Laverna Manor Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Savannah, Missouri.
- Location
- 904 Hall Avenue, Savannah, Missouri 64485
- CMS Provider Number
- 265787
- Inspections on file
- 28
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Laverna Manor Health & Rehabilitation during CMS and state inspections, most recent first.
Staff failed to properly secure a sling to a mechanical lift during a transfer, resulting in a resident with severe cognitive and physical impairments falling to the floor and sustaining pain to the shoulders and hip. Despite facility policy and equipment guidelines requiring verification of secure sling attachments, staff did not confirm all loops were attached before moving the resident, leading to the incident.
Two residents with cognitive impairment and pain management needs had fentanyl patches go missing, and staff failed to follow protocol by not conducting or documenting investigations into the missing controlled substances. Leadership was either not notified or did not ensure proper follow-up, resulting in unaccounted-for narcotics and a lack of compliance with facility policy.
A resident with multiple complex medical conditions fell from a mechanical lift and complained of pain. Although a physician ordered the resident to be sent to the hospital for x-rays and evaluation, facility administration directed staff to use mobile x-ray services at the facility instead. The physician and medical director both expected the original order to be followed, but the facility did not comply.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident's prescribed Oxycodone was found missing due to inadequate inventory procedures, as staff only counted in-use narcotic sheets and not full, unopened ones. This failure in controlled substance reconciliation and documentation made it impossible to determine when the medication was taken or who was responsible, and the loss was not identified until mid-shift rather than at shift change.
A resident with a history of sexual outbursts and severe cognitive impairment in a memory care unit inappropriately touched another cognitively impaired resident in a common area. The incident occurred while a CMT was preparing medications nearby, and both residents were unsupervised in close proximity despite known behavioral risks. The facility's abuse prevention measures did not prevent the incident, resulting in a failure to protect residents from abuse.
The facility failed to ensure accurate MDS assessments for five residents, affecting care planning. Discrepancies included incorrect coding of tobacco use and anticoagulant medications, contrary to RAI Manual guidelines. The MDS Coordinator followed external advice without verification, leading to misclassification. The administrator expected accurate assessments, revealing a gap between expectations and practice.
The facility failed to provide written transfer notices to two residents transferred to the hospital, as required by policy. Despite having medical conditions necessitating hospital transfers, there was no documentation of written notices in their EMRs. Staff interviews revealed reliance on verbal communication rather than written notices, which was confirmed by the Social Services Director.
The facility failed to provide written bed hold notices to two residents transferred to the hospital, as required by policy. Despite the policy's requirement for written information on bed-hold rights and transfer details, neither resident received such notices. Interviews with staff revealed reliance on verbal notifications, with no written documentation found in the residents' records.
A facility failed to complete and submit a quarterly MDS assessment for a resident, who had not been assessed in over 120 days. The resident's last completed MDS was an annual assessment, and the subsequent quarterly assessment was listed as 'In Progress' but not signed or submitted. The MDS Coordinator admitted the oversight during an interview. The resident has a complex medical history including cerebral infarction and Alzheimer's dementia.
A resident with a history of aggression hit another resident unprovoked, leading to a failure in protecting the resident's right to be free from abuse. Both residents were severely cognitively impaired. The incident was not documented in the nurse's notes, and the LPN forgot to document a skin assessment or progress note. The facility's abuse prevention policy was not effectively implemented, and the incident was substantiated by the Administrator.
A cognitively impaired resident with a known elopement risk was inadequately supervised, leading to multiple attempts to leave the facility unassisted. Despite being placed on one-on-one supervision after an initial elopement, the facility failed to continue this supervision or secure the resident's bedroom window. The resident subsequently exited through a second-story window, resulting in fractures to both heels and the lumbar spine. The facility's policies on accidents, wandering, and supervision were not adequately followed.
The facility did not prepare menus in advance or offer residents the opportunity to choose their meal options, nor were alternatives posted for residents to see. This affected three residents in a facility with a census of 58.
