Ignite Medical Resort St Marys Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Blue Springs, Missouri.
- Location
- 111 Mock Avenue, Blue Springs, Missouri 64014
- CMS Provider Number
- 265759
- Inspections on file
- 16
- Latest survey
- August 27, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ignite Medical Resort St Marys Llc during CMS and state inspections, most recent first.
The facility failed to provide adequate pressure ulcer care and prevention, leading to the development and worsening of pressure ulcers in residents. A resident's pressure ulcer worsened due to inconsistent implementation of interventions and missing documentation. Another resident was admitted with multiple pressure injuries, but the facility did not document a comprehensive wound assessment or consistently document wound care treatments. A third resident had a Stage III pressure ulcer, but daily wound care was not consistently documented, and weekly skin checks were not always completed.
The facility failed to maintain cleanliness and proper food storage standards in the kitchen, with food debris and dust buildup observed in various areas. Milk was stored at an improper temperature, and the Dietary Manager admitted to not instructing staff to check milk temperatures. These issues potentially affected all residents consuming food from the kitchen.
The facility failed to maintain a safe and clean environment, with deficiencies including uncleanable commode risers, dust buildup on fans and vents, unclean floors, missing tiles in a shower room, a loose grab bar, and a broken shower chair. These issues potentially affected at least 30 residents.
The facility failed to ensure timely physician visits for several residents, as required by policy. A resident was not seen by a physician for 10 months, while another had not been seen since admission. Staff were unaware of visit frequency requirements, and there was no monitoring system in place.
The facility failed to ensure timely physician responses to pharmacist recommendations for Gradual Dose Reduction (GDR) of psychotropic medications for two residents. One resident's Bupropion and Duloxetine were not reviewed for GDR, and another resident's Quetiapine dosage was increased without appropriate indications. Additionally, a third resident's Lorazepam dosage was increased without a documented rationale or anxiety diagnosis.
The facility failed to maintain safe temperatures for hot foods and milk on room trays for residents on C and E Hall. Observations showed that hot foods were below the required 120°F, and milk was above the required 41°F. Delays in tray delivery due to CNAs assisting residents contributed to the issue. Staff interviews revealed inconsistent monitoring of tray temperatures, affecting at least 12 residents.
The facility failed to ensure the call system was audible on C Hall, affecting 14 residents with dementia. Observations showed that while call lights were flashing, they were not audible within the hall. The CNO confirmed the issue, and the North Unit Manager noted the lack of a Touch Screen Nurse Console in the area. A CNA also reported being unable to hear the call system from their location.
The facility failed to secure cleanout covers, creating a hazard for residents and staff. On C Hall, a cover moved when stepped on due to a broken cap, as noted by the EVS Director. Similarly, a cover between D Hall and the Rehabilitation Unit Nurse's station was loose, with the EVS Director attributing the issue to accidental damage during carpet removal. This affected 14 residents on C Hall and 19 residents passing through the affected area.
A resident with cognitive impairment and physical limitations was exposed to bystanders during care due to open window curtains. Staff interviews revealed an expectation to maintain privacy, but a CNA admitted forgetting to close the curtains. The ADON and DON acknowledged the oversight.
The facility failed to obtain physician orders and evaluate the ability of two residents to self-administer medications. One resident with COPD was observed using a Ventolin inhaler without staff monitoring or documentation, while another resident with COPD and Pneumonia used a Trelegy inhaler independently without a care plan or evaluation. Staff interviews revealed a lack of awareness and adherence to protocols for self-administration of medication.
The facility failed to promptly address and document skin issues for two residents. One resident had multiple skin integrity concerns upon admission, but treatment orders were delayed, and weekly skin assessments were inconsistently documented. Another resident, at risk for skin issues, had a facility-acquired wound that was not identified or treated in a timely manner. Staff interviews revealed inconsistencies in skin assessment documentation and communication, leading to deficiencies in resident care.
A facility failed to provide proper catheter care for a resident, risking urinary tract infections, by not cleaning the catheter insertion site and not emptying the drainage bag as required. Additionally, the facility did not implement hospital discharge orders for another resident to attempt a voiding trial for catheter removal, failing to assess urinary continence or consult a urologist. Staff interviews revealed misunderstandings and non-compliance with care protocols.
A resident with COPD and dementia had their oxygen tubing improperly stored on the floor, contrary to the facility's policy requiring storage in a labeled bag. Observations over several days showed the tubing remained on the floor, and interviews with staff revealed a lack of awareness and adherence to proper storage practices.
