James River Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Missouri.
- Location
- 3550 East Battlefield, Springfield, Missouri 65809
- CMS Provider Number
- 265664
- Inspections on file
- 19
- Latest survey
- November 4, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at James River Nursing And Rehabilitation during CMS and state inspections, most recent first.
Three residents who required assistance with bathing did not consistently receive showers according to their care plans and preferences, often going extended periods without bathing. Residents reported feeling dirty and uncomfortable, and staff interviews confirmed that staffing shortages and turnover led to missed showers, with management aware of the ongoing concerns.
The facility failed to ensure cups and glasses were air-dried before storage, leading to potential contamination risks. Observations showed improper storage of 102 cups/glasses, contrary to FDA guidelines. Interviews revealed staff were unaware of proper drying procedures, and the facility lacked a relevant policy.
A facility failed to maintain resident dignity and respect in two incidents. In one, a resident felt intimidated during a group discussion with staff about care prioritization. In another, a CNA handled a cognitively impaired resident roughly and used derogatory language. These actions violated the facility's policies on resident dignity.
The facility failed to provide a clean, safe, and homelike environment for residents, as evidenced by unaddressed maintenance issues. A resident reported trash and stained ceilings, another faced wall damage from a power chair, and a third had a loose electrical outlet affecting device charging. Despite residents notifying staff, these issues persisted, indicating a breakdown in maintenance reporting and follow-up.
The facility failed to secure medication carts, leaving them unlocked and unattended on three occasions. An LPN, a CMT, and the DON were involved in incidents where carts were left unsecured in hallways and near resident areas. Staff interviews confirmed that carts should be locked when unattended, but no formal policy was provided.
Facility staff failed to maintain proper infection control during medication administration and glucometer disinfection. An LPN used a gloved finger to stir medications for a resident with complex medical needs, while a CNA/CMT improperly handled spilled medications for another resident. Additionally, staff did not follow proper disinfection procedures for glucometers used on multiple residents, risking cross-contamination. These actions were acknowledged as breaches of infection control protocols by facility leadership.
The facility failed to provide scheduled showers to two residents, impacting their right to self-determination. One resident, with multiple health conditions, received showers sporadically, leading to feelings of uncleanliness. Another resident, also with significant health issues, experienced long delays between showers, despite needing substantial assistance. Staff interviews revealed inconsistencies in shower provision, with the DON and Administrator acknowledging the issue.
A resident's privacy was compromised when a CNA left the room door open during incontinence care, exposing the resident to the hallway. Despite the resident's discomfort and the facility's policy on maintaining privacy, the door was left open due to the roommate's preference. Staff interviews confirmed that privacy should have been ensured by closing the door or using the privacy curtain.
A resident was admitted to the facility without the required PASARR screening, which is necessary to identify mental disorders or intellectual disabilities. Despite the facility's policy requiring a Level I PASARR before admission, the documentation was missing from both electronic and paper records. The MDS Coordinator and other staff acknowledged the oversight, noting the resident's long-term stay and relevant diagnoses.
A resident in an LTC facility did not receive necessary services for personal hygiene, as staff failed to provide adequate peri-care and change urine-soaked items. The resident, dependent on staff for mobility and hygiene, was observed sitting in a urine-soaked wheelchair pad. Staff did not follow proper procedures for incontinent care, including hand hygiene and changing soiled clothing, leading to a deficiency.
A resident's code status was inconsistently documented across their medical records, with a DNR order on the face sheet and a full code status in the care plan. Staff interviews revealed confusion about who was responsible for ensuring consistency, despite the information being available in multiple locations. The DON and Administrator acknowledged the need for consistent documentation, but discrepancies remained.
A facility failed to document a diagnosis justifying catheter use for a resident, despite policy requiring such documentation. The resident's records, including the MDS and physician's orders, lacked a diagnosis for the catheter, and staff interviews confirmed the expectation for such documentation. The resident had a history of kidney complications and UTIs, but these were not linked to the catheter use in the records.
