Jackson Creek Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Independence, Missouri.
- Location
- 3980 South Jackson Drive, Independence, Missouri 64057
- CMS Provider Number
- 265820
- Inspections on file
- 27
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Jackson Creek Post Acute during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, Huntington’s Disease, and a cognitive communication deficit fell out of bed, sustaining a head injury, mouth laceration, facial bruising, and leg injuries, and was transported to the hospital for treatment. Facility policies required staff to notify the resident’s representative of falls, injuries, significant condition changes, and hospital transfers, and the resident’s DPOA was clearly listed as the emergency contact and responsible party. An LPN on duty notified the physician, DON, and ambulance but did not notify the DPOA, despite knowing this was required, and the DPOA only learned of the incident about eight hours later from a non-nurse family friend who worked at the facility.
A resident with end stage renal disease and diabetes was not given prescribed Sevelamer at lunch after refusing it at breakfast, and this was not communicated to the charge nurse or physician. Additionally, sliding scale insulin was administered late after lunch without notifying the physician. Staff failed to document refusals and delays properly or follow required notification protocols.
A resident with complex medical needs did not receive prescribed medications and treatments as ordered, including missed doses of Sevelamer and delayed insulin administration. Staff failed to document medication refusals and omissions accurately, did not communicate these issues to management, and did not update the care plan to address ongoing medication refusals. Facility policies lacked guidance on sliding scale insulin, and the MAR contained inaccurate entries.
A resident with end stage renal disease did not receive coordinated care due to a breakdown in communication between the facility and the dialysis provider. For several weeks, there was no written or verbal exchange of information regarding the resident's dialysis treatments. Staff and the resident confirmed that forms with vital signs and treatment details were not consistently shared or retrieved, and the expected process for reporting was not followed by either the facility or the dialysis clinic.
A nurse failed to follow infection prevention protocols during a central venous catheter dressing change for a resident on hemodialysis. The nurse did not wear a gown or mask, did not use a barrier for supplies, and did not cleanse the catheter site before applying a new dressing, contrary to facility policy and CMS guidance. The DON confirmed that required procedures, including use of PPE and site cleansing, were not followed.
A resident with end-stage renal disease missed two dialysis sessions due to a lack of transportation arrangements, leading to severe health complications and hospitalization. The facility's staff failed to communicate and coordinate effectively, resulting in the resident not receiving dialysis for six days. The deficiency was identified as an immediate jeopardy situation.
A resident with ESRD missed two dialysis sessions due to transportation issues, and the facility failed to notify the physician, family, or department heads in a timely manner. Additionally, the resident experienced an unwitnessed fall, and the necessary notifications were not made promptly. This lack of communication and coordination led to the resident's hospitalization for elevated potassium and low hemoglobin levels.
The facility failed to maintain cleanliness and proper labeling in the kitchen, with grime buildup, leaks, and debris observed. Dietary Aide's hair was not fully covered, and milk was stored at an unsafe temperature. The Dietary Manager and Maintenance Director had attempted to address some issues, but problems persisted, potentially affecting all 105 residents.
The facility failed to maintain commode risers in an easily cleanable condition and did not ensure mechanical lifts on the 300 and 400 Halls were in sound condition. Observations revealed issues with the commode risers and mechanical lifts, which staff did not notice or document properly. This potentially affected 14 residents who used these devices.
The facility failed to properly assess and monitor medication administration for a resident, leaving medications at the bedside without proper authorization. Additionally, two residents with severe cognitive impairments were incorrectly allowed to keep OTC medications at their bedside due to errors in the electronic medical record system.
The facility failed to ensure pureed eggs were palatable and hot foods on room trays were maintained at a safe temperature during breakfast. Observations showed the Dietary Manager did not follow a recipe or add seasonings, and room trays were delivered over an extended period, causing food to cool. Residents reported consistently receiving cold meals, and temperature checks confirmed food was below the recommended 120 F.