A resident with PTSD and other mental health conditions did not receive trauma-informed care at the facility. The care plan lacked focus on PTSD, and staff were unaware of the diagnosis and potential triggers. The resident and family expressed concerns about the absence of therapy and support services, highlighting a failure to implement the facility's trauma-informed care policy.
A resident with major depressive disorder in an LTC facility did not receive adequate social services support, as evidenced by a lack of documented supportive visits or counseling services. Despite the resident's expressed feelings of depression and desire to return home, staff interviews revealed inconsistent engagement with the resident's mental health needs. The facility's leadership expected social services to provide support, but there was no documentation of such actions being taken.
The facility failed to ensure physicians documented their rationale for disagreeing with pharmacists' recommendations for two residents. One resident continued using a medication as-needed despite a recommendation for routine use, and another resident was on a risky medication combination without documented rationale for continuing it. The facility's policy did not address the need for physician documentation, contributing to the deficiency.
The facility failed to ensure pureed sausage was smooth, affecting six residents on pureed diets. Observations revealed the sausage was grainy, confirmed by dietary staff. The dietary staff did not taste the sausage after pureeing it, contrary to expectations.
The facility did not comply with its Visitor's Food Policy, as observed in the resident unit refrigerator where several food items were improperly labeled or not labeled at all. This included a fruit tray without a name or date, cans of soda with names but no dates, and a foam cup with a date but no name. The Rehab Unit Manager acknowledged the requirement for all food and drink to be labeled with a date and resident's name, highlighting a failure in policy adherence that potentially affected several residents.
The facility failed to ensure the outdoor dumpster was in good repair, with a 15-inch crack in the lid and trash accumulating on the ground around it. The EVS Director was unaware of the crack and noted that employees sometimes miss when placing trash in the dumpster.
Inadequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention, resulting in the development and worsening of pressure ulcers in several residents. Resident #74 was admitted with a Stage I pressure ulcer and was at high risk for further skin integrity issues. Despite having orders for a low air loss mattress and Prevalon boots, these interventions were not consistently implemented, and documentation of wound care was often missing. Observations revealed that the resident's pressure ulcer worsened, with an increase in size and necrotic tissue, indicating a lack of proper care and monitoring. Resident #1 was admitted with multiple pressure injuries, including Stage IV ulcers, but the facility did not document a comprehensive wound assessment upon admission. There was a lack of initial wound measurements and detailed descriptions, and wound care treatments were not consistently documented. The resident's wounds were not properly assessed or documented by the facility's nursing staff, leading to inadequate monitoring and care. Resident #62 had a Stage III pressure ulcer on the right ankle, but the facility failed to document daily wound care consistently. Weekly skin checks were ordered but not always completed, and there was a lack of comprehensive wound assessments. The facility's failure to adhere to physician orders and document wound care interventions contributed to the inadequate management of the resident's pressure ulcer.
Kitchen Cleanliness and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage standards in the kitchen, as observed during a survey. There was a buildup of food debris under the shelves in the dry goods storage room and under the six-burner stove, deep fat fryer, and convection oven. Additionally, dust accumulation was noted on the sprinkler heads over the baking preparation area and on the utensil rack. The Dietary staff admitted to not having moved the appliances for cleaning in a few days due to being short-staffed. The Dietary Manager also acknowledged not having notified the Maintenance Department about cleaning the sprinkler heads. Further observations revealed that the milk in a serving container in the dining room was at a temperature of 63°F, which is above the recommended 41°F. Dust was also found on the self-closing fixture and the top of the door between the main kitchen and the galley. The Dietary Manager admitted to not having instructed the dietary staff to check the temperature of the milk during meals and stated that they would ask the maintenance department to clean the top of the door. These deficiencies potentially affected all residents who consumed food from the kitchen, with the facility census being 84 residents.
