Lebanon North Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Lebanon, Missouri.
- Location
- 596 Morton Road, Lebanon, Missouri 65536
- CMS Provider Number
- 265123
- Inspections on file
- 39
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Lebanon North Nursing & Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple mental health diagnoses, who was known to have episodic behavioral outbursts, became upset after a visit to the business office. When the resident refused to return to the unit and began swinging arms, a NA positioned behind the resident and held the resident’s arms and hands up behind the back in an arrest-like manner while walking the resident from the front area back to a special care unit, during which the resident cried continuously. Witness CNAs reported that the BOM walked alongside and attempted to calm the resident but did not intervene to stop the hold. Facility policies required residents to be free from physical restraints unless ordered by a physician for a specific medical symptom, yet there was no restraint order, no care plan for restraint use, and no documentation of the restraint in the medical record. The facility physician later characterized the maneuver as an excessive and unacceptable physical restraint.
Multiple residents with intact cognition and significant physical care needs reported that certain staff, particularly one NA, were rude, loud, and dismissive, failed to return after agreeing to help, and sometimes told residents to be quiet instead of responding promptly to requests or call lights. One resident described being left in a heavily saturated incontinence brief that had not been changed all day, while CNAs and an LPN confirmed ongoing shortages of briefs and wipes, use of incorrect sizes, and residents sometimes being found soaking wet in the morning. Another resident reported feeling uncomfortable when staff talked over them about personal dating lives during incontinence care, and staff interviews confirmed that such conversations occurred despite expectations not to talk about personal lives or over residents during care. A further resident stated that an NA ignored a request to remake an improperly made bed, and a CNA reported witnessing the same NA inappropriately restrain a resident by holding the resident’s arms behind the back while the resident cried and verbally refused, all of which conflicted with stated expectations that staff respect residents’ dignity, preferences, and rights.
A resident with chronic severe pain, osteoporosis with pathological fracture, and insomnia repeatedly reported that a bed mattress with a pronounced dip caused significant back pain, difficulty positioning, and poor sleep. The care plan required assessing pain’s impact on sleep and positioning for comfort, and the MDS documented almost constant severe pain interfering with daily activities. The resident stated they had informed multiple staff and yelled out at night due to the bed pain. A CNA confirmed the resident’s complaints about a dip in the mattress and noted the mattress could not be flipped. The DON acknowledged the resident slid into a “hole” in the bed and yelled out at night but had not inspected the mattress, and the Administrator was unaware of the issue, despite stating staff could have changed the mattress and should report bed concerns. The facility did not correct the mattress problem, resulting in continued discomfort and an uncomfortable environment for the resident.
The deficiency involves a failure to report an allegation of staff-to-resident abuse involving an unauthorized physical restraint to the state agency. A resident with severe cognitive impairment and multiple mental health diagnoses became upset in the business office and began swinging their arms. A CNA then moved behind the resident, placed the resident’s arms behind their back "like handcuffs," and escorted the resident back to the unit while the resident cried. Other staff, including a CNA and an LPN, witnessed the restraint and recognized it as inappropriate physical contact. Staff interviews confirmed they were trained that physically restraining a resident constitutes a restraint and that any allegation of abuse or neglect must be reported promptly to the DON/Administrator and to the state. Although a CNA reported the incident internally, the DON and another nurse decided on their own that it was not abuse or neglect and did not notify the state, and records review confirmed there was no self-report to the state regarding this allegation.
A resident with severe cognitive impairment and multiple mental health diagnoses, who had a care plan directing calm, non-restrictive behavioral interventions, became upset after a visit to the business office. A nurse aide reported that when the resident began swinging and hitting, the aide restrained the resident from behind with the resident’s arms held behind the back while walking the resident back to the unit, causing the resident to cry; another CNA described the hold as similar to being arrested and stated the resident should not have been taken off the locked unit. Although the facility’s abuse policy requires investigation and measures to prevent further potential abuse, the DON acknowledged that no formal, written investigation of this alleged abuse/restraint incident was completed, and no documented protective steps were provided.
The facility failed to provide pressure ulcer care according to standards of practice for two residents with multiple pressure injuries. One resident was admitted with a left heel eschar and later developed buttock and coccyx wounds, yet weekly skin assessments often documented intact skin, wound assessments were missed, treatment orders were incomplete or not updated to match wound care specialist recommendations, and several ordered treatments were not administered or documented. Another resident with sacral, heel, calf, and foot pressure ulcers had detailed treatment plans from a wound care company, but the POS was not updated to reflect these orders, weekly skin assessments were inconsistent or nonspecific, and treatment records showed missed or incomplete wound care, with incorrect dressings found in place during specialist visits. Across both cases, nursing documentation lacked accurate, timely wound assessments and failed to ensure that current, appropriate orders were followed and recorded.