The facility failed to ensure that food in the resident use refrigerator was labeled with the resident's name and the date the food item was brought in, as per the facility's policy. Several items, including salad dressings, mayonnaise, coffee creamer, relish, restaurant sauce, and dietary supplements, were found without proper labeling. Interviews revealed that the refrigerator had not been cleaned recently, leading to the presence of expired and unidentified food items.
The facility failed to ensure proper hand hygiene, use of barriers for supplies, and cleansing of the glucometer during blood glucose monitoring and insulin administration for three residents. Staff did not follow the facility's policies, leading to multiple instances of non-compliance.
The facility failed to complete a required PASARR Level I screening in a timely manner for a resident with major mental illness, including PTSD and depression. The social worker did not realize the screening was required for private pay residents, leading to a delay in the assessment and care planning process.
The facility failed to provide an ongoing activity program based on a comprehensive assessment and care plan for two residents. Both residents, who were receiving hospice care and had multiple diagnoses, were observed to spend most of their time not engaged in meaningful activities. Interviews revealed staffing and time management issues, as well as difficulties with a new electronic health records system, contributing to the deficiency.
The facility failed to ensure timely fall prevention interventions for a resident with a history of falls and did not use a gait belt for another resident requiring assistance with transfers. The deficiencies were identified through observations, interviews, and record reviews, highlighting lapses in updating care plans and following transfer protocols.
A facility failed to ensure a resident requiring dialysis received ongoing assessments and accurate documentation of the dialysis site. The resident's care plan and progress notes lacked specific details, and interviews revealed that the dialysis site was not regularly assessed or documented. The DON confirmed the expectations for site assessments, but due to the absence of a unit manager and proper documentation, necessary assessments were assumed not performed.
The facility failed to ensure a comprehensive PTSD care plan and staff education for a resident with PTSD. The care plan lacked detailed information on the resident's trauma history, triggers, and guidance for staff. Interviews revealed staff were unaware of the resident's PTSD diagnosis and specific triggers, indicating a gap in the facility's trauma-informed care process.
A facility failed to consider all appropriate alternatives before installing bed rails for a resident with a history of falls. Despite the facility's policy against using bed rails as restraints, the rails were installed primarily due to the family's insistence, without thorough assessment or documentation of other interventions.
A facility failed to ensure bed rails for a resident with multiple diagnoses were compatible with the bed and safely installed. The bed rail's measurements were outside safety guidelines, and the adjustable tightening knob was loose, posing a risk for entrapment. Staff had not reported any issues, and the Maintenance Supervisor did not perform safety audits, relying on nursing staff to report problems.
Failure to Notify Resident Representative After Fall With Injury and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s representative of a fall with injury and subsequent transfer to the hospital, as required by facility policy. The facility had written policies titled “Assessing Falls and Their Causes” and “Change in a Resident’s Condition or Status,” which directed staff to notify the resident’s family or representative when a resident fell, sustained an injury, experienced a significant change in condition, or required transfer to a hospital or treatment center. Despite these policies, the resident’s Durable Power of Attorney (DPOA), listed as the emergency contact and responsible party in the admission record, was not notified when the resident experienced a fall and was sent to the hospital. The resident involved had moderate cognitive impairment and diagnoses including Huntington’s Disease and a cognitive communication deficit, as documented on a Quarterly MDS. On the night of the incident, the resident’s roommate alerted the nurse that the resident had fallen out of bed. When the nurse entered the room, the resident was found on the floor with blood on the mouth and a red mark on the back of the head. The nurse contacted an ambulance, the DON, and the resident’s physician, and the resident was transported to the hospital, where the resident received sutures for a laceration sustained from the fall. During interviews, the LPN who was the charge nurse at the time acknowledged being aware that the resident had a responsible party and was not considered his or her own decision-maker, and also acknowledged knowing that the DPOA should have been notified of the fall and hospital transfer. The LPN stated that the DPOA was not notified and that this was due to forgetting to make the call. The DPOA later learned of the fall and injuries indirectly from a family friend who worked at the facility approximately eight hours after the incident, rather than from the responsible nursing staff. The DPOA reported not being informed by the charge nurse, expressed that they would have wanted to be present at the hospital, and described the resident’s injuries, including a laceration requiring sutures, facial bruising and swelling, and leg injuries.
