Lakeview Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Florissant, Missouri.
- Location
- 1201 Garden Plaza Drive, Florissant, Missouri 63033
- CMS Provider Number
- 265838
- Inspections on file
- 29
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Lakeview Post Acute during CMS and state inspections, most recent first.
The facility failed to follow its own wound care, order, and documentation policies for two high-risk residents, resulting in missed skin assessments, delayed or absent physician notification, and inconsistent implementation and recording of ordered treatments. One resident admitted with intact skin and at-risk Braden scores developed a shear injury and later an unstageable sacral pressure ulcer; staff did not complete required weekly skin assessments, did not promptly obtain or document treatment orders, omitted wound measurements and staging, and failed to document or consistently perform ordered wound care on multiple days, even after a family member reported skin breakdown and foul odor. Another resident with quadriplegia and very high Braden risk was admitted with a sacral pressure injury documented by the hospital, but facility records showed no skin assessments during the stay, and the resident returned to the hospital with a deep tissue injury to the coccyx while still wearing the original hospital-applied dressing. The MD later reported he had not been informed of either resident’s wounds or dressings when they were first identified or present.
A resident with severe cognitive impairment and multiple medical conditions developed a wound on the great toe and a blister on the second toe, but the facility failed to document or treat these wounds according to policy. The wounds were not properly assessed, documented, or reported to the physician, resulting in the great toe wound becoming infected before any treatment was initiated. Staff interviews revealed incomplete assessments and lack of awareness regarding the resident's condition.
The facility failed to provide a homelike environment by not ensuring hot water was available for residents' personal care, affecting multiple residents and rooms. Observations showed water temperatures below the required range, with residents expressing dissatisfaction. Staff interviews revealed awareness of the issue but inadequate resolution, and logs indicated systemic problems with maintaining appropriate water temperatures.
A facility failed to provide proper care for two residents, leading to deficiencies in medication administration and wound care. One resident did not receive their rheumatoid arthritis medication due to cost, resulting in increased pain. Additionally, the facility did not follow wound care orders due to a lack of supplies and staff knowledge, requiring the resident's family to perform care. Another resident did not receive daily wound care due to unavailable supplies, yet staff inaccurately documented treatments as completed.
The facility failed to maintain an effective pest control program, leading to a gnat infestation in the rooms of three residents. A resident with open wounds had gnats landing on their wounds and food, while another resident receiving palliative care had to cover their food and drinks. A third resident with cognitive impairment had gnats near their bathroom. The Maintenance Director was aware of the issue but had not effectively addressed it, and the pest control vendor had not treated the specific rooms.
A facility failed to apply leg wraps to a resident with CHF as per physician orders, leading to observed swelling. The resident's care plan was not followed, and staff inaccurately documented the application of wraps. Interviews revealed the resident's non-compliance and potential cognitive issues affecting understanding of treatment importance.
Two residents in an LTC facility did not receive necessary incontinence care and hygiene services. One bed-bound resident was found with a saturated brief and pad, and reported being changed only once a day. Another resident was left in a wheelchair surrounded by urine, with no documentation of their frequent urination on the floor. The facility failed to document shower refusals and preferences, leading to inadequate personal hygiene maintenance.
The facility failed to accurately document wound care treatments for three residents. One resident did not receive a wound vac as ordered, leading to incorrect documentation of treatment. Another resident's wound dressings were not changed due to supply issues, despite records indicating otherwise. A third resident's leg wraps were not applied as required, with inaccurate documentation of compliance. The facility's leadership acknowledged the documentation failures.
Several residents were found without working call lights, with some systems briefly illuminating or failing to alert staff at the nurses station. Residents, including those with cognitive impairment and fall risk, reported being unable to reliably summon assistance, sometimes using bells or a roommate's call light instead. Maintenance staff confirmed multiple call lights were out of order due to damaged cords, and staff awareness of the issue varied.
An LPN diverted Schedule II controlled medication intended for a resident with multiple medical conditions, resulting in missing narcotics and discrepancies in medication counts. The LPN was observed acting confused and tired, and video footage captured the unauthorized removal of medication. The incident was reported to police as felony theft of a controlled substance.
The facility failed to notify responsible parties of several residents after significant incidents and changes in condition. A resident eloped and was found confused, another had a change in condition with delayed family notification, and others were transferred to the hospital without informing families. The facility's policy requires immediate notification, which was not consistently followed.
The facility failed to report and investigate three incidents involving residents, including an elopement, an alleged physical abuse by a CNA, and a resident-to-resident altercation. In each case, the facility did not notify the Department of Health and Senior Services (DHSS) as required by regulations, and there was a lack of documentation and investigation into the incidents.
The facility failed to maintain complete and individualized care plans for residents, leading to deficiencies in addressing specific needs such as elopement risks, use of side rails, and medical device management. Several residents' care plans lacked critical updates and information, compromising their safety and well-being.
The facility failed to ensure complete physician orders and adequate staff training for respiratory care, affecting residents with tracheostomies. A resident with heart failure and respiratory issues had incomplete orders and malfunctioning oxygen monitoring equipment. Another resident with COPD lacked continuous oxygen monitoring, and a third resident had incomplete tracheostomy orders. Staff were not trained on equipment use, leading to deficiencies in care.
The facility failed to provide sufficient nursing staff, resulting in residents calling 911 for assistance due to unaddressed medical needs and unanswered call lights. Staffing shortages, particularly during night shifts, led to delays in care, with some residents going hours without necessary interventions. The facility's reliance on agency staff and lack of a system to ensure adequate coverage further exacerbated the issue.
The facility failed to ensure licensed staff were competent in tracheostomy care and equipment use, affecting 15 residents with tracheostomies. An LPN was unable to properly suction a resident, requiring intervention from a respiratory therapist. Staff interviews revealed a lack of training and competency assessments for the facility's equipment and policies, with insufficient trained staff for evening and night shifts.
The facility failed to maintain accurate records for controlled substances, with multiple blank entries on shift change count sheets for two medication carts. Interviews revealed that nurses were not consistently signing the logs, indicating a failure to perform required duties. This issue had the potential to affect all residents with controlled substance orders.
The facility failed to properly label and store medications, leaving medication carts unlocked and unsupervised, and not dating opened insulin and PPD solutions. Unopened insulin was improperly stored outside the refrigerator, contrary to guidelines. Staff interviews confirmed these practices were against facility policies.
The facility's assessment was incomplete, lacking details on staffing needs and competencies necessary for resident care. It did not include respiratory therapists, restorative therapy, social services, and dietary staff, nor did it document staff ratios for specific care needs. Issues such as insufficient nursing staff and inappropriate tracheostomy care were identified, with respiratory therapy not scheduled 24/7.
The facility failed to follow infection control standards, with staff not performing hand hygiene between glove changes and not wearing appropriate PPE for residents requiring Enhanced Barrier Precautions. Additionally, a resident's Foley catheter bag was observed on the floor, contrary to infection prevention protocols. These deficiencies were confirmed through observations and staff interviews.
The facility failed to offer and document vaccinations for influenza, pneumococcal, and COVID-19, as well as PPD skin tests, for several residents. Two residents did not receive influenza and pneumococcal vaccines, and three did not receive COVID-19 vaccines. Additionally, four residents did not complete PPD skin tests. Documentation of informed consent or refusal was missing, despite the facility having the necessary supplies and policies in place.
The facility's call light system on the 100 and 200 halls was deficient, as lights illuminated without sounding at the nurse's station, requiring staff to visually check for activated lights. Staff interviews confirmed the issue, and the Maintenance Director noted that two call lights needed rewiring. Residents were given bells as a temporary measure, which were ineffective if staff were not nearby.
A resident with severe cognitive impairment was left exposed in a common area, compromising their dignity. Despite the facility's policy to treat residents with respect, staff did not promptly cover the resident, who was wearing a loose-fitting dress that exposed their brief. Eventually, a CNA covered the resident, but the delay highlighted a failure to uphold the facility's dignity standards.
Facility staff failed to ensure call lights were within reach for three residents, leading to unmet needs and preferences. A resident with cognitive impairment and a contracted hand could not locate their call light, while another resident's call light was clipped out of reach. A third resident, at risk for falls, was found calling for help without a functioning call light. Staff interviews revealed non-compliance with call light policies, contributing to the deficiency.
A resident with cognitive impairment reported being hit by a CNA, but the LTC facility failed to investigate the allegation. The nurse who witnessed the aftermath did not document the incident, and the social worker's findings were not followed by a formal investigation. Despite the facility's policy, no investigation was conducted, and the incident was not reported to DHSS.
The facility failed to conduct necessary lab tests for a resident with severe cognitive impairment and did not perform required neuro checks for another resident after a fall. Lab tests were delayed by over two months, and neuro checks were incomplete, with 10 out of 12 opportunities left blank. Staff interviews confirmed that procedures were not followed as per facility protocols.
The facility failed to provide timely wound care for two residents due to delays in entering treatment orders into the computer system and inadequate communication among staff. One resident's pressure ulcer treatment was delayed for nine days, leading to deterioration, while another resident was found without the ordered treatment in place. Interviews revealed systemic issues in communication and documentation, with no wound nurse available on weekends, contributing to the deficiencies.
A resident identified as an elopement risk wandered away from the facility and was found by police without shoes, leading to hospitalization. The facility failed to document the incident in the resident's medical record or care plan. Staff communication was lacking, with no report given during shift change, and the facility's camera system was not functioning. The Administrator admitted the incident was not thoroughly reported or investigated.