A facility failed to obtain a physician's order for a resident's CPAP therapy, resulting in inconsistent application of the CPAP machine at bedtime. The resident, who had chronic respiratory failure and was cognitively intact, reported that staff did not always assist with the CPAP. Interviews with staff revealed a lack of awareness and communication regarding the resident's CPAP needs, and there was no documented order for the therapy in the resident's records.
A resident with significant health conditions, including bilateral above-knee amputations, experienced loose bed rails that were not properly maintained or documented by the facility staff. Despite the resident's notification to staff, the issue persisted, highlighting a deficiency in the facility's monitoring and maintenance processes.
A facility experienced a 14% medication error rate due to improper administration practices. An LPN failed to prime an insulin pen before use, and another LPN mixed medications without a physician's order for a resident with a PEG tube. Staff interviews confirmed these actions were against facility protocols.
A resident with type two diabetes received insulin without the pen being primed, as required by the manufacturer's instructions. An LPN administered 4 units of insulin without priming the NovoLog FlexPen, despite the facility's expectation to prime before each use. The resident was cognitively intact and received insulin injections daily.
The facility failed to provide timely written notifications to residents and their representatives regarding hospital transfers. Three residents did not receive written notices in a timely manner, with delays ranging from 30 to 47 days. Staff interviews revealed a lack of awareness and implementation of the process for sending out these notices, and the Business Office Manager admitted to delays due to availability. The Administrator confirmed that the facility did not issue written transfer notices, relying instead on verbal communication and monthly logs sent to the Ombudsman.
The facility failed to protect residents from misappropriation when an LPN was found with multiple pills in their pockets, leading to 17 missing doses of medication affecting twelve residents. The facility's policies on abuse, neglect, exploitation, and misappropriation were not followed, and the investigation process was not thoroughly documented.
The facility failed to ensure complete and accurate medical records for four residents, as staff did not document or verify the administration of prescribed treatments. The ADON assumed treatments were completed by a nurse who left unexpectedly and did not confirm with the residents.
The facility failed to administer a resident's as-needed pain medication despite multiple requests and visible signs of pain. The resident, with severe sepsis and other conditions, reported significant pain, but the medication was not given, and proper documentation was lacking.
Failure to Honor Resident Shower Preferences and Promote Self-Determination
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not honoring reasonable shower preferences for three residents. Observations, interviews, and record reviews revealed that these residents, all of whom had no cognitive impairment and required partial to moderate assistance with bathing, did not consistently receive showers according to their stated preferences or care plans. Documentation showed significant gaps between showers, with some residents going up to 13 days without a shower, despite care plans indicating a preference for two showers per week on specific days. There was no documentation of resident refusals or additional showers provided. Interviews with the affected residents confirmed that they felt dirty, had oily hair, and experienced discomfort such as itching and skin issues due to infrequent bathing. One resident with cellulitis reported that infrequent showers led to skin cracking under abdominal folds. All three residents expressed a desire for more frequent showers and indicated that their preferences were not being met, often receiving only one shower per week instead of the two specified in their care plans. Staff interviews corroborated these findings, with CNAs and LPNs acknowledging that residents were not receiving the required number of showers due to staffing shortages and turnover among shower aides. Staff reported being pulled to other duties, which resulted in missed showers, and confirmed that residents had voiced concerns about the lack of regular bathing. Management was aware of these concerns, and staff were unsure how many showers residents actually received each week, despite a process for reviewing shower sheets.
Improper Drying and Storage of Cups and Glasses
Penalty
Summary
The facility failed to adhere to professional standards for food safety by not ensuring that cups and glasses were air-dried before storage, potentially leading to contamination or bacterial growth. Observations on two separate occasions revealed that a total of 102 small water and juice cups/glasses were stored upside down in a manner that trapped water, preventing proper air drying. This practice was contrary to the 1999 Food Code issued by the FDA, which mandates that equipment and utensils must be air-dried before being stored to prevent microorganism growth. Interviews with dietary staff and the dietary manager indicated a lack of awareness and understanding of the proper procedures for drying dishes. Dietary aides admitted to not knowing that dishes needed to be completely dry before storage, while the dietary manager was unaware of the improper storage method being used. The facility also lacked a specific policy regarding the air drying of dishes, and the administrator acknowledged the absence of such a policy and the inadequate air gap for drying, which contributed to the deficiency.