Failure to Notify Physician of Medication Refusal and Delayed Insulin Administration
Penalty
Summary
The facility failed to notify a resident's physician of the resident's refusal of dialysis medication and the late administration of sliding scale insulin. The resident, who had diagnoses of end stage renal disease, dependence on renal dialysis, and diabetes, was prescribed Sevelamer to be taken with meals and insulin Lispro per sliding scale. On the day in question, the resident refused Sevelamer at breakfast and was not offered the medication at lunch, yet the Certified Medication Technician (CMT) documented that the medication was given at both meals. The CMT did not inform the charge nurse of the refusal or omission, despite knowing the importance of the medication and the requirement to report such incidents. Additionally, the Agency Registered Nurse (RN) did not perform the resident's lunch time blood glucose monitoring or administer the sliding scale insulin after lunch, and did not communicate this to anyone. The Medication Administration Record (MAR) indicated that the insulin was administered later in the afternoon, but there was no documentation that the physician had been notified of the delay. Interviews with facility staff, including the Nurse Unit Manager and Director of Nursing, confirmed that the physician was not notified of the missed or refused medications, and that proper documentation and communication protocols were not followed.
Failure to Document and Communicate Medication Refusals and Omissions
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease, diabetes, and dependence on dialysis did not receive medications and treatments as ordered, and staff failed to document and communicate these omissions and refusals appropriately. The resident reported not receiving required medications, including Sevelamer and insulin, after meals. Staff interviews revealed that a Certified Medication Technician (CMT) did not offer the Sevelamer at lunch after the resident refused it at breakfast, and incorrectly documented that the medication was administered at both meals. The CMT also failed to inform the charge nurse or unit manager about the resident's refusal and the omission of the medication. Additionally, the resident did not receive blood glucose monitoring or sliding scale insulin after lunch as ordered, due to the assigned nurse being occupied with other care tasks. The nurse did not communicate this missed care to management. The resident's care plan was not updated to address the ongoing refusal of medications, as the care plan coordinator was unaware of the issue. The facility's policies on insulin administration and medication administration did not address sliding scale insulin, and staff did not follow procedures for timely administration and accurate documentation. Facility leadership, including the unit nurse manager and Director of Nursing, confirmed that refusals and omissions should have been documented correctly and communicated to management, and that the resident's care plan should have addressed medication refusals. The Medication Administration Record (MAR) showed inaccurate documentation, and the timing of insulin administration was not consistent with policy or physician orders.
Failure to Ensure Communication and Coordination for Dialysis Care
Penalty
Summary
The facility failed to ensure effective communication and coordination between the facility and the dialysis provider for a resident with end stage renal disease who required regular dialysis treatments. According to the facility's own policy, the resident's care plan should reflect dialysis needs and there should be ongoing communication between the dialysis clinic and the facility. However, for approximately two months, there was no written or verbal communication between the facility and the dialysis provider regarding the resident's dialysis treatments. The dialysis clinic nurse confirmed that the facility had not provided a form for reporting, nor had they called to obtain verbal updates. Similarly, facility staff acknowledged that written communication from the dialysis clinic had ceased for at least four weeks, and no efforts were made to reestablish this communication or request reports from the dialysis provider. The resident, who had diagnoses of end stage renal disease and dependence on renal dialysis, reported that while facility nurses initially placed a form with vital signs and weight in a bag on the wheelchair, dialysis nurses stopped retrieving the form and the resident eventually stopped reminding them. The resident also stated that no information was provided back to the facility after dialysis treatments for a significant period. The Director of Nursing stated that it was expected for licensed nurses to send and receive written reports for each dialysis appointment, but this process was not followed, resulting in a lack of coordinated and consistent care for the resident.
