorganize the laundry area due to a high volume of lost clothing and that clothing often arrived without proper identification. Additionally, the facility had recently let go of most of its laundry staff, leading to further disorganization and confusion. The residents expressed dissatisfaction with the handling of their clothing, with one resident resorting to washing clothes by hand to prevent further losses. The facility's social worker and administrator were not fully aware of the extent of the missing clothing issue. The social worker was unaware of the missing clothing for the residents involved, and the administrator was only aware of one resident's missing items. The facility's policy requires that missing items be reported to social services, who then report to laundry, but this process was not effectively followed. The lack of proper inventory updates and communication breakdowns contributed to the deficiency in managing residents' personal possessions.
Failure to Address Resident's Call Light Behavior
Penalty
Summary
The facility failed to address a specific behavior of a resident related to pulling the call light out of the wall, which was not included in the resident's care plan. The resident, who has severe cognitive impairment and multiple diagnoses including Alzheimer's disease, was observed multiple times with the call light unplugged, and the notification light above the door was lit without an audible sound at the nurse's station. Despite these observations, there was no documentation in the medical record or care plan addressing this behavior. Interviews with staff revealed that the call light was removed due to the resident's behavior, and alternative notification methods like bells were mentioned but not effectively implemented. The Director of Nursing and Administrator were unaware of the issue, and the Regional Director of Plant Operations and Director of Maintenance were not informed about the call light being removed. This lack of communication and documentation contributed to the deficiency in addressing the resident's behavior and ensuring a functioning call light system.
Failure to Document Resident Involvement in Discharge Planning
Penalty
Summary
The facility failed to document a resident's involvement in discharge planning, which is a requirement according to their Transfer and Discharge Planning policy. The policy mandates that Social Services staff conduct a Discharge Planning Assessment and document the resident's involvement in the discharge process. However, for a resident who was transferred to another facility, there was no documentation of the resident's involvement in the decision to transfer, nor was there a Discharge Planning Assessment filed in the resident's medical record. The resident, who had a history of stroke, atrial fibrillation, and bilateral leg amputations, was transferred to another facility at their request to be closer to their previous home. Despite the Social Services Director's involvement in the discharge planning, there was no documentation of conversations with the resident regarding their request to transfer. The Administrator confirmed that the transfer was the resident's choice and expected documentation to reflect the resident's involvement in the discharge planning process.
Failure to Complete Discharge Summary for Resident Transfer
Penalty
Summary
The facility failed to ensure a discharge summary was completed for a resident, including a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge. The resident, who had a history of stroke, atrial fibrillation, and bilateral leg amputations, was transferred to another facility with medications and personal belongings. However, there was no documentation related to the reason for the transfer, whether the resident was involved in the discharge planning, or a comprehensive final discharge summary of the resident's status at the time of discharge. Interviews with facility staff revealed that the Social Services Director (SSD) did not document conversations with the resident about the transfer request or complete a discharge summary. The Minimum Data Set (MDS) nurse noted the discharge order but was not responsible for the discharge process. The Administrator confirmed that the SSD was responsible for providing the discharge summary, which should have been signed by the resident and retained in the medical record. The lack of documentation and discharge summary represents a failure to comply with the facility's Transfer and Discharge Planning policy.
Hazardous Chemicals Found in Resident's Room
Penalty
Summary
The facility failed to ensure that a resident's room was free from hazardous chemicals, which posed a potential health risk. The resident, who has diagnoses of schizoaffective disorder, dementia, and major depressive disorder, was observed to have several hazardous chemicals on the nightstand in their room. These included a half-full can of Raid bug spray, two full cans of Odoban odor spray, and two full spray bottles of Febreeze odor spray. The resident is ambulatory, has full function of their arms, and is moderately cognitively impaired, which could increase the risk of misuse of these chemicals. Observations were made over several days, consistently noting the presence of these chemicals in the resident's room. Interviews with facility staff, including a CNA, an LPN, and the Administrator, revealed that there was an expectation for staff to ensure resident rooms were free from harmful chemicals. However, this expectation was not met, as evidenced by the repeated observations of hazardous chemicals in the resident's room. The staff acknowledged the potential harm these chemicals could pose to residents, indicating a lapse in the facility's supervision and safety protocols.