A resident with a gastrostomy tube did not receive continuous tube feeding for approximately five hours due to staffing and communication issues. The resident, with a history of stroke and dysphagia, was ordered Jevity 1.5 Cal at 70 ml/hr. Observations showed the feeding pump was off, and an empty bottle was hanging. Staff interviews revealed a lack of awareness and monitoring, leading to the deficiency.
The facility failed to document and monitor dialysis care for a resident with ESRD, lacking physician orders and consistent vital sign checks. Staff interviews revealed incomplete communication forms and inadequate documentation practices. The facility was developing a new form to address these issues.
The facility did not follow the consultant pharmacist's recommendations for two residents, failing to update physician orders for medication instructions and necessary lab tests. Despite prescriber agreement, the recommendations were not implemented or documented, as expected by the facility's administrator.
The facility failed to follow pharmacist recommendations for GDR and documentation of behavior monitoring for two residents on psychotropic medications. One resident with cognitive impairment and bipolar disorder did not have recommended assessments or documentation, while another resident on Quetiapine for anxiety lacked appropriate diagnosis documentation. The Administrator noted that pharmacy recommendations were not reviewed by the physician as expected.
The facility failed to administer medications per physician orders for three residents, leading to significant medication errors. A resident did not receive Modafinil and Ozempic due to prior authorization issues, while another resident missed doses of Ozempic without documentation or physician notification. A third resident had multiple medications not administered, with gaps in documentation and no evidence of physician notification. Staff interviews revealed inconsistent procedures for handling unavailable medications.
The facility failed to conduct routine inspections of bed/side rails, leading to potential entrapment risks for three residents. Despite policies requiring regular checks and documentation, observations showed residents with raised side rails without proper assessments or physician orders. Interviews revealed a lack of documentation for siderail measurements, despite the maintenance department's responsibility for safety checks.
A facility failed to obtain and document physician orders for a resident requiring tracheostomy care, leading to inadequate tracheostomy maintenance. The resident, with significant cognitive impairment and tracheostomy status, experienced low oxygenation levels on multiple occasions, requiring emergency medical intervention. Despite having orders for continuous oxygen monitoring and tracheostomy equipment changes, the facility's records showed no documentation of these tasks being completed. Interviews with staff revealed a lack of oversight and documentation, particularly during night shifts.
A facility failed to implement a care plan with interventions for a high fall-risk resident, who was left unsupervised in a wheelchair. The resident fell while reaching for a blanket, leading to a seizure and cardiac arrest, resulting in their death.
The facility failed to ensure residents received their scheduled showers due to staffing shortages. Interviews with residents and staff confirmed that insufficient staffing levels made it challenging to provide the necessary care, resulting in missed showers for multiple residents.
The facility failed to report and monitor a resident's excoriated buttocks, ensure another resident with pressure ulcers wore heel protectors and was repositioned timely, and document care plans for pressure ulcers. Observations showed residents not receiving treatments as ordered and not wearing protective boots as required.
The facility failed to maintain adequate staffing levels, resulting in multiple residents not receiving scheduled showers and one resident with pressure ulcers not being cleaned or repositioned timely. Staff confirmed that frequent shortages led to missed showers and inadequate care.
The facility failed to ensure comfortable water temperatures for residents, with multiple complaints about cold water for bathing. Water temperature logs showed temperatures below the acceptable range of 105°F to 120°F. Residents with various medical conditions reported discomfort, and staff confirmed the issue had persisted for months. The Maintenance Director and Administrator were unaware of the required temperature range and the ongoing problem.
The facility failed to develop a care plan with specific fall prevention interventions for a high-risk resident, leading to a fall and subsequent death. Despite the resident's cognitive impairment and medical history, the care plan did not include measures such as close monitoring or ensuring the resident wore a protective helmet. The resident was left unsupervised in a wheelchair, resulting in a fall, seizure, and cardiac arrest.
The facility failed to ensure staff checked incontinent residents every two to three hours, resulting in two residents being left urine-saturated for extended periods. One resident was found with urine wetness extending from the buttocks to the shoulder blades, and another reported not being checked or changed since the previous night, with the night CNA not responding to the call light.
The facility failed to complete wound treatments as ordered for two residents over a weekend, leading to deficiencies in care. The residents' dressings were not changed, and staff interviews revealed systemic issues, including lack of access to supplies and insufficient staffing.
The facility failed to follow dietary recommendations and provide adaptive equipment for residents experiencing severe weight loss. Three residents were observed without necessary adaptive utensils and fortified foods, and the facility did not develop appropriate care plan interventions or ensure proper documentation and communication of dietary needs.
The facility failed to ensure nurses received training for a resident's non-invasive mechanical ventilator and were aware of back-up ventilators. The resident experienced repeated ventilator alarms over several nights, and nurses did not know how to address the issue, leading the resident to turn off the ventilator. The facility also did not obtain orders for the ventilator's use.
The facility failed to provide adaptive eating equipment as ordered for three residents, leading to their dependence on staff for eating assistance and inadequate meal consumption. Despite clear care plans and physician's orders, the necessary utensils and cups were not consistently provided during meals.
Failure to Assess, Communicate, and Treat Pressure Injuries for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing skin monitoring, timely assessment, physician notification, and ordered treatment for residents with actual or potential pressure injuries. Facility policies required physician orders for wound care, review of care plans, and detailed documentation of wound assessments, treatments, and notifications. Policies also required that all treatments and services be documented with date, time, provider, assessment findings, resident response, refusals, and notifications. Despite these requirements, staff did not consistently assess skin, obtain or implement treatment orders, or document wound care and changes in condition. For one resident admitted with intact skin and a Braden score indicating risk for pressure ulcers, weekly skin assessments were incomplete and subsequent wound care was delayed and poorly documented. An initial comprehensive skin assessment shortly after admission showed dry, intact skin and no wounds, and a Braden assessment identified the resident as at risk. A weekly skin assessment was documented one week later as intact, but the following week’s assessment was not completed. On a later date, a progress note documented a new skin shear on the left buttock, with a foam dressing applied and a message sent to the NP for treatment orders; however, there was no documentation of NP response, no new treatment orders on the POS, and no documentation that the responsible party was notified. The next day, staff documented only that the resident remained on antibiotics and that incident follow-up related to a new wound showed no changes, without recording wound size, physician or family notification, or new wound care orders. Over the next several days, there was no documentation regarding the wound. Subsequently, a comprehensive skin assessment documented the presence of wounds and identified a new sacral wound but did not include size or stage, and staff recorded that no notifications were required. An order was entered for the resident to be followed by wound care, but no specific wound care orders were present at that time. A wound care management note the next day described a sacral wound measuring 3.0 cm by 5.0 cm with 60% necrotic and 40% granulation tissue and set out a treatment plan including NS cleansing, Santyl, calcium alginate, and foam dressing, but the POS did not yet contain corresponding treatment orders. Wound care orders were not entered until the following day, and the TAR showed the first treatment documented as applied another day later. Subsequent wound care notes documented changes in wound size and tissue composition and updated treatment plans, but the TAR showed missed documentation of ordered treatments on multiple dates. A family member reported discovering an open area on the buttocks during bathing and later observing a brown and black wound with a foul odor under a dressing dated two days earlier. The ADON acknowledged being informed by the family member, checked the record and found no wound documentation, did not assess the resident, and did not document the family’s concerns, stating that wound issues and documentation were the responsibility of the Wound Nurse. The Wound Nurse recalled being informed by the family, did not complete a comprehensive skin assessment, did not measure or stage the area, and only wrote an order for specialized wound care team evaluation without notifying the physician or obtaining treatment orders. The Wound Nurse also acknowledged missing a weekly skin assessment, not performing a formal skin assessment for a two-week period, and that the resident developed the wounds in the facility. For a second resident with quadriplegia, bowel incontinence, and very high risk for pressure ulcers, the facility failed to assess and treat an existing pressure injury documented at the hospital prior to admission. The resident’s care plan identified risk for skin breakdown and included interventions such as administering treatment as ordered, applying barrier cream, and checking skin during daily care. A hospital discharge summary referenced a sacral pressure injury, and a Braden assessment at the facility showed a very high risk score. However, there were no documented skin assessments from admission through several days of stay, and the progress note on the day of transfer back to the hospital for respiratory distress contained no skin evaluation. A hospital nurse reported that the resident returned to the hospital with a deep tissue injury to the coccyx and was still wearing the same protective dressing that hospital staff had applied before discharge to the facility, indicating that the dressing had not been changed during the facility stay. The facility’s Medical Director and primary care physician for both residents stated he was not informed of the first resident’s wounds when initially identified and was not informed that the second resident had a coccyx dressing on readmission, and he stated that residents should be assessed head to toe on admission or readmission and that weekly skin assessments should be completed at minimum, noting existing problems with communication regarding pressure ulcers and wound care.