Facility Maintenance Deficiencies Affect Resident Safety and Cleanliness
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by multiple deficiencies observed during a survey. Commode risers in several resident rooms, including A110, A105, A102, B104, C106, C104, C102, E107, E108, G104, and D107, were found to be not easily cleanable, which could potentially affect the safety and hygiene of the residents using them. Additionally, a buildup of dust was observed on the fan blades in resident room B105, and a heavy buildup of dust was found inside the ceiling vent in resident room A101. The floor in resident rooms A105 and C109 was not maintained clean, with an old spill and a buildup of dust and powder, respectively. Further deficiencies included missing tile pieces from the countertop in the A Hall shower room, which could potentially cause skin damage, and a grab bar in the restroom of resident room B106 that was not securely affixed to the wall. The shower chair in the restroom of D105 was also found to be broken. These deficiencies indicate a lack of proper maintenance and oversight in ensuring the safety and cleanliness of the facility's environment, potentially affecting at least 30 residents who resided in or used those areas.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility's physician failed to conduct timely face-to-face visits with several residents, as required by the facility's policy. Specifically, the physician did not visit Resident #8 at least once every 30 days for the first 90 days after admission, nor did the physician visit Residents #25, #38, #41, #62, and #15 every 60 days thereafter. The facility's policy mandates that residents must be seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter, with visits considered timely if they occur no later than 10 days after the required date. Resident #25, who was admitted with multiple diagnoses including dementia, depression, and diabetes, was seen by a nurse practitioner monthly, but the last documented physician visit was on 10/30/23, indicating a 10-month gap without a physician's visit. Similarly, Resident #8, admitted with dementia and other conditions, had not been seen by the facility's physician since admission, as noted in the nurse practitioner's encounter notes. Resident #41, with a history of stroke and seizures, was only seen by the facility's physician once in 11 months, despite being seen by nurse practitioners multiple times. The facility staff, including LPNs and ADONs, were unaware of the required frequency of physician visits, and there was no system in place to monitor compliance with the visit schedule. This lack of awareness and monitoring contributed to the failure to ensure that the physician conducted the necessary visits, as evidenced by the absence of physician progress notes in the residents' medical records. The DON acknowledged the expectation for physician visit progress notes and the requirement for physicians to visit each resident every 60 days, alternating with nurse practitioner visits, but was unsure who was responsible for monitoring this compliance.
Failure to Ensure Timely Physician Response to GDR Recommendations
Penalty
Summary
The facility failed to ensure timely physician responses to pharmacist recommendations for Gradual Dose Reduction (GDR) of psychotropic medications for two residents. For Resident #25, the pharmacist recommended a GDR for Bupropion and Duloxetine, but there was no documented response from the physician regarding these recommendations. Although Quetiapine was discontinued, the lack of documentation for the other medications indicates a failure to follow up on the pharmacist's suggestions. The resident's medical records did not show any rationale for not attempting a GDR, despite the psychiatrist's follow-up visits and medication reviews. Resident #50 experienced multiple falls, and the facility increased the dosage of Quetiapine without documented behaviors or appropriate indications for the antipsychotic medication. The pharmacist's review noted the absence of an appropriate diagnosis for Quetiapine, yet the physician agreed to continue the medication without providing comments. The facility did not document any behaviors that would justify the increase in Quetiapine, and there was no evidence of behavior monitoring or rationale for the medication adjustments. For Resident #62, the facility did not provide a rationale for the physician's decision to increase Lorazepam dosage despite a pharmacist's recommendation for a GDR. The resident's records lacked a diagnosis of anxiety, which was the stated reason for the medication. The facility's failure to document the physician's rationale for not following the GDR recommendation and the absence of an anxiety diagnosis highlight a lack of compliance with medication management protocols.
Failure to Maintain Safe Food Temperatures on Room Trays
Penalty
Summary
The facility failed to maintain appropriate temperatures for hot foods and milk on room trays for residents on C and E Hall. Observations revealed that hot foods on room trays were not kept at or close to the required temperature of 120°F, with eggs and bacon measuring at 108.1°F and 102.2°F, respectively. Additionally, milk was not maintained at the required temperature of 41°F, with measurements showing 63.9°F and 53.2°F. These deficiencies were observed during the room tray delivery process, where delays occurred as CNAs had to assist residents, causing trays to sit on the cart longer than necessary. Interviews with staff indicated a lack of regular monitoring and evaluation of the room tray delivery procedure. The Chief Nursing Officer acknowledged not having reviewed the room tray service, and the Dietary Manager admitted to checking tray temperatures randomly rather than regularly. This lack of consistent oversight and adherence to the facility's policy on food temperatures potentially affected at least 12 residents who received room trays towards the end of the delivery time, compromising the safety and quality of their meals.