Failure to Implement Psychiatric Recommendations for Resident with Dementia
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia and depression, as evidenced by not following the psychiatric Nurse Practitioner's (NP) recommendations. The resident, who had moderate cognitive impairment and depression, was prescribed cognition-enhancing medications, donepezil and Namenda XR, which were not transcribed into the resident's physician orders. This oversight resulted in the resident not receiving the prescribed medications. Additionally, there was no documentation from Social Services regarding the resident's behaviors or individualized interventions, despite the resident exhibiting frequent crying episodes and distress. Interviews with facility staff revealed a breakdown in the process of handling psychiatric recommendations. The Licensed Practical Nurses (LPNs) were unaware of the new medication orders and did not know where to locate the psychiatric NP notes. The Director of Nursing (DON) acknowledged that prior to May 2024, recommendations were sent to the DON and then to Unit Managers for transcription into the electronic medical record. However, at the time of the report, psychiatric recommendations were only available upon request, leading to a lack of awareness and implementation of necessary treatments for the resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards and facility policy. Observations revealed that the first floor medication room's refrigerator contained wet boxes of medication due to water leaking from the freezer, with temperatures recorded at 42 degrees Fahrenheit initially and later at 28 degrees Fahrenheit, which is outside the acceptable range. Additionally, the temperature log did not reflect the required second daily reading. Expired medications were found in the third floor medication room and on the second floor nurse medication cart, including an open bottle of Active Liquid Protein and Nystatin Powder stored improperly with eye and oral medications. Furthermore, the second floor Certified Medication Technician (CMT) cart contained an undated Advair Diskus inhaler and expired medications, such as Artificial Tears and iron supplements. Interviews with staff revealed a lack of awareness and adherence to the facility's medication storage policy. A Certified Medication Technician was unaware of the water leakage issue, and the Assistant Director of Nursing acknowledged that expired medications should be removed. Staff members, including a Licensed Practical Nurse and the Director of Nursing, confirmed that medications should be dated when opened and expired medications should be removed. The Director of Nursing was also unaware of the policy requiring twice-daily temperature checks for refrigerators containing vaccines. These deficiencies indicate a failure in maintaining proper medication storage and monitoring practices, leading to potential risks for medication integrity and safety.
Failure to Provide Mechanically Altered Diets as Ordered
Penalty
Summary
The facility failed to ensure that two residents received mechanically altered diets as per physician orders. Resident #127, who has moderate cognitive impairment and diagnoses including malnutrition and dysphagia, was observed receiving regular textured food instead of the prescribed mechanical soft diet. The resident was seen struggling to chew and spitting out food, indicating difficulty with the food texture. Interviews with staff revealed that the resident's diet card incorrectly indicated a regular diet, and there was confusion about who changed the diet card. The Dietary Manager acknowledged the error and stated that dietary staff should not alter diet cards and must adhere to physician orders. Resident #15, with diagnoses including malnutrition, dementia, and a cognitive communication deficit, also did not receive the prescribed mechanical soft diet. Observations showed the resident being served whole foods, such as egg rolls and hamburgers, despite a physician order for a mechanical soft diet. The resident reported missing dentures, which further complicated their ability to chew whole foods. The care plan failed to reflect the physician's order for a mechanical soft diet, and the resident's diet card was not updated to match the prescribed diet. Interviews with various staff members, including CNAs, LPNs, and the Dietary Manager, highlighted inconsistencies in meal preparation and delivery. Staff reported that dietary often sent out incorrect food textures, requiring nursing staff to intervene and request the correct meals. The Director of Nurses and Administrator emphasized the importance of checking diet cards before serving meals to ensure residents receive the correct food texture, as per physician orders, to prevent health issues such as choking or aspiration.