Failure to Provide Proper Foot and Wound Care
Penalty
Summary
The facility failed to provide appropriate foot and wound care for a resident with a wound on the great toe and a blister on the second toe. The resident, who had severe cognitive impairment and multiple diagnoses including epilepsy, stroke history, and muscle weakness, was identified as being at risk for skin breakdown. Despite this, the facility did not document or treat the wounds according to professional standards and the facility's own foot care policy. The great toe wound was first noted during a shower, but a comprehensive skin assessment was not completed at that time, and the second toe blister was not documented in subsequent skin assessments. There were no treatment orders for either the great toe wound or the second toe blister in the resident's physician orders summary. Progress notes indicated that the DON believed she had received an order to leave the wound open to air, but the resident's physician and nurse practitioner were unaware of the wounds and had not given such orders. The wound was left uncovered and untreated for several days, and the first documented treatment occurred only after the wound became infected. The wound management company was not consulted until after the infection developed, and the wound nurse expected the wound to have been covered to prevent infection. Documentation on skin monitoring shower sheets and the facility's wound report failed to include the second toe blister, and the great toe wound was inconsistently noted. Interviews with staff revealed a lack of awareness and incomplete assessments, with the LPN unaware of the blister and the DON acknowledging that a thorough assessment and treatment order should have been obtained when the wound was first discovered. The resident's family was also not fully informed about the extent of the wounds.
Facility Fails to Provide Adequate Hot Water for Residents
Penalty
Summary
The facility failed to provide a homelike environment by not ensuring hot water was available for bathing and personal care for residents. Observations and measurements revealed that the hot water temperatures in several resident rooms and shower rooms were below the facility's policy and state regulations, which require water temperatures to be between 98 and 120 degrees Fahrenheit. The deficiency affected six out of nine sampled residents and multiple rooms, with water temperatures recorded as low as 77 degrees Fahrenheit. Residents expressed dissatisfaction with the water temperature, stating that it was too cold for their needs. For instance, Resident #6, who has moderately impaired cognition and requires assistance with daily living activities, reported that the water in their room was too cold and had informed staff about it two weeks prior without any resolution. Similarly, Resident #5, who requires assistance with activities of daily living and has multiple health issues, mentioned that the water was too cold for bed baths and took too long to warm up. Interviews with staff, including the Administrator and Maintenance Supervisor, revealed that the facility was aware of the hot water issues and had been working on them. However, they were not fully aware of the extent of the problem across the facility. The Maintenance Supervisor admitted to only ensuring that the water was not too hot, without adequately addressing the low temperatures. The facility's water temperature logs showed that several measurements were below the required 105 degrees Fahrenheit, indicating a systemic issue with maintaining appropriate water temperatures.
Deficiencies in Medication and Wound Care Management
Penalty
Summary
The facility failed to provide care consistent with professional standards for two residents, leading to deficiencies in medication administration and wound care. One resident, who was on Medicare Part A, did not receive their prescribed medication for rheumatoid arthritis due to its high cost, which was not covered by the facility. This resident experienced increased pain and decreased function in their hands and knees as a result. Additionally, the facility did not follow physician-ordered wound treatments for this resident, as the wound vac was not applied for several days due to a lack of supplies and staff knowledge. The resident's family had to perform wound care themselves, and there was no documentation of the wound's condition or the alternative dressing applied. Another resident did not receive daily wound care treatments as ordered. The facility failed to change the resident's dressings due to a lack of supplies and staff availability, resulting in the resident's dressings not being changed for several days. The resident reported that the wound care nurse was unavailable, and the facility did not have the necessary supplies to perform the treatments. Despite this, staff documented that the treatments were completed as ordered, which was inaccurate. Interviews with staff and the resident's family members revealed that the facility did not have adequate procedures in place to ensure the timely ordering and availability of wound care supplies. The facility's documentation practices were also found to be lacking, as treatments were recorded as completed when they were not. The facility's administration acknowledged these issues, noting that it was unacceptable to document treatments that had not been provided and that all wound treatments should have corresponding orders.
Facility Fails to Control Gnat Infestation in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant gnat infestation in the rooms of three residents. Resident #87, who was cognitively intact and independent in decision-making, was observed with gnats swarming around their room, particularly in the trash can and on the over-bed table. The gnats were landing on the resident's open wounds and food, and the resident reported that this had been an ongoing issue. Despite the resident's complaints, the Director of Nursing was unaware of the problem until it was brought to her attention during a skin assessment. Resident #25, who was receiving palliative care, also experienced a gnat infestation in their room, with gnats flying around and necessitating the covering of food and drinks. Similarly, Resident #64, who had moderate cognitive impairment and required assistance with daily activities, had gnats near the bathroom door, and the floor was sticky. The Maintenance Director acknowledged awareness of the issue but had not effectively addressed it, and the pest control vendor had not treated the specific rooms despite being contacted. The Administrator and Director of Nursing were not initially aware of the extent of the problem.
Failure to Apply Leg Wraps as Ordered for Resident with CHF
Penalty
Summary
The facility failed to provide services that met professional standards of practice and the resident's plan of care by not applying leg wraps to a resident as per physician orders. The resident, who had diagnoses including congestive heart failure (CHF), diabetes, high blood pressure, and chronic obstructive pulmonary disease (COPD), required daily leg wraps to manage swelling. However, observations on January 2, 2025, revealed that the resident's legs were not wrapped, and they appeared swollen with tight socks around the ankles. The facility's Wound Care policy mandates verifying physician orders and documenting any refusal of treatment, but these procedures were not followed. Interviews with facility staff, including a Certified Medication Technician (CMT) and the resident's Nurse Practitioner (NP), indicated that the resident was not always compliant with wearing the wraps and that the NP was unsure if the resident fully understood the consequences of refusal due to potential cognitive issues. The Director of Nursing (DON) confirmed that staff should not document treatments as completed if they were not done and should record any refusals. This deficiency highlights a failure in adhering to the resident's care plan and ensuring accurate documentation of care provided.
Inadequate Incontinence Care and Hygiene Services
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for two residents who were incontinent of bladder. One resident, who was bed-bound and under hospice care, was found with a saturated brief and pad, indicating inadequate incontinence care. The resident reported being changed only once a day, leading to discomfort and a strong odor. The resident's care plan did not address their refusal to take showers or their preferences related to bathing, and there was a lack of documentation regarding the resident's shower schedule and refusals. Another resident, who required substantial assistance with toileting and showering, was left in a wheelchair surrounded by a large puddle of urine. The resident's care plan did not address their shower or bathing preferences, and there was no documentation of the resident refusing showers. The resident reported that this situation happened frequently, and staff were expected to check on residents at least every two hours, which was not adhered to in this case. Interviews with staff revealed that the resident in the wheelchair had a tendency to urinate on the floor, a behavior that had been occurring for at least a year, yet there was no documentation of this in the resident's medical record. The Director of Nursing acknowledged that residents should receive showers at least twice a week and that any refusals should be documented in the care plan. The failure to provide adequate incontinence care and showers was identified as a dignity issue.
Inaccurate Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to ensure accurate and complete documentation of resident treatments, specifically regarding wound care for three residents. Resident #24 had a physician's order for a wound vac to be applied to a wound on the left lower leg, but the treatment was not consistently provided as ordered. The wound vac was not available on several occasions, and staff documented the treatment as completed when it was not. The resident reported that the wound vac was not applied until three days after admission, and there were issues with the wound vac alarming due to a full collection canister, which staff were unable to replace. Consequently, a wet to dry dressing was applied instead, but this was not documented accurately. Resident #87 also experienced issues with wound care documentation. The resident had multiple orders for wound treatments, but staff failed to change the dressings as required due to a lack of supplies. Despite this, the Treatment Administration Record (TAR) indicated that treatments were completed as ordered. The resident reported that the wound dressings had not been changed since a specific date, and the facility's wound physician had left, leaving the resident without proper care. Resident #13 had an order to wrap legs daily to manage swelling, but observations showed that the resident's legs were not wrapped, and the TAR inaccurately reflected that the treatment was provided. The resident's Nurse Practitioner noted that the resident was not always compliant with wearing wraps, which was crucial due to the resident's congestive heart failure (CHF). The facility's Administrator and Director of Nursing acknowledged that it was unacceptable to document treatments as provided when they were not, and they expected staff to notify physicians if treatments or medications were unavailable.
Non-Functional Resident Call Light System
Penalty
Summary
The facility failed to ensure that the resident call light system was functional and available in resident rooms, bathrooms, and bathing areas, as required by policy. Multiple observations and interviews revealed that several residents did not have working call lights for extended periods. In some cases, the call lights would briefly illuminate and then turn off, with no audible alert or hallway notification. Residents reported that staff were aware of the issue, but repairs had not been completed, and alternative measures such as providing bells were not effective, as staff did not always respond to them. Specific residents affected included those with varying cognitive abilities and care needs, such as one resident who was cognitively intact and another with mild cognitive impairment and a history of rejecting care. These residents described being unable to reliably summon assistance, sometimes resorting to using a roommate's call light or physically seeking staff in the hallway. Maintenance staff confirmed that call light cords had been damaged, often due to being wrapped around bed rails and pulled out of the wall when beds were moved, resulting in the need for rewiring and replacement. At the time of the survey, ten call lights were reported as non-functional, and replacement parts had been ordered but not yet received. Interviews with staff, including CNAs, LPNs, and the Maintenance Director, indicated inconsistent awareness of the extent of the problem. Some staff were unaware of the non-functioning call lights, while others acknowledged the issue and the use of bells as a temporary solution. The facility's policy required that the call system remain functional at all times, but this standard was not met for at least four residents, as observed and documented during the survey.