Inaudible Call System on C Hall
Penalty
Summary
The facility failed to ensure the audible portion of the call system was operational at the Nurse's area on C Hall, which is a unit with residents who had some level of dementia. This deficiency affected 14 residents residing on C Hall. Observations revealed that while the call light was flashing and alarming outside of C Hall, it was not audible within the hall itself. During an interview, the Chief Nursing Officer confirmed that the alarm did not sound on that unit, and the North Unit Manager acknowledged that the installers of the call light system did not consider placing a Touch Screen Nurse Console at the nurse's area on C Hall. Further observations showed that the call light in a resident's room was activated, and the sound was only heard at the North Unit Nurse's Station, which was located outside of C Hall. A Certified Nursing Assistant (CNA) stated that they could not hear the call system from their location at the nurse's area. The Administrator later acknowledged that placing a Touchscreen Console on C Hall would make the call system more audible on that hall.
Loose Cleanout Covers Pose Hazard
Penalty
Summary
The facility failed to maintain the covers of cleanouts in a secure manner, creating a potential hazard for residents and staff. On C Hall, the cleanout cover was observed to move when stepped on, with the blue tape that previously secured it broken. The Environmental Services (EVS) Director explained that the cap into which the screw of the cover fits was broken, causing the cover to be loose. Similarly, in the area between D Hall and the Rehabilitation Unit Nurse's station, another cleanout cover was found to move when stepped on. The Rehabilitation Unit Manager was unaware of how long this cover had been loose, and the EVS Director noted that the cap was accidentally broken during carpet removal. This issue potentially affected 14 residents on C Hall and 19 residents who passed through the area between D Hall and the Rehabilitation Unit.
Failure to Ensure Privacy and Dignity During Resident Care
Penalty
Summary
The facility failed to provide dignity and privacy during the care of a resident, specifically during activities of daily living and perineal care. The resident, who had a history of cognitive impairment, depression, and physical limitations, was exposed to bystanders outside the window during care procedures. On two separate occasions, the window curtains were left open while care was being administered, allowing bystanders to view the resident, thus compromising the resident's privacy and dignity. Interviews with staff members, including CNAs and the ADON, revealed that there was an expectation to maintain privacy by closing curtains and blinds during personal care. However, it was admitted by CNA J that they forgot to close the curtains during the care of the resident. The ADON and DON also acknowledged the importance of ensuring privacy and dignity for residents and admitted that the window curtains should have been closed during the care of the resident.
Failure to Obtain Physician Orders and Evaluate Self-Administration of Medication
Penalty
Summary
The facility failed to obtain a physician's order for self-administration of medication at bedside and did not evaluate or document the ability of two residents to self-administer their medications. Resident #343, who was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), did not have a physician's order for self-administration of medication or an evaluation completed prior to the survey. The resident was observed with a Ventolin inhaler at the bedside, which was used without staff monitoring or documentation. The resident, who had a left arm amputation, self-administered the inhaler but was unaware if staff monitored or documented the administration. Resident #345, admitted with diagnoses of Pneumonia and COPD, also did not have a care plan or evaluation for self-administration of medication. The resident was observed with a Trelegy inhaler at the bedside and reported using it independently. The inhaler was not found in the medication cart during a medication administration observation, indicating it was left at the bedside without a physician's order. Interviews with staff, including a Certified Medication Technician (CMT), Licensed Practical Nurse (LPN), Assistant Directors of Nursing (ADONs), and the Director of Nursing (DON), revealed a lack of awareness and adherence to protocols for self-administration of medication. Staff acknowledged the need for a physician's order and evaluation for self-administration, as well as the requirement to monitor and document the administration of medications by residents.
Failure to Address and Document Skin Issues Timely
Penalty
Summary
The facility failed to act promptly on skin issues identified during the initial skin assessment for Resident #47. Upon admission, the resident had several skin integrity concerns, including redness and inflammation in various areas, and an open area on the coccyx. Despite these findings, there were no documented physician's orders for treatment of the resident's skin issues. The resident's medical record lacked timely documentation of treatment orders, and weekly skin assessments were not consistently completed or documented, leading to a delay in addressing the resident's skin conditions. Additionally, the facility did not ensure timely documentation and follow-up on a change in skin condition for Resident #62. The resident was at risk for skin integrity issues and had a physician's order for weekly skin checks. However, there were gaps in the documentation of skin observations, and a wound on the resident's buttocks was not identified or treated during perineal care. The wound was later discovered to be facility-acquired, indicating a failure in the facility's monitoring and documentation processes. Interviews with facility staff, including the Administrator, ADONs, and the DON, revealed inconsistencies in the completion and documentation of skin assessments. The facility's nursing staff were responsible for conducting weekly skin assessments, but there were lapses in communication and documentation, leading to unaddressed skin issues. The facility's policies and procedures for skin integrity were not adequately followed, resulting in deficiencies in the care provided to the residents.