A resident with severe cognitive and mobility impairments, who was care planned for two-person assistance during personal care, fell from bed and sustained a head laceration and neck fracture when only one staff member was actively providing care. Staff interviews revealed a lack of awareness of the care plan requirements, and the facility lacked a process to ensure staff were informed of each resident's care needs, directly leading to the incident.
A resident with a signed DNR order did not have their code status consistently documented across the EMR, face sheet, and door sticker. Due to delays in updating records, staff initiated CPR when the resident became unresponsive, as available documentation indicated full code status. Staff interviews confirmed that delays and inconsistencies in updating advance directives contributed to the failure to honor the resident's wishes.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident admitted with bilateral groin surgical wounds did not have hospital wound care orders transcribed into the MAR, and staff failed to document wound care or notify the physician in a timely manner about the resident repeatedly removing dressings and changes in wound condition. The care plan was not updated to reflect wound care needs, and there was no evidence of a wound treatment or skin assessment policy being provided. Staff interviews confirmed inconsistent documentation and lack of physician notification regarding wound care issues.
A resident with urinary retention did not have key events documented in their medical record, including physician contact for catheter orders, a catheterization attempt, hospital transfer, and family notification of a change in condition. Staff interviews confirmed that these actions were either not documented or not performed according to facility policy, resulting in incomplete and inaccurate medical records.
Staff were not educated on enhanced barrier precautions (EBP) and did not use required PPE, such as gowns, when providing high-contact care to two residents—one with a urinary catheter and one with a wound. Multiple CNAs and an LPN provided care using only gloves, and staff reported not receiving EBP education or being able to locate gowns. The care plans for these residents did not address EBP, and the facility did not ensure PPE was readily available at the point of care.
A resident who required extensive assistance with bathing did not receive showers or baths as preferred or documented in their care plan, with records showing long periods without showers being offered or completed. Staff interviews revealed there was no designated shower aide or schedule, and showers were provided only once per week due to short staffing, contrary to facility policy and the resident's needs.
A resident with dementia and significant ADL needs did not consistently receive timely showers or bathing assistance, as required by their care plan. Staff interviews revealed the absence of a shower aide, lack of a shower schedule, and short staffing, resulting in showers being provided only about once per week and incomplete documentation of care. The DON acknowledged that resident shower preferences had not been updated and that monitoring was inconsistent.
A resident reported an allegation of sexual abuse to facility staff, but the incident was not reported to the State Survey Agency within the required two-hour timeframe. Despite the resident's distress and the facility's policy mandating immediate reporting, the Administrator and corporate QA Nurse advised waiting for hospital findings, leading to a delay. Interviews with staff confirmed the failure to adhere to reporting protocols.
A deficiency was identified due to the presence of accident hazards and inadequate supervision in a nursing home area. The facility failed to ensure a safe environment, lacking sufficient oversight to prevent accidents, thus compromising resident safety.
A resident with a left leg amputation was not properly secured in a facility van, leading to an injury when they slid out of their wheelchair during transport. The transportation staff failed to fasten the shoulder/lap seat belt due to obstruction by other wheelchairs, despite previous training and warnings. The incident highlighted the absence of a specific policy for resident transport in the facility van.
The facility failed to ensure an RN was on duty for eight consecutive hours on two specific days. The Nurse Monthly Staff Schedule and timecards confirmed the absence of RN coverage. Interviews with the DON, MDSC, and Administrator revealed the facility's non-compliance and difficulties in hiring RNs.
The facility failed to provide an ongoing group or individual activity program to support the physical, mental, and psychosocial well-being of three residents on the secure unit. Staff did not document alternate approaches or one-to-one activities for residents who refused scheduled activities, and there were no scheduled activities or specific resident interactions on the secure unit.
The facility failed to provide timely Notice of Medicare Non-Coverage (NOMNOC) for two residents, resulting in a deficiency. Both residents did not receive the required NOMNOC or Advanced Beneficiary Notice of Non-coverage (ABN) before the last date of services. Interviews revealed a lack of awareness and understanding of the ABN process among staff, leading to the oversight.
The facility failed to complete a significant change assessment within 14 days for a resident admitted to hospice services. The MDS Coordinator acknowledged the oversight, and the DON confirmed the requirement for timely assessments when there is a significant change in a resident's condition.
The facility failed to refer a resident with new mental disorder diagnoses for a Level II PASARR evaluation. The resident had been diagnosed with anxiety disorder, major depressive disorder, and bipolar disorder, but the facility did not update the PASARR screening or notify the state authority for re-screening.