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature. Observations showed that hot food was not served at an appetizing temperature for several residents, one resident received meat that was too hard to cut, and another was not offered condiments. These issues affected all sampled residents in the facility.
The facility failed to maintain food safety standards by not ensuring proper food temperatures during distribution, reheating, and transport. Food was not consistently checked for safe temperatures, and meal trays were reused for different residents. Additionally, dishwashing temperatures were not regularly documented. The facility census was 58 residents.
The facility failed to provide a dignified dining experience by serving meals on Styrofoam plates with plastic cutlery due to a malfunctioning dishwasher. Three residents, who had no cognitive loss and required assistance with daily activities, expressed dissatisfaction with the disposable dinnerware. The dishwasher had been malfunctioning for over two months, leading to the use of paper products. Staff confirmed the ongoing issue and residents' dislike for the disposable dinnerware, but the Administrator did not consider it a dignity concern.
The facility failed to prepare menus in advance and offer meal choices to residents, affecting their dining experience. Three residents, who were cognitively intact, reported not being able to choose their meals, and observations showed no menus or alternatives posted. Staff interviews revealed issues with meal ticket management and a lack of a standard alternative menu.
The facility failed to serve meals at a safe and appetizing temperature, with residents frequently receiving cold food. Additionally, meals were not always served with appropriate textures or condiments, despite availability. Staff confirmed ongoing complaints about food temperature and taste.
The facility failed to maintain food safety standards, with food temperatures not consistently checked or maintained, improper food coverage during transport, and unsanitary practices such as reusing meal trays without sanitization. Additionally, the facility did not adhere to dishwashing procedures, with incomplete temperature logs and untrained staff.
Failure to Secure Sling During Mechanical Lift Transfer Results in Resident Fall
Penalty
Summary
Facility staff failed to ensure a safe transfer of a resident with significant cognitive and physical impairments by not properly securing the sling to the mechanical lift during a transfer from bed to shower chair. The resident, who had a history of stroke, Alzheimer's disease, hemiparesis, and was assessed as requiring extensive assistance with all activities of daily living, was being transferred by two CNAs using a mechanical lift and mesh sling. According to interviews and documentation, one of the lower sling loops became detached from the lift during the maneuver, causing the resident to fall from the lift to the floor, resulting in pain to the resident's shoulders and left hip. The facility's policy on safe lifting and movement of residents required staff to use appropriate techniques and devices, ensure slings were properly attached, and verify secure connections before moving residents. The user manual for the mechanical lift also specified that all sling attachments must be checked before lifting and moving a patient. Despite these requirements, staff did not confirm that all sling loops were securely attached before proceeding with the transfer. Both CNAs involved in the transfer stated that they each attached loops on one side of the sling, but during the transfer, a loop on the left lower side came off, leading to the resident's fall. Following the incident, the resident was assessed by nursing staff and reported significant pain. The primary care physician was notified and initially ordered the resident to be sent to the hospital for evaluation, but administration directed that mobile x-rays be performed at the facility instead. The resident was subsequently treated for pain. Interviews with staff, including the DON and administrator, confirmed the expectation that staff ensure slings are securely attached before transfers, but this was not done in this case, directly leading to the resident's fall and injury.
Failure to Investigate and Account for Missing Fentanyl Patches
Penalty
Summary
The facility failed to ensure that two residents were free from misappropriation of their controlled pain medication, specifically fentanyl patches, when staff did not follow established protocols for investigating and accounting for missing patches. For one resident with significant cognitive loss and total dependence on staff for activities of daily living, a fentanyl patch was found missing during a scheduled change. The nurse and CNA searched the resident's environment but did not locate the patch, and although the Director of Nursing (DON) was notified via a communication application, no formal investigation or documentation was completed, and the nurse was not questioned further about the incident. A second resident, who had mild cognitive loss and required moderate assistance with daily activities, also experienced a missing fentanyl patch. The resident reported being in severe pain when the patch was discovered missing at the time of a scheduled change. The nurse applied a new patch, but no investigation was initiated, and the resident was not questioned about the missing patch. The DON was unaware of this incident and did not conduct or document an investigation. Interviews with facility leadership, including the DON, Medical Director, President of Clinical Operations, and Administrator, revealed that they expected missing narcotics to be reported, investigated, and documented. However, in both cases, there was a lack of follow-through on these expectations, and the missing patches were not accounted for or formally investigated, contrary to facility policy and standard practice for controlled substances.