Inappropriate Staff Behavior and Lack of Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by two separate incidents involving inappropriate staff behavior. In the first incident, a resident with multiple sclerosis and other health conditions was involved in a disagreement with CNAs regarding the prioritization of care. The situation escalated when the resident was taken to the library for a discussion with multiple staff members, including an LPN and an ADON. The resident felt intimidated by the presence of multiple staff members and the loud, demanding tone used by the LPN, which was audible and visible to others in the facility. In the second incident, a resident with severe cognitive impairment and multiple health issues was subjected to rough handling and verbal abuse by a CNA. The CNA was reported to have transferred the resident roughly and used derogatory language, referring to the resident as a "fucking goat" in the presence of other staff and the resident. This behavior was corroborated by multiple staff members who witnessed the incident, and it was noted that the CNA had a history of being rude and using inappropriate language with residents. These incidents highlight a failure to adhere to the facility's policies on treating residents with dignity and respect. The staff's actions, including the use of inappropriate language and rough handling, were not in line with the facility's guidelines for maintaining a respectful and dignified environment for residents. The facility's policies emphasize the importance of treating residents with kindness and respect, which was not upheld in these cases.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. Resident #70 reported trash and debris under the bed and recliner, as well as stained ceilings, which were confirmed upon observation. The maintenance request log showed a previous report of a leak by the smoke detector, but no entry regarding the ceiling damage above the bed was documented. This indicates a lack of follow-up on maintenance issues, contributing to the resident's discomfort and perception of an unclean environment. Resident #30 experienced wall damage in their room, reportedly caused by staff driving a power chair into the wall, which left the metal drywall corner bracket exposed. The resident also noted peeling wallpaper above their bed, which they attempted to cover with a plant. Despite the resident's awareness of the maintenance staff's efforts to address repairs, there were no documented maintenance requests for the wall damage, highlighting a gap in communication and documentation of maintenance needs. Resident #49 faced issues with a loose electrical outlet that could not securely hold plugs, affecting their ability to charge devices like a cell phone. The resident had informed staff multiple times, but the issue persisted, as observed with the CPAP machine's plug hanging loosely from the outlet. Interviews with staff, including the Maintenance Director, revealed a lack of awareness of the specific issues in the residents' rooms, suggesting a breakdown in the reporting and addressing of maintenance concerns. The facility also lacked a policy for monitoring electrical outlets, further contributing to the oversight of this deficiency.
Medication Cart Security Lapses
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. During observations, three separate incidents were noted where medication carts were left unlocked and unattended. On one occasion, an LPN left a medication cart unlocked in the hallway while administering medications to a resident in their room. The Assistant Director of Nursing later locked the cart. In another instance, a medication cart was left unlocked near a resident lounge area, unattended by staff, until the Director of Nursing secured it. A third observation noted a medication cart left unlocked in a hallway, with several residents and staff passing by, until a Certified Medication Technician locked it. Interviews with various staff members, including a CNA/CMT, an Admissions Nurse, and the Director of Nursing, confirmed that the facility's practice is to lock medication carts when not attended by staff. However, the facility did not provide a policy regarding the storage of medications, indicating a lack of formal guidance on this critical safety procedure. The facility census at the time was 101, highlighting the potential risk posed by the unsecured medication carts in a busy environment.