Drug Diversion of Controlled Medication by LPN
Penalty
Summary
A deficiency occurred when a staff member, specifically an LPN, diverted Schedule II controlled medications intended for a resident. The incident was identified on the 200 hall unit during a shift change, when discrepancies in the narcotic medication count were observed. The LPN in question was noted to be confused, disoriented, and appeared tired with slow speech during the shift. Upon further review, a narcotic count sheet for a resident was found in the medication cart, but the corresponding medication card was missing. The pharmacy confirmed that the medication had been delivered and received by the LPN, but it could not be located. The medication label was later found torn in the shred box. The resident involved was cognitively intact and had diagnoses including heart disease, kidney disease, septicemia, and COPD. The resident was prescribed Hydrocodone-Acetaminophen for pain management. According to the Medication Administration Record, the LPN had documented administration of the medication during the relevant shifts. However, the resident reported that there were times when the medication was not received at the requested time, though specific dates were not recalled. Video footage showed the LPN retrieving a medication card from the cart, appearing to take some medication, and placing the card in a backpack at the nurse station. The police were notified, and the incident was reported as felony stealing of a controlled substance. The LPN denied taking any resident medications during an interview but admitted to taking personal prescription medications. The facility's policy strictly prohibits misappropriation of resident property, including drug diversion, and requires staff to report any suspected incidents.
Failure to Notify Responsible Parties of Resident Incidents and Condition Changes
Penalty
Summary
The facility failed to immediately notify the responsible parties of several residents following significant incidents and changes in their conditions. One resident eloped from the facility and was found by emergency services in a confused state, yet the family was not informed until hours later. The Director of Nursing (DON) was aware of the situation but did not notify the family immediately due to a lack of complete information. The staff involved were from a nursing agency and could not be reached for further clarification. Another resident experienced a change in condition with an increased heart rate and shallow breathing, but the family was not notified until the following morning. The night shift nurse, who noticed the change, did not inform the family, leaving it to the day shift nurse who was absent. The family was upset upon learning of the delay and questioned why the resident was not sent to the hospital. The nurse practitioner expected the facility to follow policy and notify the family promptly. Additionally, a resident with pressure ulcers was not reported to their representative, and another resident was transferred to the hospital twice without family notification. The facility's policy requires immediate notification of the resident's representative in such cases, but this was not adhered to, as confirmed by interviews with staff and family members. The Assistant Director of Nursing and the Administrator both expected staff to notify families of any changes in condition or hospitalizations, which was not consistently done.
Failure to Report and Investigate Incidents
Penalty
Summary
The facility failed to notify the Department of Health and Senior Services (DHSS) as required by state and federal regulations in three separate incidents involving residents. In the first incident, a resident identified as an elopement risk was found by police after wandering away from the facility. The resident was confused and disoriented, and the facility did not report the elopement to DHSS. The facility's staff, including the Administrator, were unaware of the incident until after the fact, and there was no documentation of the elopement in the resident's progress notes. In the second incident, a resident alleged that a Certified Nurse Aide (CNA) hit them in the head with a closed fist. The allegation was reported to the Director of Nursing (DON) and the Administrator, but the facility did not report the incident to DHSS. The resident expressed feeling scared and abused, and although the CNA was sent home, the facility allowed the CNA to return to work after the resident later denied the incident occurred. The lack of documentation and failure to report the allegation to DHSS were noted. The third incident involved a resident who claimed they were attacked by another resident in their room. The resident reported the incident to staff, including the Administrator and Social Worker, but the facility did not report the incident to DHSS. The Administrator dismissed the incident, believing there was no physical altercation, and did not document the resident's report. The facility's failure to report and investigate these incidents as required by regulations resulted in deficiencies in their handling of suspected abuse, neglect, and elopement.
Deficiencies in Resident Care Plans
Penalty
Summary
The facility failed to ensure that residents had complete, accurate, and individualized care plans to address their specific needs. This deficiency was observed in several residents, including one who was identified as an elopement risk. Despite being cognitively impaired and having a history of wandering, the resident's care plan was not updated to reflect an elopement incident that occurred. The resident was found 0.2 miles away from the facility, and there was a lack of updated interventions in the care plan to address this risk. Another resident with mild cognitive impairment and multiple diagnoses, including heart failure and diabetes, was observed using side rails for repositioning in bed. However, the resident's care plan did not include any information regarding the use of side rails, which were in use daily. This omission indicates a lack of comprehensive planning to ensure the resident's safety and needs are met. Additionally, a resident with a tracheostomy and gastrostomy was found to have no information regarding these medical devices in their care plan. The resident's care plan also lacked documentation of behaviors or potential side effects related to antipsychotic or antidepressant medications. The facility's failure to include these critical details in the care plans demonstrates a significant oversight in addressing the residents' specific medical and behavioral needs.
Inadequate Respiratory Care and Monitoring in LTC Facility
Penalty
Summary
The facility staff failed to ensure that physician orders for tracheostomy and ventilation machines were complete with all pertinent information necessary for the care of residents. This included the absence of orders for continuous oxygen monitoring for residents with a tracheostomy. The facility also did not have staff adequately trained on how to set and monitor the functioning of ventilation machines and continuous oxygen monitoring devices. This deficiency was observed in the cases of Residents #13, #25, and #245, who required specific respiratory care due to their medical conditions. Resident #13, who had a history of heart failure, pulmonary edema, pneumonia, and respiratory failure, was found to have incomplete physician orders for tracheostomy care. The orders lacked specific information needed for the resident's ventilator settings and continuous oxygen monitoring. During an observation, it was noted that the resident's continuous oxygen monitor was turned off, and a malfunction error was displayed when it was turned on. This indicated a failure in ensuring the equipment was functioning properly. Resident #25, diagnosed with COPD and requiring a tracheostomy, was observed without a continuous oxygen monitoring machine in their room, and their oxygen source was not attached. Similarly, Resident #245, who required a tracheostomy, had incomplete orders that did not specify the type or size of the tracheostomy equipment. The facility's staff, including the respiratory therapist and nursing staff, were not adequately trained on the use of the facility's specific equipment and policies, contributing to the deficiencies in care provided to these residents.
Inadequate Staffing Leads to Critical Incidents in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, resulting in several critical incidents. One resident, who was experiencing acute shortness of breath, had to call 911 for intervention as staff were unavailable to assist. Another resident called 911 twice due to staff not responding to their call light, once for repositioning a tube and another time for being left in a soiled brief for 10 hours. Additionally, a resident dependent on staff for nutrition went over five hours without receiving their physician-ordered tube feeding. The facility's staffing issues were further highlighted by observations of call lights being left unanswered for extended periods, with staff walking past rooms without responding. One resident's call light was observed to be on for almost two hours without being addressed. Interviews with staff and residents revealed that the facility was frequently understaffed, particularly during night shifts, with some halls having only one nurse and two CNAs to care for a large number of residents. This lack of adequate staffing led to delays in care and residents having to resort to calling emergency services for assistance. The facility's reliance on agency staff, who were often not adequately trained or familiar with the residents' needs, compounded the staffing issues. There were reports of staff sleeping during shifts and being unresponsive to residents' needs. The facility's assessment tool indicated a lack of a system to ensure required coverage, and interviews with staff confirmed that the facility struggled to maintain sufficient staffing levels to provide adequate care for its residents.
Inadequate Staff Training for Tracheostomy Care
Penalty
Summary
The facility failed to ensure that their licensed staff were competent in providing tracheostomy care and suctioning to residents, as well as in using the facility's continuous oxygen monitoring system, piped in oxygen system, and wall suctioning equipment. This deficiency had the potential to affect 15 residents with tracheostomies who required frequent suctioning and oxygen saturation monitoring. The facility did not have specific policies or procedures for the equipment used, nor did they provide manufacturer guidelines to their staff. During an observation, a certified nursing assistant alerted an LPN that a resident needed suctioning. The LPN attempted to perform the procedure but was unsuccessful, as the resident indicated that it was being done incorrectly. A registered respiratory therapist had to intervene to provide the necessary care. Interviews with staff revealed that the LPN had not received any training specific to the facility's equipment or policies and was unaware of the responsibilities involved in caring for residents with tracheostomies or ventilators. Further interviews with other staff members, including respiratory therapists and registered nurses, confirmed that the facility had not provided adequate training or competency assessments for the use of their specific equipment and policies. The facility lacked sufficient trained staff to care for the number of residents with tracheostomies and ventilators, particularly during evening and night shifts when respiratory therapists were not available. The facility's administrator and medical director were unaware of the gaps in training and staffing, leading to a situation where untrained staff were responsible for critical respiratory care.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to establish a comprehensive system of record for controlled drugs, which are regulated by the government, to ensure accurate reconciliation. This deficiency was identified during a review of two out of three medication carts, where it was found that the controlled substance shift change count sheets had multiple blank entries. Specifically, on the 100 hall, six out of 28 opportunities for the oncoming shift and nine out of 28 for the off-going shift were left blank. Similarly, on the 300-400 hall, three out of 28 opportunities for the oncoming shift and five out of 28 for the off-going shift were not documented. This lack of documentation had the potential to affect all residents with controlled substance orders, with the facility census being 99. Interviews with several LPNs and the Director of Nursing revealed that controlled substances should be counted every shift by both the oncoming and off-going nurses, and any discrepancies should be reported. However, the interviews indicated that the nurses were not consistently signing the controlled substance shift count sheet, which was supposed to confirm the accuracy of the count. The Director of Nursing acknowledged that a blank on the control log indicated a failure to perform the required duties. The facility's Administrator also expressed an expectation for staff to adhere to the established policies and procedures.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, as observed during a survey. On one occasion, medication carts on the 100 hall were left unlocked and unsupervised for extended periods, despite facility policy requiring them to be locked when not in use. This was confirmed through observations and interviews with staff, including an LPN who acknowledged the carts should be locked when not in use. Additionally, the facility's medication labeling and storage policy, dated 2001, was found lacking in specific guidance on dating medications. Further deficiencies were noted in the storage and labeling of insulin and PPD solutions. An unopened Novolog insulin pen was improperly stored on a medication cart instead of in a refrigerator, and an opened insulin Lispro pen was not dated. Similarly, a vial of PPD solution was found opened and undated in the medication room, contrary to FDA guidelines that require it to be discarded 30 days after opening. Interviews with staff, including the DON and the Administrator, confirmed that these practices were inconsistent with the facility's policies and standard medical guidelines.