The facility failed to ensure ongoing pre and post dialysis communication for a resident receiving dialysis three times a week. The review of the resident's Dialysis Transfer Form showed inconsistent completion, and staff did not follow up with the dialysis center to ensure there were no issues. The DON confirmed the importance of ongoing communication before and after dialysis services.
The facility failed to document clinical rationale for PRN psychotropic medication orders longer than 14 days for two residents. One resident had a PRN order for Xanax without proper review or discontinuation, and another resident under hospice care had a PRN order for lorazepam without documented rationale or review.
The facility failed to include a resident's bathing preferences and behaviors in the care plan, despite the resident's known aversion to showers and the calming effect of music. Staff were aware of these preferences but did not communicate them to the MDS Coordinator or document them in the care plan, leading to inconsistent care during bathing.
Unauthorized Physical Restraint Used on Behaviorally Challenging Resident
Penalty
Summary
The deficiency involves staff physically restraining a resident by holding the resident’s arms behind the back while escorting the resident from the business office to the special care unit, contrary to facility policy and without a physician’s order. Facility policies on Resident Rights and Abuse Prevention state that residents have the right to be free from physical restraints except when used to treat a specified medical symptom as part of a total program of care, and that restraints must be authorized in writing by a physician or, in an emergency, by designated professional personnel with immediate notification to the physician. The policies also emphasize that residents must be free from abuse and that physical restraints are prohibited for discipline or staff convenience. In this case, there was no care plan for restraint use, no physician’s order for a physical restraint, and no documentation of restraint use in the resident’s record. The resident involved had diagnoses including bipolar II disorder, anxiety disorder, personality disorder, epilepsy, and parkinsonism, with severely impaired cognition per the MDS. The care plan identified socially inappropriate or disruptive behaviors, difficulty understanding others, and disorganized thinking related to mental health issues and intellectual disabilities. Interventions included maintaining a calm environment, avoiding overstimulation, using calm and reassuring approaches, assessing for underlying needs, and allowing the resident to settle when upset. The resident’s progress notes described episodes of behavioral outbursts such as demanding immediate attention for medications or personal needs and occasionally throwing personal belongings, followed by later apologies, but did not include any plan or authorization for physical restraint. On the day of the incident, a nurse aide (NA B) was in the business office with the resident during a Social Security call. After the call, NA B and the Business Office Manager (BOM) attempted to get the resident to return to the unit, but the resident refused and became increasingly upset. NA B reported that outside the business office the resident began swinging arms and hitting NA B on the head, at which point NA B wrapped arms around the resident from behind, placing the resident’s arms behind the mid-back to prevent further hitting, and maintained this hold while walking the resident back to the unit. Multiple CNAs who witnessed the event described NA B holding the resident’s arms and hands behind the back “like being arrested,” with shoulders raised, while the resident cried throughout the walk from the front area to the special care unit. Witnesses stated that the BOM walked beside them and attempted to calm the resident but did not stop the physical hold. The facility physician later stated that staff should not physically restrain residents without appropriate indications, confirmed there was no order for a physical restraint, and characterized the maneuver used by NA B as a physical restraint that was excessive and not acceptable. The resident’s care plan and medical record contained no documentation authorizing or describing the use of this type of physical restraint for behavioral management. The quarterly MDS showed the resident was physically independent in transfers and walking, and there was no indication that a restraint was needed for mobility or safety support. The facility’s DON acknowledged that holding a resident’s hands behind the back “may or may not be considered abuse” and stated that the determination depended on intent and whether marks were left, but also acknowledged that staff had reported the incident as possible abuse. The DON and an LPN decided on their own that the incident did not constitute abuse or restraint and did not conduct an investigation into the allegation, despite staff reports that the resident was upset and crying and that the hold resembled an arrest-type restraint. No documentation was made in the resident’s progress notes about the restraint used when returning from the business office to the special care unit.