Deficiencies in Catheter Care and Discharge Order Implementation
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling Foley catheter, which put the resident at risk for urinary tract infections. The resident, who was cognitively intact and required total assistance for toileting, had diagnoses including quadriplegia, neurogenic bladder, and pressure injuries. During an observation, a CNA did not clean around the catheter insertion site and surrounding skin, which is a critical part of catheter care. The CNA also failed to empty the drainage bag, which contained dark tea-colored urine and a white/yellowish substance, as required by the facility's policy. Interviews with staff revealed a lack of adherence to the facility's catheter care policy, which mandates cleaning the insertion site and surrounding skin every shift. Another deficiency involved the failure to transcribe and implement hospital discharge orders for a resident who was supposed to undergo a voiding trial to remove a urinary catheter. The resident, who had diagnoses of high blood pressure, renal failure, and benign prostatic hyperplasia, was not assessed for urinary continence or catheter removal. Despite hospital orders to attempt a voiding trial within a week of discharge, the facility did not conduct the trial or consult with a urologist. Interviews with facility staff, including the DON and ADON, indicated a misunderstanding of the discharge orders and a lack of assessment for catheter removal, attributing the continued use of the catheter to the resident's BPH diagnosis. The facility's failure to adhere to catheter care protocols and discharge orders resulted in deficiencies in the care provided to residents with indwelling urinary catheters. The staff did not perform necessary assessments or follow through with physician orders, leading to potential risks for the residents involved. The facility's policies and staff training did not ensure compliance with catheter care standards, as evidenced by the observations and interviews conducted during the survey.
Improper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to ensure proper infection control practices for storing oxygen equipment for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD), unspecified chronic bronchitis, and dementia. The resident's care plan indicated a potential for altered respiratory status, but did not specify the route or amount of oxygen used. Observations over several days showed that the resident's oxygen concentrator was left on with the tubing on the floor, even when the resident was not in the room. The facility's policy required oxygen equipment to be stored in a labeled bag, but this was not followed. Interviews with staff, including a CNA, the ADON, the DON, the MDS Coordinator, and an LPN, revealed a lack of awareness and adherence to the facility's policy on oxygen equipment storage. The CNA and other staff members acknowledged that the oxygen tubing should not be on the floor and should be stored in a labeled bag. However, they were unaware of the tubing's condition in the resident's room. The staff expected CNAs to notice and replace the tubing if necessary, but this expectation was not met, leading to the deficiency.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD), among other mental health conditions. The resident was admitted with diagnoses including unspecified dementia, major depressive disorder, insomnia, anxiety disorder, and borderline personality disorder. Despite these diagnoses, the resident's care plan lacked focus or interventions related to PTSD or trauma-informed care. Observations noted the resident exhibiting signs of distress, such as taking sharp, quick breaths and expressing feelings of upset and worry, particularly about not receiving medications on time. Interviews with facility staff revealed a lack of awareness and action regarding the resident's PTSD diagnosis. The Social Services Designee was unaware of the diagnosis and had not completed an initial trauma screening. The Certified Nursing Assistant (CNA) and other staff members were also unaware of the resident's PTSD and any potential triggers. The Assistant Director of Nursing and the Director of Nursing acknowledged the diagnosis but noted that the resident had not received psychiatric services, and there was a lack of communication and documentation regarding trauma-informed care. Family members and the resident expressed concerns about the lack of therapy and support services offered. The resident's family, who held the Durable Power of Attorney, indicated that the facility had not discussed psychiatric services, and they believed therapy would benefit the resident. The facility's policy on trauma-informed care was not implemented effectively, as evidenced by the absence of a trauma assessment and the lack of individualized care planning for the resident's PTSD.