Failure to Follow Infection Control Protocols During Central Line Dressing Change
Penalty
Summary
A deficiency occurred when a nurse failed to follow established infection prevention and control protocols during a central venous catheter (CVC) dressing change for a resident with end stage renal disease requiring hemodialysis. The nurse entered the resident's room without donning a gown or mask, placed a prepackaged dressing on a surface without using a barrier, and after hand hygiene and gloving, applied an adhesive dressing over the resident's dialysis access site without first cleansing the site. The nurse also did not provide a mask for the resident, as required by facility policy and the contents of the central line dressing kit. Facility policies and recent CMS guidance require the use of enhanced barrier precautions (EBP), including gown and glove use, and the cleansing of the catheter insertion site with an approved antiseptic solution prior to dressing application. The nurse did not follow these protocols, and the Director of Nursing confirmed that the expected procedures were not adhered to, including the use of appropriate PPE, site cleansing, and supply barriers. The resident's care plan and physician orders specified regular and as-needed dressing changes for infection prevention, but the observed dressing change did not meet these standards.
Failure to Provide Dialysis Services Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis three times a week received the necessary physician-ordered dialysis services on two occasions. The resident, who was severely cognitively impaired and diagnosed with end-stage renal disease (ESRD), missed dialysis appointments on two separate days due to a lack of transportation arrangements. This oversight led to the resident experiencing significant health issues, including weight gain, abdominal pain, acute encephalitis, hyponatremia, hyperkalemia, and low hemoglobin levels, which necessitated an immediate blood transfusion before dialysis could be administered. The deficiency was primarily due to a breakdown in communication and responsibility among the facility's staff. The Admissions Director, who was new to the position, was unaware of the responsibility to arrange transportation for the resident's dialysis appointments. Additionally, the charge nurse and other staff members failed to notify the appropriate personnel or the resident's family about the missed dialysis sessions. This lack of communication and coordination resulted in the resident not receiving dialysis for six days, ultimately leading to hospitalization. Interviews with various staff members, including LPNs, the Unit Manager, and the Director of Nursing, revealed that there was a general lack of awareness and follow-through regarding the resident's dialysis schedule and transportation needs. The facility's policies on care coordination and transportation were not effectively implemented, contributing to the resident's missed dialysis treatments and subsequent health decline. The deficiency was identified as an immediate jeopardy situation, indicating a severe risk to the resident's health and safety.
Failure to Notify of Missed Dialysis and Fall
Penalty
Summary
The facility failed to ensure proper communication and coordination of care for a resident with End-Stage Renal Disease (ESRD) who missed dialysis appointments on two occasions. The resident, who was severely cognitively impaired and dependent on renal dialysis, missed dialysis on two separate days due to transportation issues. Despite the facility's policy requiring prompt notification of significant changes in a resident's condition, the staff did not notify the physician, family, or department heads about the missed dialysis sessions until several days later. Additionally, the resident experienced a fall, which was unwitnessed, and the facility staff failed to notify the necessary parties, including the physician and family, in a timely manner. The fall was reported to the Director of Nursing (DON) and family member, but not until after the incident occurred. The resident's medical record showed no documentation of notification to the physician or family about the missed dialysis or the fall until much later, which was a significant oversight in communication and care coordination. The lack of timely communication and coordination resulted in the resident being hospitalized due to elevated potassium and low hemoglobin levels. Interviews with facility staff, including the DON, Nurse Practitioner, and Medical Director, revealed that they were not informed of the missed dialysis sessions or the fall until after the resident's condition had deteriorated. The facility's failure to adhere to its Coordination of Care Policy and ensure effective communication among staff and with external parties contributed to the resident's hospitalization.