Failure to Ensure Dignity, Respect, and Adequate Incontinence Care for Multiple Residents
Penalty
Summary
The deficiency involves multiple failures to honor residents’ rights to dignity, respect, self-determination, and appropriate care, particularly related to staff interactions, incontinence care, and response to call lights. Resident #4, who is cognitively intact with significant mobility limitations, pain, osteoporosis with pathological fracture, and urinary incontinence, reported that a nurse aide (NA B) repeatedly failed to return after agreeing to assist and ignored requests for help, including assistance to prepare for scheduled smoking breaks. Resident #4 described NA B yelling down the hall, accusing the resident of “putting things in my mouth,” and characterized NA B as rude, lacking compassion, and potentially aggressive. The resident also reported that another CNA told the resident to be quiet when calling for help, that staff often told the resident to wait and then did not return, and that the only way to get staff attention was to yell. Progress notes documented that the resident frequently yelled and screamed for help if not assisted right away, and Resident Council minutes noted call lights not being responded to on time. Resident #4 further reported significant issues with incontinence care and supplies. The resident stated that staff did not check on or change incontinence briefs for extended periods, leading to a brief that, when weighed with a CNA, was found to weigh about one to 1.3 pounds, and that this was reported to LPNs and the DON, who allegedly responded dismissively. The resident reported being left without appropriate briefs, being out of briefs the prior day, and that staff used briefs that were too big or too small because the facility frequently ran out of the correct size. CNAs corroborated that the facility had ongoing supply shortages of briefs and wipes, that several residents did not have enough briefs, that staff sometimes had to use bariatric or incorrect sizes, and that wipes were unavailable at times, requiring use of wet paper towels and washcloths. One LPN stated that residents may be left soiled at night because some mornings residents were found soaking wet. The DON acknowledged a shortage of briefs, ordering constraints tied to budget, and that staff were instructed to place only a few briefs in rooms at a time. Resident #5, cognitively intact with osteoporosis, anxiety, depression, COPD, and frequent incontinence, reported that NA B was rude and talked over the resident about the aide’s personal dating life while the resident was being changed, making the resident uncomfortable and leading the resident to request that NA B no longer provide care. LPN J confirmed that Resident #5 complained about NA B’s rudeness and that NA B and another CNA had an inappropriate conversation about dating while providing incontinence care. LPN J also reported that residents had complained about NA B being rude, and had personally heard NA B say impatiently in front of the nurse’s desk, “My God, [resident’s name], what do you want now?” Other staff, including a CMT and CNA, stated that staff were expected not to yell at residents, not to talk about personal lives, and not to talk over residents during personal care, indicating that NA B’s conduct was inconsistent with these expectations. Resident #6, cognitively intact with paraplegia, depression, and chronic pain, reported that when the resident asked NA B to remake an improperly made bed, NA B became irritated, walked off to use a phone, did not return to complete the task, and subsequently ignored the resident when passing by. Additionally, CNA D reported witnessing NA B inappropriately restrain another resident (Resident #2) by holding the resident’s arms and hands behind the back “like he/she was being arrested” while walking the resident from the business office manager’s office to the special care unit, during which the resident was upset, crying, and verbally refusing. CNA D stated that other staff witnessed this incident and that it was reported to the DON. Across these events, the administrator and DON both articulated expectations that staff should not tell residents to be quiet, should not yell at or talk over residents, should not ignore residents, and should respect residents’ wishes, but the described staff behaviors and supply failures did not align with those expectations and contributed to the identified deficiency in resident rights and dignity. Additional documentation supports a pattern of delayed response to residents’ needs and disregard for resident comfort and preferences. Progress notes for Resident #4 described frequent yelling for help when assistance was not provided promptly, and staff interviews indicated that some staff told the resident that they were not the only resident needing care and that the resident should not yell because it disturbed others. The DON stated that if a call light was not answered as quickly as the resident wanted, the resident should not be yelling, and that staff encouraged call light use, while Resident Council minutes documented concerns about call lights not being answered timely. For Resident #5, progress notes described the resident as demanding and yelling out “help” after a few minutes when slightly incontinent, and preferring to stay in the room with the door closed, but there was no indication that staff adjusted their approach to address the resident’s expressed discomfort with staff conversations during care. Collectively, the report details multiple instances where staff actions and inactions, including rude and dismissive communication, failure to respond promptly to requests and call lights, inadequate incontinence care, and inappropriate physical handling, failed to uphold residents’ rights to dignity, respect, and appropriate care as outlined in facility policy and resident care plans.
Failure to Address Defective Mattress Causing Ongoing Pain and Discomfort
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, comfortable, and homelike environment for a resident with chronic severe pain by not addressing a defective mattress that contributed to the resident’s discomfort and difficulty sleeping. The resident, cognitively intact and admitted with diagnoses including right hip pain, left shoulder pain, osteoporosis with pathological fracture, insomnia, and unspecified pain, had a care plan that called for acknowledging pain, assessing its effects on sleep and activity, monitoring non-verbal pain signs, and positioning for comfort. The resident’s MDS documented almost constant severe pain (rated 8/10), frequent interference with day-to-day activities, and occasional sleep disturbance due to pain, with both scheduled and PRN pain medications in use. Progress notes showed the resident yelling for assistance to get into bed. During interviews, the resident repeatedly reported that the bed had a dip or “hole” that caused significant lower back pain, made it difficult to get out of bed, and prevented decent sleep, stating that staff were aware because the resident had told several staff members and yelled out at night due to the pain. A CNA confirmed that the resident complained of hip and back pain and specifically of a dip in the mattress that the resident fell into, and noted the mattress could not be flipped and that the resident had slept in a recliner for a few nights to see if that helped. The DON acknowledged that the resident slid down in bed, yelled out at night about slipping into a hole in the bed, had not personally inspected the mattress, and believed any bed issues should be in the maintenance book, while also stating the resident should have a comfortable mattress. The Administrator reported being unaware of the bed-related pain or nighttime yelling and stated staff could have changed the mattress and should notify nursing or housekeeping if a resident had a bed concern. Despite these reports and the resident’s documented chronic severe pain, the mattress issue was not addressed, resulting in the resident’s ongoing discomfort and inability to rest comfortably.