Incomplete Facility-Wide Assessment and Staffing Deficiencies
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment lacked details on staffing needs, including the absence of respiratory therapists, restorative therapy, social services, and dietary service staff. Additionally, it did not address staff competencies required to meet resident needs. The facility's assessment was undated and did not include the names or titles of staff involved in its completion. It also failed to document the ratios of direct care staff needed for specific care requirements such as tracheostomy care and respiratory therapy, which was not scheduled 24/7. During the survey, issues were identified, including insufficient nursing staff to meet resident needs, evidenced by missed treatments and inappropriate tracheostomy care. The facility's administrator acknowledged that the assessment is developed by the administrator and reviewed by the regional office and interdisciplinary team, with updates made annually or as needed. However, the assessment did not accurately reflect the facility's staffing needs or include all resources necessary for resident care.
Infection Control Deficiencies in PPE Use and Foley Catheter Management
Penalty
Summary
The facility failed to adhere to proper infection control standards, as evidenced by multiple instances of staff not performing hand hygiene between glove changes and not wearing appropriate personal protective equipment (PPE) for residents requiring Enhanced Barrier Precautions (EBP). Specifically, a Registered Respiratory Therapist did not perform hand hygiene between glove changes while caring for a resident with a tracheostomy, and Certified Nurse Aides (CNAs) did not wear gowns or change gloves appropriately while providing personal care to residents with pressure ulcers and other conditions requiring EBP. Additionally, the facility did not ensure that a resident's Foley catheter bag was kept off the floor, which is a critical measure to prevent infection. The catheter bag was observed lying on the floor, contrary to the facility's infection control policy. This oversight was noted during an observation and confirmed by interviews with the Infection Control Preventionist and a Licensed Practical Nurse, who both acknowledged the importance of keeping Foley bags off the ground to prevent infection. The facility's failure to follow its own Enhanced Barrier Precautions Policy and infection control procedures was further highlighted by the lack of proper signage indicating EBP requirements for certain residents. This lack of adherence to infection control protocols was confirmed through interviews with the Infection Control Preventionist, the Assistant Director of Nursing, and the facility Administrator, who all expressed expectations that staff should follow the established policies and procedures to ensure resident safety.
Failure to Administer and Document Vaccinations and PPD Skin Tests
Penalty
Summary
The facility failed to offer and provide vaccinations in accordance with the current CDC guidelines, resulting in deficiencies for several residents. Two residents did not receive influenza and pneumococcal vaccines, and three residents did not receive COVID-19 vaccines. Additionally, four out of five sampled residents did not receive a completed PPD skin test for tuberculosis. The facility's policies and procedures for vaccinations were not followed, as there was no documentation of informed consent or refusal for the vaccines and PPD skin tests in the residents' medical records. Resident #89, with moderate cognitive impairment and diagnoses including heart failure and kidney failure, was not offered influenza, pneumococcal, or COVID-19 vaccines, and there was no documentation of a PPD skin test. Resident #245, admitted to the facility, also lacked documentation of receiving these vaccines and did not complete the second step of the PPD skin test. Resident #47, with moderate cognitive impairment and multiple diagnoses, declined influenza and pneumococcal vaccines but had no documentation of COVID-19 vaccines or PPD skin tests, nor any informed consent or refusal for these. Resident #68, who was cognitively intact and had several diagnoses, declined influenza and pneumococcal vaccines and signed a declination form for the COVID-19 vaccine. However, there was no documentation of a PPD skin test or informed consent or refusal for it. Interviews with the Infection Control Preventionist Nurse and the Administrator revealed that the facility had the necessary supplies and expected staff to complete the immunizations and skin tests per policy, but these were not administered or documented as required.
Deficient Call Light System on 100 and 200 Halls
Penalty
Summary
The facility failed to ensure that all call lights were in working order, specifically on the 100 and 200 halls, where the call lights illuminated but did not produce an audible sound at the nurse's station. This deficiency was observed during a survey, where it was noted that Resident #20's call light was illuminated without any audible notification. Interviews with staff, including LPNs and CNAs, confirmed that the call lights on these halls only lit up without sounding, requiring staff to visually check for activated call lights. Additionally, there was no board at the nurse's station to indicate which call lights were on, and a ceiling light at the station only indicated that a call light was active on the hall. The Maintenance Director acknowledged awareness of the issue, noting that two call lights needed rewiring. Staff reported frequent malfunctions, and as a temporary measure, residents were given bells to ring, which were ineffective if staff were not nearby. The facility's policy required defective call lights to be reported promptly, but the lack of a reliable system for notifying staff of resident needs on the 100 and 200 halls was evident, leading to potential delays in response to resident requests.
Resident Dignity Compromised Due to Inadequate Staff Intervention
Penalty
Summary
The facility failed to ensure the dignity of a resident with severe cognitive impairment and multiple diagnoses, including heart failure, diabetes, and aphasia. The resident was observed sitting in the common area with their brief exposed, and staff did not intervene promptly to address the situation. The resident's care plan indicated a need for extensive assistance with activities of daily living, including dressing and hygiene, due to impaired balance and incontinence. Despite this, the resident was left exposed in the common area for an extended period. Interviews with staff revealed that the resident's family had provided loose-fitting dresses with splits, which contributed to the exposure when the resident moved their legs. A Certified Nurse Aide eventually covered the resident with a sheet, and a Licensed Practical Nurse stated that they would adjust clothing or use a blanket to maintain dignity. The facility's Dignity Policy emphasized treating residents with respect and ensuring their well-being, but the staff's delayed response in this instance did not align with these standards.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility staff failed to provide reasonable accommodations for the needs and preferences of three residents by not ensuring that call lights were within reach. Resident #51, who had moderate cognitive impairment and a contracted right hand, was unable to locate their call light, which was found on the floor and hidden by a privacy curtain. The resident expressed frustration at not being able to find the call light and having to call out for help, which sometimes went unnoticed by staff. Staff had previously attempted to locate the call light but were unsuccessful, leaving the resident without a means to request assistance. Resident #41, also with moderate cognitive impairment, was unable to reach their call light, which was clipped to a privacy curtain pushed back towards the wall. The resident reported having to beat on a table to get staff attention and expressed dissatisfaction with the response time when they did manage to use the call light. The resident felt that staff intentionally placed the call light out of reach, possibly due to frequent calls for assistance, and noted that staff often did not return after turning off the call light. Resident #58, with moderate cognitive impairment and a history of falls, was found calling out for help without a functioning call light. The resident's call light was illuminated but without sound, and staff passing by did not respond to the resident's verbal requests for assistance. The resident's care plan indicated a need for assistance with repositioning to prevent falls and skin breakdown, but staff failed to provide the necessary support. Interviews with staff, including an LPN and CNAs, revealed a lack of adherence to the facility's policy on call light accessibility and response times, contributing to the residents' unmet needs.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to investigate an allegation of staff-to-resident abuse involving a resident with moderate cognitive impairment and multiple diagnoses, including diabetes, high blood pressure, stroke, hemiplegia, and schizophrenia. The resident reported that a CNA hit them in the head with a closed fist during the night shift, which made them feel abused and scared. The resident had reported the incident to a nurse and a social worker, but the facility did not conduct a thorough investigation as required by their policy. The nurse who witnessed the aftermath of the alleged incident did not document it, citing a lack of knowledge about the protocol. The nurse sent the CNA home and reported the incident to the DON, but no documentation was made. The social worker interviewed the resident, who described the CNA as rough but did not report any signs of abuse. The social worker reported her findings to the Administrator, but no formal investigation was conducted. The DON and Administrator both acknowledged that no investigation took place, and the resident later denied the incident when interviewed. Despite the facility's policy requiring thorough investigation and documentation of abuse allegations, the facility deemed that no abuse occurred without conducting a proper investigation. The Administrator admitted that allegations of abuse and neglect should be investigated and reported to the Department of Health and Senior Services (DHSS).
Failure to Conduct Lab Tests and Neuro Checks as Ordered
Penalty
Summary
The facility failed to provide services in accordance with acceptable standards of practice by not obtaining necessary laboratory tests for a resident as per physician orders. Resident #27, who had severe cognitive impairment and diagnoses including dementia, stroke, and hemiplegia, had a physician's order for a comprehensive metabolic panel and pre-albumin tests to be conducted monthly. These tests were crucial for monitoring the resident's nutritional status and wound healing. However, the facility did not complete these lab tests until over two months after the order was given, with no documentation of refusal or change in the physician's order. Additionally, the facility did not adhere to its neurological assessment protocol for Resident #52, who had moderately impaired cognition and was at risk for falls. After a fall incident, the facility's policy required neuro checks to be conducted at specific intervals for 72 hours. However, the neurological evaluation flow sheet showed that 10 out of 12 opportunities for neuro checks were left blank, indicating a failure to perform the required assessments. This lapse occurred despite the resident being on close observation following the fall. Interviews with facility staff, including the Assistant Director of Nursing and Licensed Practical Nurses, confirmed that the expected procedures for lab requisitions and neuro checks were not followed. The staff acknowledged the importance of completing lab orders and neuro checks as per the facility's protocols, yet these were not executed as required, leading to deficiencies in the care provided to the residents.