Failure to Follow Physician's Order for Hospital Evaluation After Resident Fall
Penalty
Summary
The facility failed to follow a physician's order for a resident who experienced a fall from a mechanical lift. After the fall, the resident was found on the floor, covered with a blanket, and was assessed by an LPN. The resident, who had a history of cerebral infarction, Alzheimer's disease, hemiplegia, and other significant medical conditions, complained of pain in the shoulders and left hip. The physician was notified and gave a direct order to send the resident to the hospital for x-rays and evaluation. Despite the physician's order, facility administration instructed staff not to send the resident to the hospital, but instead to use mobile x-ray services at the facility. The LPN communicated this change to the physician, who reluctantly agreed to the use of mobile x-rays only if they could be performed within the hour, but expressed disagreement with the decision, stating that hospital x-rays are superior and that residents who fall from such a height should always be sent to the hospital for evaluation. The medical director and DON both stated that physician orders are expected to be followed, and the administrator indicated a preference for using contracted mobile x-ray services. The deficiency occurred because the facility did not adhere to the physician's explicit order to send the resident to the hospital following a significant fall, instead substituting mobile x-rays at the facility. This action was taken despite the physician's and medical director's expectations that such orders be followed, and without documented justification for not following the original order.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Resident from Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a significant quantity of the resident's prescribed narcotic medication, Oxycodone 5mg tablets, was found missing. The resident, who had diagnoses including depression, dementia, heart disease, and low back pain, was prescribed Oxycodone to be taken every eight hours. The missing medication was discovered after it had been received and verified by staff, but the loss was not identified until the middle of a shift rather than at shift change, as required by policy. The facility's investigation did not clearly state the reason for initiation, did not identify an alleged perpetrator, and failed to address inventory procedures or pinpoint when the medication went missing. Interviews with staff and review of facility policies revealed that, at the time of the incident, the process for counting controlled substances was inadequate. Staff only counted in-use sheets of narcotics and did not include full, unopened sheets in their shift-end counts, making it impossible to determine when the medication was taken or who was responsible. The count sheets and medications were accessible to all staff with access to controlled drugs, and the lack of comprehensive inventory controls prevented the facility from identifying the responsible party or the exact timing of the loss. The police investigation also noted the absence of proper inventory controls over the controlled medication.
Failure to Prevent Resident-to-Resident Sexual Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect a resident from sexual abuse when another resident, both with severe cognitive impairments, was able to physically touch the first resident inappropriately in a common area. The incident occurred when one resident, diagnosed with Alzheimer's disease, dementia with agitation, and delusional disorder, was walking through the memory care unit and was approached by another resident with Alzheimer's disease, a history of traumatic subdural hemorrhage, and mild cognitive impairment. The second resident, who had a documented history of behavior problems related to sexual outbursts and grabbing staff, reached out and ran a hand up the inside of the first resident's thighs, grabbing the genital area as the first resident walked by. At the time of the incident, the first resident had severely impaired cognition, displayed wandering behavior, and was sometimes understood in communication. The second resident also had severely impaired cognition and was noted to have behavior problems, including sexual outbursts, with care plan interventions instructing staff to redirect and distract the resident when inappropriate behaviors occurred. The incident was witnessed by a Certified Medication Technician (CMT) who was preparing medications in the common area and observed the inappropriate contact as it happened. Both residents were in the common area of the memory care unit, unsupervised in close proximity, despite the known behavioral risks associated with the second resident. The facility's abuse prevention policy required protection of residents from abuse by anyone, including other residents, but the measures in place at the time did not prevent the incident from occurring. The event was reported to the charge nurse, and both residents were assessed with no injuries noted.