Infection Control Deficiencies in Medication Administration and Glucometer Disinfection
Penalty
Summary
The facility staff failed to maintain proper infection control practices during medication administration and glucometer disinfection, leading to deficiencies in care. For Resident #254, a Licensed Practical Nurse (LPN) was observed using a gloved finger to stir crushed medications in a cup before administering them via a peg-tube. This action was acknowledged by multiple staff members, including the Director of Nursing (DON) and Administrator, as unacceptable and a breach of infection control protocols. Resident #254 had a complex medical history, including chronic obstructive pulmonary disease, respiratory failure, and dysphagia, requiring careful medication management. In another incident, a Certified Nursing Assistant/Medication Technician (CNA/CMT) was observed handling medications for Resident #8 inappropriately. After spilling pills from a medication cup onto a tapestry runner, the CMT used a plastic spoon to scoop them back into the cup and administered them to the resident. This action was contrary to infection control guidelines, which require discarding dropped medications. Resident #8 had severe cognitive impairment and multiple health conditions, including congestive heart failure and chronic renal failure, necessitating precise medication administration. The facility also failed to properly disinfect glucometers used for blood glucose testing for Residents #74, #22, and #14. Observations revealed that staff did not follow the manufacturer's disinfection procedures, such as thoroughly wiping the glucometer with a disinfectant wipe and allowing it to air dry. Instead, staff wrapped the glucometer in a sani-wipe without proper cleaning, potentially leading to cross-contamination. These lapses in infection control were acknowledged by the Admissions Coordinator and DON, who emphasized the importance of adhering to infection control guidelines.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to uphold the residents' right to self-determination by not providing showers or baths as requested and care planned for two residents. Resident #46, who has a history of cerebral infarction, COPD, SLE, cognitive communication deficit, and CHF, was scheduled to receive showers twice a week. However, records show that the resident only received showers sporadically, with gaps ranging from seven to fourteen days between showers. The resident expressed dissatisfaction with the infrequency of showers, stating that once a week was insufficient and left them feeling dirty and tired. Resident #49, with diagnoses including metabolic encephalopathy, type 2 diabetes, bilateral leg amputation, CKD, CHF, and chronic respiratory failure, also experienced a lack of regular bathing. Despite being cognitively intact and requiring substantial assistance, the resident received showers or bed baths with significant delays, sometimes up to a month apart. The resident expressed feeling unclean and uncomfortable due to the infrequent bathing schedule and mentioned a previous agreement for more frequent showers, which was not being honored. Interviews with facility staff, including CNAs and the DON, revealed inconsistencies in the provision of showers, with some staff unaware of the residents' needs or the facility's policies. The DON and Administrator acknowledged that residents should be offered showers twice a week, regardless of hospice status, and that the current practice of extended delays between showers was not acceptable.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure the personal privacy of a resident during the provision of personal care. An observation revealed that the door to the resident's room was left open while a Certified Nursing Assistant (CNA) was performing incontinence care, exposing the resident's unclothed back to anyone passing by in the hallway. The resident, who has moderate cognitive impairment and is dependent on staff for personal care, expressed discomfort with being exposed, although noted that their roommate preferred the door open due to claustrophobia. Interviews with various staff members, including a CNA/Certified Medication Technician, a Licensed Practical Nurse (LPN), the Admissions Coordinator, and the Director of Nursing (DON), confirmed that it is against facility policy to leave a resident exposed in such a manner. The staff acknowledged that privacy should be maintained by closing the door or at least pulling the privacy curtain during personal care. The facility's policy on dignity emphasizes the importance of respecting residents' privacy and ensuring their well-being, which was not adhered to in this instance.
Failure to Complete PASARR for Resident
Penalty
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASARR) for a resident prior to or upon admission. The facility's policy mandates that all new admissions and readmissions undergo a Level I PASARR screening to identify any mental disorders, intellectual disabilities, or related disorders. If the Level I screening indicates potential issues, a Level II evaluation is required. However, for one resident, no Level I or Level II PASARR was found in the records, despite the resident having diagnoses that include intellectual disabilities and dementia. The MDS Coordinator, responsible for PASARRs, stated that Level I screenings are typically completed at the hospital before admission, or by the facility if the resident comes from home. The Coordinator believed the resident should have had a PASARR completed due to their long-term stay at the facility. However, upon review, neither the electronic medical record nor the paper records contained the necessary PASARR documentation. The Director of Nursing and Administrator confirmed that a Level I PASARR should have been completed prior to admission, but it was not found in the records.