Deficiencies in Wound Care Management
Penalty
Summary
The facility failed to follow acceptable nursing standards by not entering a treatment order for a resident's pressure ulcer into the computer system for nine days, resulting in the wound treatment not being administered as per physician orders. This oversight led to a delay in the resident's wound care, causing the wound to deteriorate. The resident, who had a history of quadriplegia and chronic pressure ulcers, was admitted to the facility with existing wounds. Despite the presence of a comprehensive care plan and physician orders, the treatment was not initiated until several days after admission due to a breakdown in communication and confirmation of orders within the facility. Another resident was observed without an ordered treatment in place, highlighting further deficiencies in the facility's wound care management. This resident, who was at risk for developing pressure ulcers, was found to have several open areas on the sacrum and right buttocks, which were not documented or treated as per the facility's protocols. The wound nurse was unaware of these wounds until the day of the survey, indicating a lack of communication and documentation regarding the resident's skin integrity. Interviews with facility staff, including the wound nurse, LPNs, and the Assistant Director of Nursing, revealed systemic issues in the communication and documentation processes. The facility lacked a wound nurse on weekends, leading to inconsistencies in wound care. Additionally, there were delays in confirming and entering physician orders into the electronic system, which contributed to the failure to provide timely and appropriate wound care. The facility's administrator acknowledged these deficiencies and expressed expectations for timely entry and adherence to physician orders and facility policies.
Resident Elopement Due to Inadequate Monitoring and Documentation
Penalty
Summary
The facility failed to ensure the safety and adequate monitoring of a resident identified as an elopement risk, resulting in the resident eloping from the facility. The resident, who was cognitively impaired and had a history of wandering, was found by police wandering outside the facility without shoes and was subsequently taken to the hospital. The facility did not document the elopement in the resident's medical record or care plan, and there was no evidence of a thorough investigation or reporting of the incident. The facility's elopement policy required staff to report missing residents promptly and document incidents in the resident's medical record. However, interviews with staff revealed a lack of communication and coordination during the shift change, with no report given to the day shift nurse. The night shift staff did not report the resident's absence, and the facility's camera system was not functioning, preventing a review of the elopement. The resident was last seen by staff the previous evening, and the facility did not realize the resident was missing until several hours later. The facility's failure to monitor the resident adequately and ensure the proper functioning of security measures, such as door alarms, contributed to the resident's elopement. The Administrator acknowledged that the incident was not reported or investigated thoroughly, as staff denied being assigned to the resident and did not provide information. The lack of documentation and communication among staff members further exacerbated the situation, leading to a delay in identifying and addressing the resident's elopement risk.
Failure to Administer Enteral Nutrition as Ordered
Penalty
Summary
The facility failed to provide appropriate administration of enteral nutrition for a resident dependent on a gastrostomy tube. The resident, who had a history of cerebral infarction, hemiplegia, acute respiratory failure, and dysphagia, was ordered a continuous tube feeding of Jevity 1.5 Cal at 70 ml/hr with water flushes every four hours. However, observations revealed that the resident's tube feeding pump was off for approximately five hours, with an empty bottle hanging since the previous day. This lapse in care was due to a lack of communication and staffing issues, as the nurse assigned to the resident's hall was unaware of the situation. Interviews with staff highlighted that the tube feeding should have been administered per the physician's order, and staff were expected to monitor and replace feeding bags as needed. The LPN responsible for the resident was not informed of the absence of a nurse on the resident's hall, leading to the oversight. The Assistant Director of Nursing and the Administrator confirmed that tube feedings should be administered as ordered, and the midnight shift nurse was responsible for changing the tubing every 24 hours. The deficiency was attributed to inadequate staffing and communication, resulting in the resident not receiving the prescribed nutrition for a significant period.
Deficiency in Dialysis Care Documentation and Monitoring
Penalty
Summary
The facility failed to ensure proper documentation and monitoring for residents receiving dialysis, specifically for one resident among the ten identified as receiving dialysis. The facility's policy for the care of residents with End-Stage Renal Disease (ESRD) was not adequately followed, as there was a lack of documented assessments and communication with the dialysis center. The resident's care plan did not specify the timing of dialysis sessions, transportation arrangements, or the monitoring responsibilities of the staff. Additionally, there was no physician order for dialysis, and vital signs and weight were not consistently recorded before the resident's dialysis sessions. Interviews with staff revealed inconsistencies in the process of documenting and communicating dialysis-related information. Licensed Practical Nurses (LPNs) mentioned that a communication form should accompany the resident to dialysis, but these forms were often incomplete or not returned. The Assistant Director of Nurses (ADON) and the Administrator acknowledged the need for a monitoring tool and a physician's order for dialysis, but these were not consistently in place. The facility was in the process of developing a new form for dialysis documentation, indicating a recognition of the existing gaps in their procedures. The resident involved had moderately impaired cognition and was receiving dialysis for ESRD. Despite the facility's policy requiring staff to be trained in the care of dialysis patients, there was a lack of consistent monitoring and documentation of the resident's condition. The resident reported not having vital signs or weight checked before dialysis, relying on the dialysis center to perform these assessments. The absence of a structured communication and monitoring system for dialysis care contributed to the deficiency identified by the surveyors.
Failure to Implement Pharmacist Recommendations for Drug Regimen Review
Penalty
Summary
The facility failed to ensure that the monthly drug regimen review (DRR) recommendations were followed in a timely manner for two residents, as required by federal and state guidelines. The consultant pharmacist's recommendations for Resident #48, who had moderate cognitive impairment, depression, and bipolar disorder, were not implemented. Specifically, the pharmacist recommended adding instructions to rinse the mouth after using Advair Diskus to prevent oral candidiasis, and to take Carvedilol with food to prevent sudden changes in blood pressure. These recommendations were not reflected in the resident's physician order sheet, despite the prescriber's agreement to implement them. Similarly, for Resident #14, who had moderate cognitive impairment, a thyroid disorder, and an anxiety disorder, the pharmacist recommended ordering TSH and FLP blood tests to evaluate the effectiveness of Levothyroxine and Atorvastatin therapy. Although the prescriber agreed to order these labs, there was no documentation or new orders in the resident's progress notes to indicate that the recommendations were followed. The facility's administrator acknowledged the expectation that pharmacy recommendations should be followed or documented with a rationale for not doing so.
Failure to Implement Pharmacist Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to implement the pharmacist's recommendations for gradual dose reductions (GDR) and proper documentation of behavior monitoring, side effects, and related diagnoses for the use of antipsychotic medications for two residents. Resident #48, who has moderate cognitive impairment, depression, and bipolar disorder, was prescribed antipsychotic medications Haldol and Seroquel, as well as the antidepressant Prozac. The pharmacist recommended performing an Abnormal Involuntary Movement Scale (AIMS) assessment every three months and conducting a GDR review, but there was no documentation of these actions being taken. Additionally, there was a lack of documentation regarding behavior and side effect monitoring in the resident's care plan and medication administration records. Resident #68, who was admitted with a cognitive communication deficit and anxiety, was prescribed Quetiapine (Seroquel) for anxiety. The pharmacist recommended clarifying and adding an appropriate diagnosis to support the antipsychotic use, but this recommendation was not acted upon. The resident's medication administration record showed that Quetiapine was administered twice daily without the necessary documentation or physician review of the pharmacy's recommendations. Interviews with the facility's Administrator revealed that the pharmacy recommendations were not reviewed by the physician, and there was an expectation for staff to have these recommendations reviewed, addressed, and signed by the physician. The Administrator also expected documentation with rationale for not following the recommendations, which was not present in these cases.
Significant Medication Errors Due to Non-Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the failure to administer medications per physician orders for three residents. Resident #246 did not receive Modafinil and Ozempic due to issues with prior authorization and insurance coverage. The facility was notified multiple times by the pharmacy about the need for prior authorization, but the medications were never filled, and there was no documentation indicating that the physician was informed about the missed doses or the need for prior authorization. Resident #47 also experienced medication administration issues, with Ozempic not being administered on certain dates without any documentation explaining the omission or notifying the physician. Similarly, Resident #195 had several medications, including Bupropion, Folic Acid, Plavix, Procardia, Zyprexa, and Carvedilol, that were not administered as ordered, with documentation gaps and no evidence of physician notification. Interviews with facility staff revealed a lack of consistent procedures for handling unavailable medications, including checking the e-kit, notifying physicians, and documenting the reasons for missed doses. The Assistant Director of Nursing and the Administrator both expressed expectations for staff to follow proper procedures, but the report indicates that these expectations were not met, leading to significant medication errors.