Inaccurate Medical Record Keeping and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with professional standards and its own policies. This deficiency was identified when staff revised an assessment completed three months prior for a resident, without generating a new assessment. The facility's policies clearly state that original entries should not be destroyed or removed, and any corrections should be made in a standardized manner. However, the MDS Coordinator revised the resident's self-administration assessment from April 2024, making the original content no longer visible, which is against the facility's policy. The resident involved was cognitively intact and had diagnoses including malnutrition, anxiety, depression, psychotic disorder, and bipolar disease. The resident used a feeding tube and had a care plan that did not identify them as being able to self-administer medications. Despite this, the resident was observed self-administering medication through the feeding tube without proper supervision or guidance from the LPN, who did not cue the resident on the correct procedure or educate them on the risks of injecting air into the stomach. The MDS Coordinator later acknowledged that the assessment was incorrect and intended to generate a new quarterly assessment. The DON and Administrator confirmed that assessments should be completed by the charge nurse to determine if a resident is safe to self-administer medications, and a physician order should be obtained if they are deemed safe. The failure to generate a new assessment and the inappropriate revision of the previous assessment led to the deficiency noted by the surveyors.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection prevention and control standards by not implementing Enhanced Barrier Precautions (EBP) for Resident #22, who required such measures due to having a feeding tube. Despite a sign indicating the need for gloves and gowns for high-contact care activities, staff members Restorative Aide W and CNA V entered the resident's room without wearing protective gowns. They proceeded to provide care, including cleaning the resident and changing linens, without the necessary protective equipment, thereby increasing the risk of spreading multidrug-resistant organisms. Additionally, the facility did not follow proper infection control techniques during blood glucose monitoring and insulin administration for Resident #133, who has diabetes. Certified Medication Technician (CMT) AA failed to perform hand hygiene before and after glove use, did not clean the glucometer before and after use, and did not use a barrier for the equipment. Furthermore, CMT AA did not clean the injection site before administering insulin, which is a critical step in preventing infection. Interviews with staff, including the MDS Nurse and the Director of Nursing, revealed a lack of awareness and understanding of the EBP protocol and proper infection control practices. Staff members were unsure of the criteria and interventions involved with EBP, and there was a failure to ensure that competencies related to infection control were up to date and effectively implemented.
Lack of Privacy Curtains in Shared Rooms
Penalty
Summary
The facility failed to ensure that privacy curtains were installed around beds in three shared rooms, compromising the visual privacy of residents. Specifically, Resident #37, who has severe cognitive impairment and Alzheimer's disease, was observed multiple times without a privacy curtain around their bed. This lack of privacy was evident when a CNA assisted the resident in getting undressed while the roommate was present in the room, fully able to see the resident. Similarly, Resident #126, also with severe cognitive impairment and dementia, shared a room where only one bed had a privacy curtain, leaving the other resident without visual privacy. Observations confirmed the absence of privacy curtains in these rooms over several days. Additionally, another room shared by two unidentified residents was observed to lack privacy curtains for both beds. Interviews with staff, including CNAs, housekeeping, and maintenance personnel, revealed a lack of awareness and communication regarding the missing privacy curtains. The Housekeeping/Laundry Director acknowledged a shortage of privacy curtains and mentioned that they were on order. The Maintenance Director was unaware of the issue, and the Administrator confirmed that an audit had been conducted to identify the missing curtains, but the facility was still in the process of ordering replacements.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post nurse staffing information daily in a prominent place accessible to residents and visitors. The facility's policy, revised on 10/24/22, mandates that the facility name, current date, total number, and actual hours worked by licensed and unlicensed nursing staff per shift, along with the facility census, must be posted daily. However, from 6/3 through 7/9/24, the facility did not complete and post the staffing sheets on several days, and on other days, the sheets lacked the facility name. Observations and interviews revealed that the staffing sheets were not filled out or posted on days when the Staffing Coordinator was not working. The Staffing Coordinator was unaware of the requirement to include the facility name and to post the sheets daily. The Administrator expressed an expectation for the staffing sheets to be completed correctly and posted daily in a prominent area, indicating a lapse in adherence to the facility's policy and regulatory requirements.
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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