Inaccurate MDS Assessments Affect Resident Care Planning
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for five residents, which could potentially affect their care planning and provision. The Director of Nursing confirmed the use of the Resident Assessment Instrument (RAI) Manual, and the facility policy required comprehensive assessments to be conducted according to the RAI Manual's criteria and timeframes. However, discrepancies were found in the coding of tobacco use and anticoagulant medication, which were not aligned with the RAI Manual guidelines. For one resident, the MDS did not reflect their tobacco use, despite observations and documentation indicating they were a regular smoker. The MDS Coordinator acknowledged this might have been an oversight. For other residents, the MDS inaccurately coded the use of anticoagulant medications, listing antiplatelet medications like aspirin and Plavix as anticoagulants, contrary to the RAI Manual's instructions. The MDS Coordinator mentioned receiving guidance from an external auditing company, which led to the incorrect coding. The inaccuracies in the MDS assessments were identified through interviews, record reviews, and observations. The MDS Coordinator admitted to following external advice without verifying it against the RAI Manual, resulting in the misclassification of medications. The facility's administrator expected the MDS to accurately reflect residents' conditions, highlighting a gap between expectations and practice.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices to two residents, R29 and R61, who were transferred to the hospital. This deficiency was identified during a review of records, interviews, and policy examination. The facility's policy requires that residents and their representatives receive written notice detailing the reason for transfer, the location, and information on how to appeal the transfer. However, this procedure was not followed for the two residents in question. Resident R29, who had medical diagnoses including chronic obstructive pulmonary disease, cerebral infarction, and hemiplegia, was transferred to the hospital in April. Despite the transfer, there was no documentation in the electronic medical record (EMR) indicating that a written notice of transfer was provided. Similarly, Resident R61, with diagnoses such as cystitis, dementia, and uterine cancer, was transferred to the hospital in July. Again, there was no evidence in the EMR of a written notice being given. Interviews with facility staff revealed that the process for emergent transfers involved verbal communication with the family and the Director of Nursing, but not the provision of written notices. The Social Services Director confirmed that the required documentation was not completed for these residents. This lack of adherence to policy potentially left residents and their representatives without crucial information regarding their transfers and their rights to appeal.
Failure to Provide Written Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide a written bed hold notice to two residents, R29 and R61, who were transferred to the hospital, as required by their policy. The policy mandates that residents or their representatives receive written information about bed-hold rights and limitations, payment policies, and transfer details prior to any transfer or therapeutic leave. However, during interviews and record reviews, it was found that neither resident received such a notice. R29, who was hospitalized for kidney stones, confirmed she did not receive a written notice, and her electronic medical record showed no evidence of one being provided. Similarly, R61, who was transferred to the hospital after being found outside, also had no documentation of receiving a written bed hold notice in her records. Interviews with facility staff, including the Administrator, RN1, and the Social Services Director, revealed a lack of adherence to the policy. RN1 described the process of transferring residents, which included verbal notifications to families but not the provision of written notices. The Social Services Director acknowledged that the nursing staff was responsible for providing the bed hold notice, but it was not done in these cases. The absence of written documentation for both residents indicates a systemic issue in the facility's process for handling emergent transfers and ensuring compliance with their own policies.