Failure to Report Alleged Staff Use of Unauthorized Physical Restraint
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of staff-to-resident abuse in the form of an unauthorized physical restraint to the State Survey Agency (DHSS). The facility’s abuse prevention policy states that residents have the right to be free from abuse, neglect, misappropriation of property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat medical symptoms. The policy also emphasizes that restraints are prohibited when used for discipline, convenience, or to unnecessarily inhibit a resident’s freedom of movement. Despite this, an incident occurred involving a resident with multiple mental health diagnoses and severe cognitive impairment, where staff actions constituted a restraint without an order or care plan, and the allegation was not reported to DHSS as required. Resident #2 had diagnoses including bipolar II disorder, anxiety disorder, personality disorder, epilepsy, and parkinsonism, with care plan interventions focused on managing socially inappropriate or disruptive behaviors through calm approaches, environmental modifications, reassurance, and communication strategies. The resident’s MDS showed severely impaired cognition but independence with mobility. On the day of the incident, the resident became upset in the business office after a phone call and while receiving printed pictures, escalating into a temper tantrum. According to NA B, when the resident began swinging their arms and hitting the aide on the head, the aide used prior behavioral health training to wrap their arms around the resident from behind, tucking the resident’s arms behind the mid-back and restraining the resident while walking them back to the unit, causing the resident to become upset and cry. Another CNA and an LPN described the resident’s hands being placed behind the back “like handcuffs” or “like being arrested” as the resident cried while being escorted. Multiple staff interviews showed that facility staff understood that physically restraining a resident, including holding arms down or behind the back, constituted a restraint and that any allegation of abuse or neglect, including physical restraint, must be reported immediately to the DON/Administrator and to the state within the required timeframe (one to two hours). CNA E reported the incident to the DON, and the DON acknowledged that aides reported the resident was irate and that NA B was restraining the resident by holding the resident’s arms. The DON and another nurse stated they ruled out abuse and neglect on their own and did not contact the state. Review of facility records and DHSS records confirmed there was no documentation of notification or self-report to DHSS regarding this allegation of abuse in the form of restraint use without an order, without a care plan, and for staff benefit, resulting in the cited deficiency for failure to timely report suspected abuse.
Failure to Investigate and Document Alleged Staff-to-Resident Restraint
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of staff-to-resident abuse/restraint was fully and timely investigated and that protective measures were documented and implemented during the investigation. Facility policy on Abuse Prevention, revised 11/28/16, states that residents have the right to be free from abuse, neglect, exploitation, involuntary seclusion, and any physical or chemical restraint not required to treat medical symptoms, and that the facility must take specific actions in response to alleged violations, including preventing further potential abuse while an investigation is in progress. Despite this policy, the facility did not complete or document a formal investigation after an incident in which a staff member physically restrained a resident. The resident involved had been admitted with diagnoses including Bipolar II disorder, anxiety disorder, personality disorder, epilepsy, and parkinsonism, and had a care plan addressing socially inappropriate or disruptive behaviors, difficulty understanding others, and disorganized thinking related to mental health issues. The care plan directed staff to avoid overstimulation, maintain a calm environment and approach, assess whether behaviors endangered the resident or others, and use communication and environmental strategies such as speaking calmly, orienting the resident, and providing comfort measures. The resident’s MDS showed severely impaired cognition but independence with mobility, and progress notes described the resident as alert to self, autistic, occasionally having behavioral episodes when demands were not immediately met, sometimes throwing belongings, and later apologizing. According to staff interviews, a nurse aide (NA B) was with the resident in the business office for a Social Security call, after which the resident refused to return to the unit and became increasingly upset when given printed pictures. NA B reported that outside the business office the resident began swinging arms and hitting NA B on the head, and NA B responded by wrapping arms around the resident from behind, under the resident’s arms, with the resident’s arms tucked behind mid-back, restraining the resident while walking back to the unit, which caused the resident to cry. Another CNA witness stated that the resident should not have been taken off the locked unit, observed NA B yelling at the resident, then getting behind the resident and holding the resident’s arms behind the back “like being arrested,” with the resident crying while being walked in this position, and noted that the BOM walked beside them and attempted to calm the resident. The CNA reported the incident to the DON. The DON later acknowledged that no investigation was completed and that he and an LPN had personally “ruled out” abuse and neglect without a written investigation, and the administrator stated she would have expected a written investigation and that it was the DON’s or her responsibility to determine if it was an abuse situation. No written investigation or documented protective steps were provided for review.