Failure to Conduct Routine Bed Rail Inspections
Penalty
Summary
The facility failed to ensure routine inspections of bed/side rails were completed as part of a regular maintenance program, leading to potential entrapment risks for three residents. The FDA guidance suggests evaluating the dimensional limits of gaps in hospital beds to mitigate entrapment risks, especially for vulnerable populations such as the elderly. The facility's policy requires maintenance staff to routinely inspect beds and related equipment, with results reported to the Quality Assurance and Performance Improvement (QAPI) committee. However, the facility did not adhere to these guidelines, as evidenced by the lack of documentation and assessments for the residents involved. Resident #47, who had moderate cognitive impairment and no documented use of side rails, was observed with bilateral side rails raised on multiple occasions. Despite the resident's use of side rails for positioning, there was no physician order or care plan addressing this use. Similarly, Resident #27, with severe cognitive impairment and dependence on assistance for mobility, had a care plan that included the use of side rails for bed mobility. However, the evaluation of entrapment risk did not include measurements, and observations showed the resident with top quarter rails up. Resident #344, who was alert with limited speech and had multiple diagnoses including a traumatic brain injury, was observed with bilateral quarter side rails raised. There was no documentation of a Nursing Bed Rail Observation/Assessment or physician order for side rails. Interviews with staff revealed that the maintenance department was responsible for safety checks, but there was no documentation of siderail measurements being completed, despite the Maintenance Director's awareness of entrapment risks and possession of the necessary tools. The Administrator expected siderails to be measured and checked for entrapment quarterly, but this was not documented.
Failure to Document and Execute Tracheostomy Care Orders
Penalty
Summary
The facility failed to obtain physician orders and complete tracheostomy treatment orders for a resident requiring tracheostomy care and maintenance. The resident, who had diagnoses including anoxic brain damage, bronchiectasis, and tracheostomy status, was admitted to the facility and later discharged to the hospital on multiple occasions. The facility's Tracheostomy Care Policy required documentation of procedures completed, the condition of the stoma and surrounding skin, the resident's tolerance of the procedure, and any provider notification of unexpected or abnormal findings. However, the resident's medical record showed a lack of documentation for changing suction equipment, suctioning secretions, and changing tracheostomy ties as ordered. The resident's Physician Orders included continuous oxygen monitoring, weekly and PRN changing of the suction system and tracheostomy equipment, and PRN suctioning of the airway. Despite these orders, the Medication and Treatment Administration Record (MAR/TAR) showed no documentation of these tasks being completed between specific dates. The resident experienced low oxygenation saturation during activities of daily living care and was given high flow oxygen and suctioning by nursing staff until EMS arrived. Similar incidents occurred during subsequent admissions, with no further orders obtained regarding tracheostomy care and no documentation of required tasks in the MAR/TAR. Interviews with facility staff, including a Registered Nurse, the Assistant Director of Nursing, the Director of Therapy Services, and the Director of Nursing, revealed that staff were expected to follow and document orders as written on the MAR/TAR. However, there was a lack of oversight and documentation, particularly during night shifts when nursing staff were solely responsible for tracheostomy care. The facility had a clinical meeting to verify order sets for each resident, but respiratory therapy order audits were not provided. The Director of Therapy Services expected tracheostomy orders to be re-ordered or changed per the resident's discharge orders when returning or arriving at the facility, but this was not consistently done.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan with specific interventions to prevent falls for a resident identified as high risk for falls. Despite a Fall Risk Assessment indicating the resident's high fall risk, and a care plan noting cognitive impairment and impulsivity, the resident was left unsupervised in a wheelchair. The resident attempted to reach for a blanket, resulting in a fall from the wheelchair, with the wheelchair resting against their back and their left leg caught underneath. Following the fall, the resident experienced a seizure and cardiac arrest, leading to their death after being transported to the hospital.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that staff consistently provided residents with two showers per week as scheduled. Of the nine residents sampled, eight had issues with receiving their showers as scheduled. Interviews with seven of these residents revealed that they preferred to have their showers as scheduled, and one resident's shower record showed missed showers. The facility's assessment indicated that the average daily census was 90, with a significant number of residents requiring assistance for bathing and other activities of daily living. The staffing ratio was 1:12 on days and 1:15 on nights, which was insufficient to meet the residents' needs for scheduled showers. Resident #3, who had moderate cognitive impairment and was dependent on staff for bathing, reported not receiving showers as scheduled and feeling cleaner after a shower. The resident's shower schedule indicated that they should receive a shower every Wednesday and Saturday, but records showed they received only 9 out of 15 scheduled showers. Similarly, Resident #2, who was in a persistent vegetative state and dependent on staff for all activities of daily living, missed two out of six scheduled showers. Other residents, including Resident #1, Resident #7, Resident #5, Resident #9, Resident #10, and Resident #11, also reported not receiving their scheduled showers, with some residents stating that staff did not ask if they wanted a shower or that there were not enough staff to provide showers. Interviews with staff members, including CNAs and the DON, confirmed that staffing shortages were a significant issue. CNA A mentioned that when there were only two CNAs for over 40 residents, it was challenging to complete all tasks, including giving showers. LPN B and the facility's Staffing Coordinator also acknowledged that the unit often ended up with only two CNAs, making it difficult to provide showers as scheduled. The DON and the Administrator both recognized that the staffing levels were insufficient to meet the residents' needs for scheduled showers, leading to the identified deficiency.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to report a resident's excoriated buttocks identified upon admission to the physician for a treatment order and failed to monitor the excoriation until several days later when a nurse identified two abrasions on the buttocks. The physician was notified, and a treatment order was started. The facility also failed to ensure that another resident with known pressure ulcers on the right foot wore bilateral heel protectors as ordered and was turned and repositioned timely. Additionally, three of the four residents sampled did not have care plans that identified their pressure ulcers, and all three of those residents reported that they did not always receive their treatments as often as ordered. Another resident with an order to wear multipodus boots was observed on two separate days not wearing the boots as ordered. The facility identified 19 residents with pressure ulcers, and problems were found with all four sampled residents. The census was 90. Resident #1's admission Minimum Data Set (MDS) showed the resident was admitted with a right hip fracture and was at risk for pressure ulcers. The resident's Comprehensive Skin Evaluation Assessment noted excoriation on the right and left buttocks, but no additional care options were documented. The resident's progress notes from 2/12/24 to 2/14/24 showed no documentation regarding the excoriation or if the physician had been notified. On 2/15/24, a nurse documented two abrasions on the resident's buttocks, and a treatment order was started. The resident's Treatment Administration Record (TAR) showed gaps in documentation, indicating that treatments were not consistently administered as ordered. Resident #3's admission MDS showed the resident was at risk for pressure ulcers and had multiple diagnoses, including hemiplegia and multiple sclerosis. The resident's care plan did not document the amount of assistance required for activities of daily living (ADLs) or pressure ulcers. The resident's TAR showed multiple instances where treatments were not documented as completed. Observations on 3/5/24 revealed that the resident was not turned and repositioned timely, and the protective boots were not applied as ordered. The resident reported that treatments were not always done daily. Resident #7's admission MDS showed the resident was at risk for pressure ulcers and had an unstageable pressure ulcer. The resident's TAR showed gaps in documentation, indicating that treatments were not consistently administered as ordered. The resident reported that treatments were sometimes done every other day instead of daily. Resident #2, who was in a persistent vegetative state, had an order for bilateral multipodus boots while in bed, but observations showed the resident was not wearing the boots on two separate days.
Staffing Shortages Lead to Missed Showers and Inadequate Resident Care
Penalty
Summary
The facility failed to consistently ensure a ratio of no more than 12 residents per Certified Nursing Assistant (CNA) on the day shift, as outlined in their Facility Assessment. This staffing shortfall led to multiple residents not receiving showers as scheduled and one resident with pressure ulcers not being cleaned or turned and repositioned in a timely manner. The census at the time was 90 residents, with the majority requiring assistance for activities of daily living (ADLs) such as dressing, bathing, transfers, eating, and toileting. Resident #3, who had multiple diagnoses including hemiplegia, multiple sclerosis, and pressure ulcers, was observed to be unclean and not turned or repositioned as required. Despite having a shower schedule, the resident received only 9 out of 15 scheduled showers. On the day of observation, the resident was found with a soiled brief and had not been attended to for over two hours, despite having turned on the call light. CNA A confirmed that due to staffing shortages, showers were often missed. Other residents also reported not receiving their scheduled showers. Resident #2, who was in a persistent vegetative state, received only four out of six scheduled showers. Resident #1, who preferred showers over bed baths, received five out of six scheduled showers. Similar issues were reported by Residents #7, #5, #9, #10, and #11, who all indicated that they did not receive their showers as scheduled due to insufficient staffing. Interviews with staff, including CNAs and the Staffing Coordinator, confirmed that the facility often operated with fewer CNAs than planned, leading to missed showers and inadequate care for residents.
Facility Fails to Maintain Comfortable Water Temperatures for Residents
Penalty
Summary
The facility failed to ensure residents had comfortable water temperatures for bathing, as observed, interviewed, and reviewed in records. Residents #14, #15, #16, and #17 complained that the water temperatures in their rooms were too cold for comfortable showers or bed baths. The facility's water temperature logs from October 6, 2023, through February 26, 2024, showed water temperatures in multiple resident rooms and community shower rooms were below the acceptable threshold of 105°F to 120°F. On March 6, 2024, the sampled residents' rooms still had water temperatures below the acceptable range, despite the facility's policy requiring periodic checks and maintenance of water temperatures within safe limits to prevent scalding and ensure comfort. Resident #14, with diagnoses including heart failure, pneumonia, anxiety, depression, schizophrenia, asthma, and respiratory failure, reported no hot water in their bathroom and refused to take showers due to the cold water. The surveyor confirmed the water temperature in Resident #14's bathroom was 75°F. Similarly, Resident #15, with a history of stroke and hemiplegia, also reported discomfort due to cold water, with the surveyor measuring the water temperature at 78°F. Staff members, including an LPN and a CNA, corroborated the residents' complaints, noting that the water temperatures had been cold for a long time and that they had informed the administration and maintenance director. Resident #16, with moderate cognitive impairment and a recent fracture, and Resident #17, with cancer and dementia, also reported cold water temperatures, refusing to take showers due to discomfort. The surveyor measured water temperatures in their rooms at 78°F and 80°F, respectively. The Maintenance Director, unaware of the required temperature range of 105°F to 120°F, confirmed the water was too cold for bathing. The Administrator acknowledged being unaware of the ongoing issue until a resident complaint in a council meeting on January 29, 2024, and was not informed that the problem persisted even after replacing a hot water heater.