Inadequate Incontinent Care for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, the staff did not provide adequate peri-care and failed to change urine-soaked items for a resident who was incontinent of bladder. The resident, who was cognitively intact but dependent on staff for mobility and personal hygiene, was observed sitting in a urine-soaked wheelchair pad while waiting for care. During the observed incident, multiple staff members, including CNAs and the ADON, were involved in transferring the resident using a Hoyer lift. Despite the presence of urine on the resident's wheelchair pad and floor, the staff did not change the wet Hoyer sling or the resident's urine-soaked pants. The CNAs also failed to perform proper peri-care, using the same wipe for multiple areas and not changing gloves between dirty and clean tasks. Interviews with various staff members, including a CNA/CMT, LPN, Admissions Coordinator, and the DON, revealed that the facility's expected procedures for incontinent care were not followed. These procedures included performing hand hygiene, using one wipe per swipe, and ensuring all clothing and linens were clean before being put back on the resident. The staff's actions during the incident did not align with these expectations, leading to the deficiency.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure that a resident's code status was consistent throughout their medical record. The resident, who had a history of cerebral infarction, altered mental status, COPD, chronic respiratory failure with hypoxia, and systemic lupus erythematosus, was documented as having a do not resuscitate (DNR) order on their face sheet. However, the care plan indicated the resident was full code, meaning they wished to receive CPR if their heart or breathing stopped. Interviews with various staff members, including CNAs, CMTs, LPNs, RNs, and the Social Service Director, revealed that the code status information was available in multiple locations, such as the electronic medical record (EMR), the resident's closet care plan, and the face sheet. Despite this, there was a lack of consistency in ensuring that the code status matched across all these records. Staff members believed that the information should match and that audits were conducted to ensure accuracy, but there was confusion about who was responsible for these audits. The Director of Nursing and the Administrator both acknowledged that the code status should be consistent throughout the resident's chart. They explained that the admission nurse was responsible for entering the code status information, and a match back audit was supposed to be conducted 24 hours after orders were entered. However, discrepancies were noted, and it was unclear who was responsible for ensuring the accuracy of the code status across all records, leading to the deficiency identified by the surveyors.
Lack of Documentation for Catheter Use in Resident
Penalty
Summary
The facility failed to ensure proper documentation and justification for the use of a catheter in a resident's medical record. Specifically, Resident #47's medical record did not contain a diagnosis to justify the use of a catheter, despite the resident arriving at the facility with a catheter already in place. The facility's policy on catheter care, revised in August 2022, requires staff to review and document the clinical indications for catheter use prior to insertion, which was not adhered to in this case. The resident's face sheet, progress notes, Minimum Data Set (MDS), physician's orders, care plan, and Treatment Administration Record (TAR) all lacked documentation of a diagnosis that warranted the catheter use. Interviews with facility staff, including the Infection Control Nurse, Admissions Coordinator, Director of Nursing (DON), and Administrator, revealed that there was an expectation for a diagnosis to be documented for catheter use. The staff acknowledged that physician orders should be based on diagnoses, and the absence of such documentation was a lapse in following standard practice. The facility census at the time was 101, and the resident had a history of kidney complications and urinary tract infections (UTIs), but these were not explicitly linked to the need for a catheter in the documentation.
Failure to Obtain Physician's Order for CPAP Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with obstructive sleep apnea by not obtaining a physician's order for the use of a CPAP machine at bedtime. The resident, who was cognitively intact and had a history of chronic respiratory failure with hypoxia, had a CPAP machine at their bedside but reported that staff did not always apply the mask or turn on the machine at night. The resident expressed a willingness to use the CPAP if assisted by staff, but there was no documented order for CPAP therapy in the resident's Treatment Administration Record (TAR) or Medication Administration Record (MAR). Interviews with facility staff, including LPNs and the Director of Nursing, revealed a lack of awareness and communication regarding the resident's CPAP therapy needs. The staff believed that CPAP treatment would be documented in the nursing TAR, but there was no confirmation of its presence. The Director of Nursing and the Administrator acknowledged that there should have been an order for CPAP use, including pressure settings, and that nurses were responsible for ensuring the CPAP was applied. The deficiency was identified through observation, interviews, and record reviews, highlighting a failure to adhere to the facility's policy on CPAP support.