Failure to Provide Accurate Assessment and Consistent Treatment for Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care in accordance with standards of practice, including timely and accurate skin and wound assessments, appropriate and updated treatment orders, and consistent implementation of ordered treatments for two residents with pressure injuries. For the first resident, admitted with dark, hard eschar on the left heel and a reddened buttock present on admission, the initial wound assessment documented these areas and listed interventions such as pressure-reducing devices, turning and repositioning, and heel protectors. However, the October physician orders did not include any specific treatment for the left heel wound, and the weekly skin assessment dated 10/23 documented intact skin with no issues, contradicting the earlier documentation of a left heel wound. Subsequent weekly skin assessments in November repeatedly documented intact skin with no issues to the feet, despite ongoing references in practitioner notes and other documentation to a left heel wound and buttock/coccyx wounds. For this same resident, staff failed to complete weekly skin assessments on some weeks and did not document ongoing wound assessments for the left heel or coccyx/left buttock wounds in October and November. Nurse practitioner notes on 10/23 and 11/06 described a left heel wound with dry eschar and open areas on the right posterior thigh and left buttock, with plans for specific wound care, low air loss mattress, and wound care consults. Although orders were later entered for buttock and coccyx wound care, a low air loss bed, and wound care consult, the treatment administration records showed missed treatments on multiple dates, and progress notes did not consistently address the status of the wounds. The wound care company’s notes in December documented a large stage 2 coccyx pressure ulcer with specific treatment orders, but the facility’s physician orders did not reflect the use of calcium alginate as described by the wound care company. Additionally, new orders for bilateral heel treatments at the end of December were not carried out on the first two ordered days, and January documentation lacked progress notes regarding the left heel wound despite a dietician note referencing a left heel pressure ulcer. Further, when the wound care company evaluated the resident in early February, they documented an unstageable left heel pressure wound that had been present for several weeks and a new stage 3 pressure ulcer on the right sole, with detailed treatment orders including hypochlorous acid, calcium alginate, Medi honey, bordered foam dressings, and Tubi grips. The facility’s February physician orders, however, were not updated to match these recommendations, instead continuing older orders that omitted calcium alginate, skin protectant, Medi honey, and Tubi grips. Interviews revealed additional concerns: an NA reported finding a dressing on the ball of the resident’s foot dated nearly two weeks earlier, suggesting dressing changes were not occurring as ordered, and the wound care company nurse practitioner stated that both foot wounds were debrided on the initial visit and that staff reported the left heel blister had been present for several months. The second resident had multiple documented pressure ulcers, including a stage 3 sacral ulcer, an unstageable left heel deep tissue injury, a stage 3 left calf wound, and a stage 3 right foot ulcer. The wound care company provided detailed weekly progress notes in December and January, specifying wound measurements, staging, and treatment orders involving cleansing with hypochlorous acid, application of hydrofera blue, hydrogel, super absorbent pads, bordered gauze, and kerlix wraps, with daily dressing changes. Despite these detailed orders, the facility’s physician order sheets in December and January were not updated to reflect the wound care company’s current treatment plans. Instead, the POS continued to list older orders such as cleansing with wound cleanser and applying Santyl with wet-to-dry dressings, and later hydrofera blue combined with wet-to-dry dressings, which did not match the wound care company’s specified regimens. For this resident, weekly skin assessments were incomplete or inconsistent, with at least one week in December lacking a documented skin assessment and other assessments vaguely referencing “existing non-foot skin issues” or foot/ankle issues without specific wound details, even though multiple pressure ulcers were present and being followed by the wound care company. Treatment administration records showed missed or incomplete treatments, including days when ordered treatments to the buttock, left heel, and left lower extremity were not documented as completed, and one instance where staff documented that treatment to the lower left extremity was not done due to running out of time. Wound care company notes on multiple visits also documented that incorrect dressings were in place upon arrival, such as calcium alginate instead of hydrofera blue or the use of wet-to-dry dressings instead of the ordered advanced dressings. Throughout this period, nursing progress notes provided minimal or nonspecific information about the resident’s multiple wounds, despite ongoing changes in wound status and treatment plans documented by the wound care company. Overall, for both residents, the facility failed to ensure that wound care orders from the wound care company were promptly and accurately transcribed into the physician order sheets, failed to consistently perform and document weekly skin and wound assessments, and failed to administer and document wound treatments as ordered. Documentation often conflicted with prior assessments and specialist notes, with wounds being omitted from weekly skin assessments or described only in vague terms. Missed treatments, outdated or incorrect orders, and lack of detailed nursing progress notes regarding wound status contributed to the deficiency in providing appropriate pressure ulcer care and in preventing the development or worsening of pressure ulcers for these residents.
Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
Facility staff failed to ensure that residents were free from accident hazards and did not provide adequate supervision to prevent accidents, as evidenced by the fall of a resident during personal care. The resident, who had severe cognitive impairment, impaired mobility, and was dependent on staff for all activities of daily living, was care planned to require two staff for bed mobility and personal care. However, on the day of the incident, only one staff member was actively providing care, while another staff member was present in the room but assisting a different resident. The staff member providing care turned away from the resident to retrieve supplies, during which time the resident rolled out of bed and sustained a head laceration and a neck fracture. Interviews with staff revealed a lack of awareness and understanding of the resident's care plan requirements. The nurse aide providing care was not aware that two staff were required for personal care according to the care plan and typically provided care alone. Other staff members, including CNAs, LPNs, and the DON, confirmed that care should be provided according to the care plan and that two staff should be present and actively participating when indicated. Staff also stated that all necessary supplies should be within reach before starting care, and if additional items are needed, the resident should be safely positioned and not left unattended. Record review showed that the facility did not have a specific policy regarding falls or accidents, and there was no process in place to ensure that staff were consistently aware of and following the care planned needs of each resident. The lack of communication and implementation of the care plan directly contributed to the resident's fall and subsequent injuries. The incident was witnessed, and documentation confirmed the resident's injuries and the sequence of events leading to the fall.
Failure to Honor Resident's DNR Due to Inconsistent Documentation
Penalty
Summary
The facility failed to provide care that reflected a resident's wishes as expressed in their advance directives, specifically a Do Not Resuscitate (DNR) order. Although the resident had a signed DNR order, which was also reflected in the care plan and physician's orders, the code status was inconsistently documented across various sources, including the face sheet, EMR, and the sticker on the resident's door. At the time of the incident, the face sheet and door sticker indicated the resident was a full code, while the DNR order had not yet been uploaded into the EMR due to delays in medical records processing. When the resident experienced respiratory distress and became unresponsive, staff checked the available documentation and, based on the face sheet and door sticker, initiated CPR. Emergency services were called, and CPR was continued by both facility staff and EMS, despite the existence of a signed DNR order that had not been properly communicated or documented in all necessary locations. The resident was ultimately transported to the emergency department after prolonged resuscitation efforts. Interviews with staff revealed that there were known delays in updating and scanning advance directive documents into the EMR, and that staff relied on multiple sources, such as door stickers and face sheets, to determine code status. The medical records staff acknowledged the delay in uploading the DNR order, and other staff members indicated that information about code status was not always consistent or updated in a timely manner, especially for new admissions. This lack of consistent and timely documentation led to the administration of CPR against the resident's documented wishes.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Transcribe and Implement Wound Care Orders and Notify Physician of Changes
Penalty
Summary
Facility staff failed to provide care in accordance with professional standards for a resident admitted with bilateral groin surgical wounds. Upon admission, the resident had orders from the discharging hospital to clean the groin sites daily and to remove Silveron dressings after five days. However, staff did not transcribe these wound care orders into the resident's Medication Administration Record (MAR) or Treatment Administration Record (TAR), and there was no documentation of wound care being completed from admission through several days post-admission. The care plan was not updated to reflect the resident's wound care needs, and there was no evidence of a wound treatment or skin assessment policy being provided by the facility. Throughout the resident's stay, progress notes repeatedly documented that the resident was removing dressings and picking at the incisions, but staff did not notify the physician in a timely manner about the dressings being removed earlier than ordered or about changes in the wound condition, such as the appearance of drainage. Documentation of wound care provided was inconsistent or absent, and staff failed to record completion of wound care or reasons for non-compliance in the MAR or TAR. Communication with the physician regarding the resident's noncompliance and changes in the wounds was not documented until much later, despite ongoing issues. Interviews with facility staff, including CNAs, LPNs, the DON, and the facility physician, confirmed that wound care orders were not entered into the MAR, and that staff did not consistently document wound care or physician notifications. The physician stated that he was not notified about the early removal of dressings or the presence of drainage, and that failure to follow wound care orders could increase the risk of infection. The administrator also confirmed that wound care orders should have been entered and documented appropriately, and that weekly skin assessments and tracking should have been recorded in the electronic health record.