Facility Fails to Maintain Cleanliness and Proper Labeling in Kitchen
Penalty
Summary
The facility failed to maintain cleanliness and proper labeling in the kitchen, as observed during the survey. There was a buildup of grime under the dishwasher, a small leak from the garbage disposal, grime and debris including cups and dust under the ice machine, and grime around the nozzles of the juice machine. Additionally, the light fixtures above the steam table were dusty. Dietary Aide A's hair was not fully covered by a hair restraint, and the temperature of the milk in the 400 Hall kitchenette was measured at 48.3°F, which is above the required 41°F or colder. The Dietary Aide was unaware that their hair was not fully covered, and another Dietary Aide admitted to not checking the milk temperature prior to that day. The Dietary Manager acknowledged the issues with the garbage disposal and the lack of labeling for certain substances, including sugar and an unidentified liquid in a bottle above the stove, which was later identified as water. The observations and interviews revealed that the facility did not adhere to professional standards for food storage, preparation, and distribution. The Dietary Manager and Maintenance Director had attempted to address some of the issues, such as the garbage disposal leak, but the problems persisted. The lack of proper labeling and temperature control, along with inadequate hygiene practices, potentially affected all 105 residents in the facility.
Failure to Maintain Commode Risers and Mechanical Lifts
Penalty
Summary
The facility failed to maintain the commode risers in resident rooms in an easily cleanable condition and did not ensure that mechanical lifts on the 300 and 400 Halls were in sound condition. Observations revealed that the commode riser in one resident's room was not easily cleanable, and another had a crack. The Maintenance Director admitted to checking the commode risers monthly but did not document these checks, and CNAs were also expected to check the risers but did not do so effectively. This issue potentially affected two residents who used commode risers. Additionally, the facility did not maintain six mechanical lifts in sound condition, with observations showing that the mast of the lifts on the 400 Hall was very loose. Multiple staff members, including CNAs and a Restorative Aide, used the lifts but did not notice the looseness. The DON stated that staff should notify the Maintenance Director of any mechanical issues, place a sign on the lift indicating it should not be used, and move the lift to the service hall. This deficiency potentially affected 12 residents who depended on mechanical lifts for transfers.
Failure to Properly Assess and Monitor Medication Administration
Penalty
Summary
The facility failed to observe a resident while taking medications and left medications on the resident's bedside table without proper assessment or physician's order. Resident #88, who had been at the facility for about one and a half years, was found with a medication cup containing more than four pills on their overbed tray. The resident reported that staff frequently left medications for them to take later. The resident's medical records showed no assessment or physician's order for self-administration or bedside storage of medication, and staff interviews confirmed that medications should not be left at the bedside without proper authorization and assessment. Additionally, the facility failed to assess two other residents, Resident #6 and Resident #71, for their ability to self-administer medications. Both residents had severe cognitive impairments and were not capable of safely self-administering medications. Despite this, there were orders in their records allowing them to keep over-the-counter (OTC) medications at their bedside. Staff interviews revealed that these orders were likely clicked by mistake in the electronic medical record system, and neither resident was appropriate for self-administration of medications. The Director of Nursing (DON) and other staff members acknowledged that an assessment should be conducted before allowing any resident to self-administer medications. The facility's policies required an interdisciplinary team to assess the resident's cognitive, physical, and visual abilities, and a physician's order was necessary for self-administration. However, these procedures were not followed for the residents in question, leading to the deficiencies noted in the report.
Failure to Ensure Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to ensure that pureed eggs were prepared in a palatable manner and that hot foods on room trays were maintained at a safe and appetizing temperature during the breakfast meal. Observations revealed that the Dietary Manager (DM) did not follow a recipe or add any seasonings to the pureed eggs, resulting in a lack of flavor. The DM admitted to not consulting the Registered Dietitian (RD) for flavor enhancements and had not tasted the pureed eggs before serving them. The RD confirmed that they had not regularly tasted pureed products and did not consume eggs or dairy products themselves, leading to a lack of oversight in the preparation of pureed foods. Additionally, multiple residents reported that their food was consistently served cold. Observations showed that room trays were delivered over an extended period, causing the food to cool down significantly. Temperature checks of the food on the trays confirmed that the food was not at the appropriate temperature, with sausage and scrambled eggs measuring below the recommended 120 F. Interviews with Certified Nursing Assistants (CNAs) and the DM indicated that there was no regular practice of checking the temperatures of room trays, and the RD had not been involved in this process for some time. Several residents, including those with cognitive impairments, expressed dissatisfaction with the temperature of their meals, stating that the food was often cold by the time it reached their rooms. The facility's failure to maintain appropriate food temperatures and ensure the palatability of pureed foods affected the residents' dining experience and overall satisfaction with their meals.