Failure to Provide Medically Related Social Services for Depressed Resident
Penalty
Summary
The facility failed to provide medically related social services to a resident diagnosed with major depressive disorder. The resident, who was cognitively intact, expressed feelings of depression, hopelessness, and a desire to return home. Despite these indicators, there was no documentation of social services supportive visits or counseling services in the resident's electronic medical record. The resident's care plan included the need for staff to allow the resident to verbalize feelings and initiate referrals for counseling and psychiatric services as needed, but these actions were not documented as being carried out. Interviews with staff revealed a lack of consistent engagement with the resident's mental health needs. Certified Nurses Assistants (CNAs) reported that the resident often stayed in bed and expressed a desire to go home, but there was no indication that these observations were followed up with appropriate social services interventions. The Social Services Designees (SSDs) acknowledged the resident's depressive symptoms and stated that they would request psychiatric evaluations, but there was no evidence of ongoing supportive visits or the use of behavioral health services. The facility's leadership, including the Assistant Directors of Nursing (ADONs) and the Director of Nursing (DON), expected the SSDs to provide supportive visits and arrange counseling services for residents with mood concerns. However, the SSDs admitted to not documenting their interactions with the resident and were in the process of developing a plan to implement behavioral health services. This lack of documentation and follow-through on the care plan's directives contributed to the deficiency in providing necessary social services to the resident.
Failure to Document Physician Rationale for Disagreeing with Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that physicians documented a rationale for disagreeing with pharmacists' recommendations in a timely manner for two residents. For Resident #25, the pharmacist recommended changing the use of Nystatin-Triamcinolone Ointment from as-needed to routine, as it was not appropriate for as-needed use. The physician disagreed with this recommendation but did not provide a rationale for the decision. This lack of documentation persisted over several months, with the pharmacist not continuing to address the recommendation in subsequent reviews. Resident #62 was receiving a combination of medications that posed potential risks, including the concurrent use of Omeprazole and Clopidogrel, which could decrease the effectiveness of Clopidogrel and increase the risk of cardiovascular events. The pharmacist recommended replacing Omeprazole with Pepcid or considering Rabeprazole if PPI therapy was necessary. The physician disagreed with the recommendation but did not document a rationale. Additionally, the resident was receiving Esomeprazole at a higher than recommended dose, and the pharmacist suggested a dose reduction, which the physician also disagreed with, again without providing a rationale. The facility's Pharmacy Services policy did not address the requirement for physicians to document their rationale for not following pharmacists' recommendations. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that there was an expectation for physicians to document their rationale, but it was unclear if the current Nurse Practitioner was aware of this requirement. The lack of documentation and follow-up on pharmacists' recommendations contributed to the deficiency identified in the facility's practices.
Failure to Ensure Proper Texture of Pureed Sausage
Penalty
Summary
The facility failed to ensure that pureed sausage was prepared to a smooth consistency, affecting six residents on pureed diets. During an observation, the pureed sausage was found to be grainy, indicating the presence of small particles. Dietary staff, including Dietary [NAME] (DC) A and the Dietary Manager (DM), confirmed the grainy texture upon tasting the sausage. DC A admitted to not tasting the sausage after pureeing it earlier that morning and before placing it on the steam table. The DM stated that dietary staff are expected to taste pureed food to ensure proper texture.
Failure to Follow Visitor's Food Policy
Penalty
Summary
The facility failed to adhere to its Visitor's Food Policy, which mandates proper labeling and storage of food items brought in by residents, family members, or other visitors. During an observation, it was noted that the resident unit refrigerator contained several items that were not labeled according to the policy. Specifically, a fruit tray was found without a name or date, cans of soda were labeled with names but lacked dates, and a foam cup in the freezer had a date but no name. These observations indicate a failure to ensure that all food items were appropriately labeled with the resident's name, content, date, and room number as required by the policy. The policy also requires that nursing staff evaluate and label food items to ensure they are stored under proper sanitation conditions. However, the observed deficiencies suggest that this process was not consistently followed. The Rehab Unit Manager confirmed that all food and drink should be labeled with a date and the resident's name, and that specific items like nutrition supplemental drinks should have designated sections within the refrigerator. This lapse in following the established policy potentially affected between 3-5 residents in a facility with a census of 84 residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the outdoor dumpster in proper condition, as observed on 8/22/24. The dumpster lid had a 15-inch crack, and there was a significant amount of debris and trash on the ground surrounding the dumpster. During an interview, the Environmental Services (EVS) Director acknowledged the need to notify the dumpster company for a replacement container and admitted to being unaware of the crack in the lid. The EVS Director also mentioned that employees sometimes miss when placing trash in the dumpster, resulting in trash accumulating on the ground around it.
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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