Failure to Complete and Submit Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed and submitted for processing for a resident, identified as R14, who had not received an assessment in over 120 days. This deficiency was identified during a review of records, interviews, and the Resident Assessment Instrument (RAI) manual. The facility's policy, revised in March 2022, mandates that comprehensive assessments be conducted according to the criteria and timeframes established in the RAI User Manual. The October 2023 RAI Manual specifies that quarterly non-comprehensive assessments are due within 92 days after the Assessment Reference Date (ARD) of the most recent assessment. R14's electronic medical record (EMR) showed that the last completed and accepted MDS was an annual assessment with an ARD of 05/16/24. A quarterly MDS with an ARD of 08/15/24 was listed as 'In Progress' but had not been signed and submitted as of 10/08/24. During a telephone interview, the MDS Coordinator acknowledged that the quarterly assessment for R14 was missed, despite being on the list for completion in August. The resident's medical history includes cerebral infarction, hemiplegia, dysphagia, esophageal obstruction, heart failure, Alzheimer's dementia, depression, hypothyroidism, atrial fibrillation, chronic respiratory failure, anxiety disorder, and pain.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when a resident with a history of aggression hit another resident unprovoked. Resident 42, who was severely cognitively impaired, was hit on the shoulder by Resident 23, who also had severe cognitive impairment and a history of physical aggression related to dementia. The incident occurred when Resident 23 entered Resident 42's room and hit her with a closed fist. This incident was not documented in the nurse's notes, and there was no immediate documentation of a skin assessment or progress note by the LPN who was informed of the incident. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the lack of documentation and follow-up after the incident. The LPN admitted to forgetting to document the incident due to being overwhelmed, and the Director of Nursing was not present at the time. The Administrator confirmed the incident was substantiated and that Resident 23 was placed on 1:1 supervision until discharged for a psychiatric evaluation. The failure to document and address the incident promptly had the potential to affect all residents in the secured unit.
Inadequate Supervision Leads to Resident Elopement and Injury
Penalty
Summary
The facility failed to provide adequate supervision for a cognitively impaired resident with a known elopement risk. The resident, who had been admitted with dementia and a history of exit-seeking behavior, was involved in multiple incidents where they attempted to leave the facility unassisted. On one occasion, the resident became combative when staff tried to redirect them back inside from an outside activity and managed to reach the parking lot. The resident also threw objects out of a dining room window and later eloped through the same window, which was six feet above the ground. Despite being placed on one-on-one supervision after the first elopement, the facility did not continue this supervision or secure the resident's bedroom window. Consequently, the resident removed the window screen and exited through a second-story window, approximately 13 feet above a paved sidewalk, resulting in fractures to both heels and the lumbar spine. The facility's policies on accidents, wandering, and supervision were not adequately followed, as the resident's high risk for elopement was not effectively managed. Interviews with staff revealed that the resident had been exit-seeking since admission, and family members had previously struggled to keep the resident inside at home. Staff observed the resident's attempts to open windows and doors, and although medication was administered to manage agitation, the resident's behavior persisted. The facility's failure to maintain one-on-one supervision and secure all potential exit points contributed to the resident's injuries.
Failure to Prepare and Post Menus in Advance
Penalty
Summary
The facility failed to ensure that menus were prepared in advance and developed to meet resident choices. Specifically, menus were not posted in advance, residents were not offered the opportunity to choose their menu options, and alternatives were not visibly posted for residents. This deficiency affected three out of five sampled residents, with the facility having a census of 58.
Deficiencies in Food Service Quality
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that hot food was not served at an appetizing temperature for four residents. Additionally, one resident was served meat that was too hard to be cut, and another resident was not offered condiments. These deficiencies were noted for all five sampled residents in a facility with a census of 58.
Deficiencies in Food Service Safety and Temperature Control
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, resulting in multiple deficiencies related to food storage, preparation, and service. Staff did not maintain food temperatures during distribution from the kitchen to the steam table and from the service point to resident delivery, allowing food to remain in the danger zone. Additionally, the facility did not check the temperature of reheated food on the steam table or food warmed in the microwave to ensure it was at a safe temperature. There was also a failure to cover all foods during transport to the special care unit. Furthermore, the facility reused meal trays for meal service delivery to other residents in the dining room, compromising safe food preparation. Lastly, the facility did not consistently check and document dishwashing temperatures on the temperature log daily. The facility census was 58 residents.