Failure to Label and Monitor Food in Resident Use Refrigerator
Penalty
Summary
The facility failed to ensure that food in the resident use refrigerator was labeled with the resident's name and the date the food item was brought in, as per the facility's policy. During an observation, several items including salad dressings, mayonnaise, coffee creamer, relish, restaurant sauce, and dietary supplements were found without proper labeling. Additionally, three containers of unidentified food, one cup of an unidentified item, and a bag of corn dogs were also not labeled. This practice potentially affected an unknown number of residents who have foods brought in by visitors, with the facility census being 105 residents. Interviews with staff revealed that the refrigerator should be cleaned twice per week, and all items should be labeled with the resident's name and the date they were brought in. However, the Housekeeping Supervisor and a housekeeper admitted that the refrigerator had not been cleaned recently, and the 300 Hall Unit Manager had previously notified housekeeping employees to clean the refrigerator. The lack of proper labeling and regular cleaning led to the presence of expired and unidentified food items in the resident use refrigerator, which is a violation of the facility's policy on safe food handling for food brought in from outside sources.
Failure to Ensure Proper Hand Hygiene and Infection Control
Penalty
Summary
The facility failed to ensure proper hand hygiene, use of barriers for supplies, and cleansing of the glucometer during blood glucose monitoring and insulin administration for three sampled residents. The facility's policies on hand hygiene and blood glucose monitoring were not followed by the staff, leading to multiple instances of non-compliance. Specifically, the staff did not sanitize their hands before and after resident care, did not use barriers for supplies, and did not properly sanitize the glucometer between uses. For Resident #68, the RN did not sanitize their hands before entering the resident's room, placed a storage tray on the resident's bed without a barrier, and did not sanitize their hands before and after using gloves. The RN also failed to properly clean the glucometer and did not follow the correct procedure for insulin administration. Similar deficiencies were observed for Resident #91, where the RN did not sanitize their hands, did not use a barrier for supplies, and did not wait the required time after sanitizing the glucometer before using it again. Resident #39 also experienced similar issues, where the RN did not sanitize their hands before and after care, did not use a barrier for supplies, and did not properly document the resident's blood glucose levels. The RN admitted to not following the proper procedures due to being hurried and nervous. The facility's DON and Unit Manager confirmed the expectations for hand hygiene and infection control, but the staff failed to adhere to these protocols during the observed incidents.
Failure to Complete PASARR Screening in a Timely Manner
Penalty
Summary
The facility failed to ensure a resident with a major mental illness diagnosis had a required DA-124C/Level I Preadmission Screening and Resident Review (PASARR) completed in a timely manner. Resident #65, who was admitted with diagnoses including PTSD, depression, adjustment disorder with anxiety, and insomnia, did not have the PASARR Level I completed until several months after admission. The social worker responsible for the PASARR screenings admitted to not realizing that the screening was required for private pay residents as well as Medicaid residents until much later. The Director of Nursing confirmed that the facility's policy required the PASARR Level I to be completed for all residents regardless of payment method and that it should be done prior to or upon admission. The oversight was identified during a review of the resident's records, which showed the PASARR Level I was only completed on 5/1/24, despite the resident being readmitted on an earlier date. This delay in completing the required screening could have impacted the care planning and services provided to the resident.