Failure to Implement Fall Prevention Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a care plan that identified interventions to prevent falls for a resident who was assessed as high risk for falls. Despite the resident's cognitive impairment and history of impulsivity, the care plan did not address specific measures to prevent falls, such as ensuring the resident was in a highly visible area for close monitoring or assisting the resident to bed after activities. On one occasion, the resident was left unsupervised in a wheelchair in his room, leading to a fall when he attempted to reach for a blanket on his bed. The resident fell out of the wheelchair, which then rested against his back, and his left leg was caught underneath it. After being assisted back into the wheelchair, the resident had a seizure and went into cardiac arrest, ultimately leading to his death at the hospital. The resident's medical history included a stroke, hemiplegia, and a right decompressive hemicraniectomy, which required him to wear a helmet for protection. The resident was also receiving speech, occupational, and physical therapy. Despite these conditions and the high fall risk assessment score, the care plan did not include specific interventions to mitigate the risk of falls. The resident's spouse had informed the facility staff about the fall risk and requested that the bed be kept in the lowest position, but these precautions were not adequately implemented. Interviews with facility staff revealed that they were not fully aware of the resident's high fall risk or the need for constant supervision. The resident had a history of removing his helmet, and staff would remind him to put it back on. However, on the day of the incident, the resident was left alone in his room without his helmet, leading to the fall and subsequent medical emergency. The Director of Nursing acknowledged that the high fall risk score should have prompted the development of a more comprehensive care plan with specific fall prevention interventions.
Failure to Check Incontinent Residents Regularly
Penalty
Summary
The facility failed to ensure staff checked residents for incontinence at least every two to three hours, resulting in residents being left urine-saturated for extended periods. Resident #37, who is always incontinent of bladder and bowel and requires extensive assistance with activities of daily living, was found with a saturated incontinence brief and pad, with urine wetness extending from the buttocks to just beneath the shoulder blades. This observation was made during a wound care treatment, and the Director of Nurses (DON) acknowledged that the resident had likely not been checked within the last two to three hours. Resident #5, who is occasionally incontinent of urine and has chronic respiratory failure, muscle wasting, and other conditions, reported not being checked or changed since the previous night. The resident turned on the call light at 4:23 A.M. due to being wet with urine, but the night CNA did not respond. The resident was finally changed at 9:00 A.M. by a day shift CNA, who confirmed that the resident was completely saturated with urine, indicating that the resident had not been checked for an extended period. The DON stated that incontinent residents are expected to be checked every two to three hours.
Failure to Complete Wound Treatments as Ordered
Penalty
Summary
The facility failed to ensure wound treatments were completed as ordered for two residents, leading to deficiencies in care. Resident #31 had a physician-ordered wound treatment for a midline abdominal surgical site that was not completed on 5/4/24 and 5/5/24. Observations on 5/6/24 revealed that the dressing had not been changed since 5/3/24, and the wound showed signs of moderate drainage. The resident confirmed that no one had attempted to change the dressing over the weekend. The wound company Nurse Practitioner (NP) and the facility Wound Nurse (WN) confirmed that the dressing should have been changed daily, and the failure to do so was a recurring issue on weekends. Resident #28 also did not receive the required wound treatment for a left abdominal surgical site on 5/4/24 and 5/5/24. The resident's dressing, dated 5/3/24, had not been changed, and the resident confirmed that no one had attempted to change it. The WN and NP acknowledged that treatments were often not completed on weekends, and the NP scheduled her visits on Mondays to assess the wounds as soon as possible after the weekend. The WN stated that she had stocked the treatment cart before leaving on 5/3/24, but the supplies were locked in her office, and the nurse on duty did not have access to them. Interviews with the staff revealed systemic issues contributing to the deficiency. LPN B, who worked on 5/4/24, was the only nurse on duty and could not complete all treatments due to time constraints. LPN C, who worked on 5/5/24, did not have access to the necessary supplies and did not follow protocol to obtain them. The Administrator and Director of Nurses were aware of the issue but believed it had been resolved. The failure to complete wound treatments as ordered was a known problem, particularly on weekends, and had been previously discussed with the Administrator.
Failure to Implement Dietary Recommendations and Provide Adaptive Equipment
Penalty
Summary
The facility failed to follow their policy and promptly implement the Registered Dietician's (RD) dietary recommendations for residents experiencing severe weight loss. Specifically, the facility did not ensure that residents' heights were readily available to the RD, which is necessary for calculating body mass index (BMI) and ideal body weights (IBW). Additionally, the facility did not develop care plan interventions for residents with severe weight loss and failed to provide adaptive utensils, plate guards, and cups as ordered during meals. These deficiencies were observed in three out of four sampled residents with severe weight loss, affecting Residents #39, #40, and #42. Resident #39 experienced significant weight loss and had specific dietary recommendations from the RD, including the use of adaptive utensils and fortified foods. However, the facility did not implement these recommendations, and the resident was observed without the necessary adaptive equipment during meals. The resident's care plan did not reflect their preference for finger foods, and there was no documentation of contacting the physician for an appetite stimulant as recommended by the RD. The resident continued to lose weight, and the facility did not take appropriate actions to address the issue. Resident #40 also experienced significant weight loss and had recommendations for double portions at meals and the use of adaptive feeding equipment. However, the facility did not implement these recommendations, and the resident was observed without double portions or adaptive utensils during meals. The resident's menu slip did not reflect the RD's recommendations, and the dietary staff was unaware of the need for double portions. Similarly, Resident #42 had recommendations for fortified foods and double portions, but the facility did not implement these recommendations, and the resident was observed receiving regular portions. The facility's failure to follow the RD's recommendations and ensure proper documentation and communication contributed to the residents' continued weight loss and inadequate nutritional support.
Inadequate Training and Awareness of Ventilator Alarms
Penalty
Summary
The facility failed to ensure that nurses received adequate training for a resident's non-invasive mechanical ventilator and were aware of the availability of back-up ventilators. The resident reported that the ventilator alarmed repeatedly over two or three nights, and the nurses did not know how to address the issue, leading the resident to turn off the ventilator to sleep. The facility also did not obtain orders for the use of the non-invasive mechanical ventilator for the resident, who had a history of heart failure, pulmonary edema, pneumonia, anxiety, depression, schizophrenia, asthma, and respiratory failure. The resident's care plan included interventions for respiratory treatments, but there was no specific order for the non-invasive mechanical ventilator. Interviews with the resident and staff revealed that the nurses were not inserviced on the ventilator alarms, what the alarm numbers meant, or the location of back-up ventilators. The resident had to rely on a respiratory therapist to fix the ventilator issue after several nights of alarms. The Director of Nurses acknowledged that nurses should know how to respond to ventilator alarms and be aware of the back-up ventilators' location. However, it was unclear if the nurses had received the necessary training. The lack of training and awareness among the nursing staff led to the resident experiencing repeated ventilator alarms without proper intervention, compromising the resident's respiratory care and sleep quality.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to ensure that residents received adaptive eating equipment as ordered, which is essential for their eating independence and increased food/fluid intake. This deficiency was observed in three out of four sampled residents. Resident #39, who had severe cognitive impairment and functional limitations due to a stroke, was observed without the required adaptive utensils and cup during meals. Despite having orders for a built-up curved spoon and fork, a cup with handles and lid, and a straw, these items were not provided consistently, leading to the resident's dependence on staff for eating assistance. The dietary staff were responsible for providing these items but failed to do so regularly, as confirmed by the Dietary Manager and a Certified Nursing Assistant (CNA). The resident's care plan and physician's orders clearly indicated the need for these adaptive devices, but they were not followed through during meal times. Resident #40, who had no speech and rarely understood others, was also affected by the facility's failure to provide adaptive feeding equipment. Despite being independent in eating, the resident required a plate guard, built-up utensils, and a two-handled mug to facilitate self-feeding. Observations showed that these items were not provided during meals, and the resident was left to feed themselves without the necessary equipment. The care plan did not identify the resident's need for adaptive feeding equipment, and the dietary staff did not ensure these items were included on the meal tray, as confirmed by the resident's menu slip and observations. Resident #41, who had moderate cognitive impairment and required partial assistance with eating, also did not receive the necessary adaptive equipment. The resident's care plan and physician's orders included angled, built-up, and weighted utensils, a plate guard, Dycem, and two-handled cups, but these were not provided during meals. The resident reported difficulties with eating due to limited mobility in their hands and arms and preferred finger foods, which were not consistently provided. The Dietary Manager was aware of the resident's preference but did not discuss finger food alternatives with the resident or the Registered Dietician (RD). The resident often had to send back the regular tray and request a cheeseburger, leading to frustration and inadequate meal consumption. Observations and interviews confirmed that the adaptive equipment was not provided as required, and the resident had to keep and clean their own weighted spoon to ensure its availability.
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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