Failure to Ensure Proper Installation and Maintenance of Bed Rails
Penalty
Summary
The staff at the facility failed to ensure the correct installation and maintenance of bed rails for a resident, identified as Resident #49. The resident's bed rails were observed to be loose, allowing movement back and forth several inches, which the resident had reported to the staff. The resident, who was cognitively intact, relied on the bed rails for mobility and positioning due to bilateral above-knee amputations and other significant health conditions, including metabolic encephalopathy, type 2 diabetes, and chronic kidney disease. Despite the resident's notification to the staff about the loose rail, the issue persisted, indicating a lapse in maintenance and monitoring. The facility did not have a policy regarding the use, installation, and monitoring of side rails, which contributed to the deficiency. The Maintenance Director stated that he installed the enabler bars after therapy evaluations and checked them monthly, but did not maintain a log of these checks. The Director of Nursing mentioned that side rail assessments should be reviewed by management and monitored quarterly or when there are changes in the resident's condition. However, there was no formal documentation or consistent process to ensure the safety and security of the bed rails, leading to the deficiency observed during the survey.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 14% error rate during an observed medication pass. This deficiency was identified through two specific incidents involving medication administration errors. In the first incident, a Licensed Practical Nurse (LPN) did not prime an insulin pen before administering insulin to a resident with type two diabetes, despite the manufacturer's instructions requiring priming before each use. The resident's blood sugar level was 206 mg/dL, necessitating 4 units of insulin, which was administered without priming the pen. In the second incident, the facility did not adhere to its policy for administering medications through an enteral tube. An LPN crushed and mixed three medications—diltiazem, gabapentin, and oxycodone—before administering them via a percutaneous endoscopic gastrostomy (PEG) tube to a resident. The facility's policy requires each medication to be administered separately with flushing between medications, and there was no physician's order to crush or mix these medications. The resident involved had a diagnosis of chronic obstructive pulmonary disease, respiratory failure, encephalopathy, and dysphagia, and was on a nothing by mouth (NPO) status. Interviews with facility staff, including the Director of Nursing (DON) and the Medical Director, confirmed that the facility's expectations were not met in these instances. The staff acknowledged that insulin pens should be primed before each use and that medications administered through a PEG tube should be given separately with appropriate flushing. The lack of adherence to these protocols contributed to the medication errors observed during the survey.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility staff failed to ensure that all residents were free from significant medication errors when a Licensed Practical Nurse (LPN) did not prime an insulin pen before administering insulin to a resident. The resident, who was cognitively intact and had diagnoses including type two diabetes, obesity, dependency on renal dialysis, high blood pressure, and heart failure, was observed receiving insulin injections seven days a week. During an observation, the LPN performed a blood sugar test on the resident, which resulted in a reading of 206 mg/dL, indicating the need for 4 units of sliding scale Novolog insulin. However, the LPN administered the insulin without priming the pen, contrary to the manufacturer's instructions. The manufacturer's instructions for the NovoLog FlexPen, revised in March 2008, specify that the pen should be primed before each injection to ensure proper dosing. The LPN admitted to only priming the insulin pens for their initial use and not for subsequent administrations. Interviews with the Admissions Coordinator and the Director of Nursing (DON) confirmed that the facility's expectation was for staff to prime insulin pens prior to each administration. This oversight in following the correct procedure for insulin administration led to a significant medication error for the resident.
Failure to Provide Timely Written Transfer Notices
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers to the hospital, as required by regulations. This deficiency was identified for three residents out of a sample of ten. The facility did not have a policy in place for issuing written transfer notices, which contributed to the oversight. In the case of Resident #30, the transfer notice was not effectively communicated, as the resident and their spouse did not recall receiving any written notification. The notice was initiated on the electronic record system on the day of transfer but was not printed and mailed until 47 days later. Resident #65 experienced a similar issue, with the effective date of the transfer notice being 30 days after the initial transfer and 35 days after a subsequent transfer. The resident's family was informed by phone, but there was no evidence of a written notice being sent in a timely manner. Resident #70 also did not receive a timely written notice, with the effective date being 37 days after the transfer. Interviews with staff revealed a lack of understanding and implementation of the process for sending out written transfer notices. The facility's staff, including LPNs, RNs, and the ADON, were unaware of the requirement to send written notices to families. The Business Office Manager was responsible for sending out the notices but admitted to delays due to their availability. The Administrator confirmed that the facility did not issue written transfer notices, relying instead on verbal communication and monthly logs sent to the Ombudsman. This systemic failure to provide timely written notifications constitutes a deficiency in the facility's compliance with regulatory requirements.