Failure to Provide Comprehensive Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program based on a comprehensive assessment and care plan of each resident's interests, hobbies, and abilities for two sampled residents. Resident #7, who was receiving hospice care and had multiple diagnoses including dementia, anxiety disorder, and depression, was observed to spend most of his/her time in his/her room or in the living room area with the television on. Despite having a care plan that emphasized the importance of activities such as live music, pet visits, and religious activities, the resident's participation in these activities was minimal. The resident often expressed dissatisfaction with the television programming and lacked a remote control to change channels, leading to a lack of engagement in meaningful activities. Resident #44, also receiving hospice care and diagnosed with dementia, anxiety disorder, and depression, was similarly observed to spend most of his/her time in the living room area or in bed, not engaged in any activities. The resident's care plan included goals for positive responses to activities such as pet visits, snacks, and live music, but the resident's participation in these activities was limited. Observations showed the resident often sitting in the living room area with his/her head down or asleep, indicating a lack of engagement in the planned activities. Interviews with the Activities Director and other staff revealed that the facility had issues with staffing and time management, which impacted their ability to provide adequate activities for all residents. The Activities Director mentioned that they could do more for the residents if they had additional staff. The facility's transition to a new electronic health records system also contributed to difficulties in tracking residents' participation in activities. Overall, the facility's failure to implement a comprehensive and individualized activity program led to the deficiency observed by the surveyors.
Failure to Implement Timely Fall Prevention Interventions and Use Gait Belt
Penalty
Summary
The facility failed to ensure adequate fall prevention interventions were added to a care plan in a timely manner and implemented for a resident with a history of falls. Resident #6, who had multiple diagnoses including multiple sclerosis and a history of falling, experienced a fall on 2/17/24. The immediate intervention was to lower the resident's bed and evaluate toileting needs, but these interventions were not documented in the care plan. The resident fell again on 4/9/24, resulting in a hematoma on the forehead and a hospital visit. The care plan was updated only on 4/28/24 to include keeping the bed in a low position and monitoring for changes in condition, indicating a delay in implementing necessary interventions after the initial fall in February. The facility also failed to ensure staff utilized a gait belt for Resident #226, who required assistance with transfers. On 5/2/24, a CNA assisted the resident in transferring from bed to wheelchair without using a gait belt, despite the resident's need for maximal assistance and a history of falls. The CNA admitted to not using the gait belt because it was the first time meeting the resident and the resident felt sick. Other staff interviews confirmed that gait belts should always be used for residents requiring assistance with transfers, but this protocol was not followed in this instance. The Director of Nursing (DON) acknowledged that the Unit Manager was responsible for fall investigations and should have ensured that interventions were added to the care plan. The DON also confirmed that staff should always use a gait belt when assisting residents with transfers. The failure to promptly update care plans with fall prevention interventions and the improper transfer technique without a gait belt contributed to the deficiencies identified in the report.
Failure to Ensure Proper Dialysis Care and Documentation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received ongoing assessments of the dialysis site and accurate documentation of the dialysis site. The resident, diagnosed with End-Stage Renal Disease (ESRD) and dependent on renal dialysis, had no documented orders for dialysis treatments, site care, or frequency of site assessments. The resident's baseline care plan and progress notes lacked specific details about the dialysis access type and schedule. Observations confirmed the presence of a dialysis catheter, but there was no consistent documentation or assessment of the site by the nursing staff. Interviews with the resident and nursing staff revealed that the dialysis site was not regularly assessed, and there were no documented assessments in the computer system. The Director of Nursing (DON) confirmed that it was expected for nurses to know the type of dialysis access, assess the site every shift, and document these assessments. However, due to the absence of a unit manager and lack of proper documentation, it was assumed that the necessary assessments were not performed. The facility also lacked a specific policy for dialysis care, further contributing to the deficiency in care for the resident requiring dialysis.