Use of Styrofoam Dinnerware Due to Dishwasher Malfunction
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents by serving meals on Styrofoam plates with plastic cutlery due to a malfunctioning dishwasher. This issue affected three residents who were observed and interviewed, all of whom expressed dissatisfaction with the use of disposable dinnerware. The residents, who had no cognitive loss and required varying levels of assistance with activities of daily living, preferred to eat on glass dishes. The facility's policy on dignity emphasizes providing a dignified dining experience, which was not upheld in this situation. The dishwasher had been malfunctioning for over two months, leading to the use of paper products for meal service. Staff interviews revealed that the dishwasher was fixed and broke down multiple times, resulting in the continued use of Styrofoam plates. The Dietary Director and CNAs confirmed the ongoing issue with the dishwasher and the residents' dislike for the disposable dinnerware. The Administrator acknowledged the dishwasher's problems but did not consider the use of Styrofoam a dignity concern, despite residents' preferences.
Failure to Provide Menu Choices and Alternatives
Penalty
Summary
The facility failed to ensure that menus were prepared in advance and that residents were given the opportunity to choose their meal options. This deficiency was observed when menus were not posted in advance, and residents were not offered choices or alternatives. This affected three of the five sampled residents, who were cognitively intact and capable of making their own meal choices. The facility's policy, 'The Dining Experience,' aimed to provide a person-centered dining experience, but this was not implemented effectively. Resident #2, who had a history of stroke and dysphagia, reported never being able to choose meals except at breakfast. Resident #3, with renal failure and other health issues, also stated they could not choose their meals. Resident #4, who had impaired vision and depression, mentioned being forgotten at lunch and having to wait for meals to be prepared. Observations showed no menus or alternative options were posted in the dining room, and meal tickets were mishandled, leading to confusion and delays in meal service. Interviews with staff revealed that the facility did not have a standard alternative menu, and meal tickets were often lost, causing residents to miss meals. The Dietary Manager admitted that menus were not posted since new ownership took over, and residents were informed of food choices through a printed ticket system. The Administrator was unaware of the requirement to post menus, indicating a lack of communication and organization in meal service management.
Deficiency in Meal Service Quality and Temperature
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that hot food was not served at an appetizing temperature for several residents, with meals often arriving cold. For instance, one resident reported receiving their meal an hour late, resulting in cold food. Another resident expressed dissatisfaction with the quality and temperature of the food, noting that it was generally not good and often cold. Additionally, the facility did not provide appropriate food textures and condiments as per residents' preferences and dietary needs. One resident was served a hamburger on bread without the desired condiments like pickles and cheese, despite the facility having these items available. Another resident was served meat that was too hard to cut, indicating a failure to provide food that met the required texture and consistency for safe consumption. The facility's failure to maintain proper food temperatures was further evidenced by a test tray showing food items below safe holding temperatures. Staff interviews confirmed that residents frequently complained about the temperature and taste of the food, with trays often left sitting out before being served. The dietary manager acknowledged the issue with food temperatures and the lack of condiments, while the administrator was aware of complaints but attributed them to age-related loss of taste buds.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, resulting in multiple deficiencies related to food storage, preparation, and service. Observations revealed that food temperatures were not consistently maintained within safe ranges during distribution from the kitchen to the steam table and from the service point to resident delivery. Specifically, several food items, such as pureed carrots, ground chicken, and pureed chicken, were found to be below the required serving temperature of 135 degrees Fahrenheit. Additionally, the facility did not consistently check the temperature of food reheated in the microwave, and there was a lack of documentation for serving temperatures, which were only recorded for cooking temperatures. The facility also failed to ensure proper food coverage during transport, as observed with hall trays where desserts and soups were not covered. This lack of coverage was confirmed by interviews with staff, who indicated that only the main dish was typically covered. Furthermore, the facility did not maintain sanitary conditions during meal service, as evidenced by the reuse of meal trays without proper sanitation, which could lead to cross-contamination. The Dietary Manager acknowledged that reusing trays without sanitization was not sanitary. Additionally, the facility did not adhere to its own policies regarding dishwashing procedures. The dishwasher temperature log was not consistently completed, with records showing it was only filled out once a day instead of the required three times. The Dietary Manager admitted that the staff was new and unaware of the need to record temperatures on the dishwasher sanitation log. These deficiencies highlight significant lapses in maintaining food safety and sanitation standards, as required by local, state, and federal regulations.
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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