Failure to Account for Missing Medications and Protect Residents from Misappropriation
Penalty
Summary
The facility failed to keep all residents free from misappropriation when staff could not account for 17 doses of medication, affecting twelve residents. The incident involved a Licensed Practical Nurse (LPN) who was found with multiple pills in their pockets, which were identified as controlled substances such as oxycodone, Lortab, Xanax, and Norco. The police were called, and the LPN was arrested. The facility's Assistant Director of Nursing (ADON) and other staff members conducted a medication count and found discrepancies in the narcotic log, indicating that 17 pills were missing from the count. The missing medications were not documented as administered in the Medication Administration Record (MAR) or Treatment Administration Record (TAR), and the narcotic records showed slash marks indicating doses given but not properly accounted for. The facility's policies on abuse, neglect, exploitation, and misappropriation were not followed, as the medications were not signed out correctly, and the investigation process was not thoroughly documented. The Director of Nursing (DON) and other staff members were unaware of the exact number of missing pills and relied on sticky notes and handwritten lists to track the discrepancies. Interviews with staff members revealed that it was not appropriate to put resident medications in staff's pockets or to pop multiple residents' medications at the same time. The facility's failure to account for the missing medications and to follow proper procedures for documenting and investigating the incident resulted in a deficiency in protecting residents from misappropriation of their belongings or money.
Failure to Document and Verify Resident Treatments
Penalty
Summary
The facility failed to ensure all residents' medical records were complete and accurate, as staff did not document whether treatments were completed for four residents and did not follow up on potentially missed treatments. Resident #2, who had multiple diagnoses including cellulitis, multiple sclerosis, and severe sepsis, had orders for various creams to be applied to different parts of the body. On a specific date, the evening doses of these treatments were not documented as administered, and the Assistant Director of Nursing (ADON) noted this without confirming with the residents if the treatments were actually given. Resident #4, who had diagnoses including rhabdomyolysis and chronic pain syndrome, also had orders for skin treatments and blood sugar checks. On the same date, the evening treatments and blood sugar checks were not documented as completed, and the ADON again noted this without verifying with the resident. Similarly, Resident #9, who had type two diabetes and other conditions, had an order for a vaginal cream that was not documented as administered on the same date. Resident #10, diagnosed with COVID-19 and pneumonia among other conditions, had an order for a compression stocking that was not documented as addressed on the same evening. The ADON assumed the treatments were completed by a nurse who had to leave unexpectedly and did not verify with the residents. The Director of Nursing (DON) deferred questions about the missed treatments to the ADON, emphasizing that treatments should be administered as ordered by the physician.
Failure to Administer Pain Medication as Requested
Penalty
Summary
The facility failed to ensure effective pain management for a resident who required such services. Specifically, the staff did not administer the resident's as-needed pain medication when requested, despite the resident showing physical signs of pain. The resident, who had severe sepsis with septic shock, type 2 diabetes mellitus with diabetic chronic kidney disease, and bacteremia, reported experiencing significant pain on the night in question. The resident requested pain medication multiple times from the CNA, who reported the requests to the nurse three times, but the medication was never administered. The resident described the pain as a 10 on a scale of one to 10 and was visibly uncomfortable. The facility's policy on administering oral medications was not followed, as evidenced by the lack of documentation on the MAR/TAR and narcotic records. The ADON, who arrived to cover for a nurse, was unaware of any residents being in pain due to not receiving their medication. The DON confirmed that medications should be administered as ordered by the physician. The failure to administer the pain medication as requested and the lack of proper documentation led to the deficiency noted in the report.
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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