Failure to Implement Comprehensive PTSD Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive PTSD care plan was in place and that staff were educated on ways to decrease a resident's exposure to triggers and manage the effects of a trigger. Resident #65, who was diagnosed with PTSD, did not have a specific care plan addressing his/her PTSD needs. The existing care plan lacked detailed information on the resident's trauma history, typical reactions to triggers, and comprehensive guidance for staff on how to decrease exposure to triggers and manage the effects of a trigger. The resident identified loud noises, war and violent movies, the 4th of July, and certain conversations as triggers, but this information was not adequately reflected in the care plan or communicated to the staff. Interviews with staff revealed a lack of awareness and training regarding the resident's PTSD and specific triggers. A CNA and an LPN both indicated they were unaware of the resident's PTSD diagnosis, the resident's trauma history, or how to identify and manage triggers. The Director of Nurses acknowledged that the PTSD care plan should include all known triggers, strategies to decrease the likelihood of a trigger, and actions to take if the resident was triggered, but this was not implemented. This deficiency highlights a significant gap in the facility's trauma-informed care process and staff education on managing PTSD in residents.
Failure to Consider Alternatives Before Installing Bed Rails
Penalty
Summary
The facility failed to ensure that all appropriate alternatives were considered before installing bed rails for a resident with a history of falling from bed. The resident, who had multiple diagnoses including Multiple Sclerosis, dementia, muscle weakness, and a history of falls, was assessed for bed rail use only after the family insisted on it following two falls. The facility's Bed Entrapment Prevention policy stated that bed rails were to be used only by rare exception and after proper assessment, but the documentation showed that other alternatives were not thoroughly explored or justified before resorting to bed rails. The resident's care plan included interventions such as a lowered bed and frequent rounds, but these were not consistently documented or followed. After the resident's falls, the family requested bed rails, and the facility installed them despite their policy against using bed rails as restraints. The Bed Rail Observation/Assessment form indicated that the family was educated about the risks and benefits, but there was no documentation of other devices being attempted or why they were deemed inappropriate. The facility's staff, including the Director of Nursing and the Director of Rehabilitation, confirmed that the bed rails were installed primarily due to the family's insistence and not as a fall precaution intervention. Interviews with staff revealed that the resident had previously used bed canes for repositioning and that other interventions like a parameter mattress or a larger bed were not considered. The facility's documentation and staff interviews indicated a lack of thorough assessment and exploration of alternatives before installing the bed rails, leading to a deficiency in ensuring resident safety and compliance with the facility's policies.
Failure to Ensure Bed Rail Safety
Penalty
Summary
The facility failed to ensure that bed rails for one resident were compatible with the bed and were installed and maintained safely. Resident #6, who had multiple diagnoses including multiple sclerosis, dementia, muscle weakness, and a history of falling, had bed rails that were not properly secured. The bed rail's Zone Six measured seven and one-half inches, which was outside the facility's safety guidelines of less than two and three-eighths inches or over twelve and one-half inches. Additionally, the bed rail had a metal lever that could cause the rail to fall quickly and with force, and the adjustable tightening knob was found to be loose, allowing the rail to move and change spacing, posing a risk for entrapment and not providing adequate support for repositioning the resident in bed. The facility's Bed Entrapment Prevention Policy aimed to improve bed safety and mitigate the risk of entrapment, with specific guidelines for testing bed rails across all seven potential zones of entrapment. Despite this, the Maintenance Supervisor, who was responsible for installing and ensuring the safety of the bed rails, did not perform audits on bed rail safety and relied on nursing staff to report any issues. The Director of Nursing (DON) acknowledged that the bed rail was not safe and that nursing staff should observe the bed rails each shift and report any instability or unsafe spacing to the Maintenance Supervisor. Interviews with staff revealed that the bed rails had been installed in April, and no problems had been reported by staff. However, observations showed that the bed rail was loose and could be easily adjusted, which compromised its safety. The DON and Maintenance Supervisor both confirmed that the bed rail was not installed correctly and that staff might have loosened the bars, indicating a need for better staff education on bed rail safety. The facility's failure to ensure the bed rails were compatible with the bed and maintained safely led to a significant risk of entrapment and injury for Resident #6.
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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