Failure to Document Physician Orders, Catheterization, Hospital Transfer, and Family Notification
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who experienced urinary retention and was subsequently transferred to the hospital. The staff did not document contacting the physician for catheter orders, did not record an attempt to insert a catheter, failed to document the hospital transfer, and did not document notification to the resident's family regarding a change in condition. The facility's own policies required documentation of treatments, intake and output, physician and family notifications, and changes in condition, but these were not followed in this case. The resident in question had a history of chronic obstructive pulmonary disease and benign prostatic hyperplasia, and was moderately impaired, requiring substantial assistance for activities of daily living. The resident reported difficulty urinating, which persisted for several days before any intervention was attempted. Staff interviews revealed that the DON attempted an in and out catheter, which was unsuccessful, and the resident was then sent to the hospital. However, there was no documentation in the medical record of the catheter order, the catheterization attempt, the hospital transfer, or family notification, despite staff stating these actions were taken. Interviews with staff, including the DON and LPNs, confirmed that expected documentation practices were not followed. The DON admitted to failing to enter the physician's orders for the catheter and hospital transfer into the resident's record, and also failed to document family notification. The facility physician did not recall giving a verbal order for the catheter, and there was no evidence of such an order in the records. The lack of documentation was confirmed by review of the resident's progress notes and physician orders, which showed no entries for the events in question.
Failure to Educate Staff and Provide PPE for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain a complete and effective infection prevention and control program by not ensuring staff were educated on enhanced barrier precautions (EBP) and by not making appropriate personal protective equipment (PPE) readily available for staff use. Observations revealed that staff did not use gowns when providing high-contact care to residents with indwelling devices or wounds, as required by both CDC guidance and the facility's own policy. Specifically, multiple certified nurse aides (CNAs) and a licensed practical nurse (LPN) provided care to residents with a urinary catheter and a wound, respectively, using only gloves and not gowns during activities such as catheter care, wound care, and incontinent care. One resident with an indwelling urinary catheter was observed receiving care from several CNAs who wore gloves but did not don gowns during high-contact activities, including emptying the catheter bag, transferring the resident, and providing incontinent care. The resident's care plan did not address the catheter or EBP, and the MDS/Care Plan Coordinator confirmed that no care plan was developed for these issues due to competing duties. Another resident with a wound requiring dressing changes was also not care planned for EBP, and staff were unable to locate gowns when preparing for wound care. The LPN performing wound care did not wear a gown, citing lack of availability. Interviews with staff, including CNAs, LPNs, the Director of Nursing (DON), and the Administrator, revealed that staff had not received education on EBP, were unaware of the requirement to wear gowns for residents with catheters or wounds, and often could not find necessary PPE such as gowns. While the DON and Administrator stated that PPE should be available and that staff should be following EBP protocols, direct care staff reported otherwise, and observations confirmed the lack of compliance with EBP requirements.
Failure to Provide Showers According to Resident Preference Due to Staffing and Scheduling Issues
Penalty
Summary
The facility failed to promote and facilitate a resident's right to self-determination by not providing showers or baths according to the resident's preferences and needs. Documentation showed that, for an extended period, staff did not record offering or completing showers for a resident who was dependent on staff for bathing. The resident's care plan required extensive assistance with activities of daily living, including bathing, and specified the need for assistance with showers or baths. Despite this, shower sheets for multiple weeks showed no documentation of showers being offered or completed, both before and after a hospital stay. The resident reported not receiving a shower for two or three weeks prior to hospitalization and expressed that showers were preferable for cleanliness, especially for areas difficult to reach independently. Interviews with staff, including CNAs, the Care Plan Coordinator, and the DON, confirmed that there was no designated shower aide, no shower schedule, and that residents typically received only one shower per week. Staff cited short staffing as a reason for the lack of regular showers and indicated that they did the best they could to provide showers in between other care duties. The DON acknowledged that residents should receive more than one shower or bed bath per week and that shower preferences had not been updated since her tenure began. Facility policy required staff to encourage residents to participate in their own care and to maintain comfort and cleanliness, but these standards were not met for the resident in question.
Failure to Provide Timely Showers and ADL Assistance Due to Staffing and Documentation Issues
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs), specifically showering, for a resident with vascular dementia, depression, and pain who resided in the dementia unit. The resident required substantial to maximal assistance with showering and bathing, as well as partial to moderate assistance with toileting and dressing, and was always incontinent of bowel and bladder. Documentation showed that after receiving showers on two consecutive days and refusing one, there was no record of showers being offered or completed for over two weeks in February, and again, no documentation for another two-week period in March. The resident's care plan indicated a need for staff assistance with bathing and hygiene, but this was not consistently provided or documented. Interviews with staff, including CNAs, an LPN, the Care Plan Coordinator, and the DON, revealed that the facility did not have a designated shower aide or a shower schedule. Staff reported being short-staffed and stated that they did the best they could to provide showers, but residents typically only received one shower per week. The DON confirmed that shower preferences had not been completed since her start and that monitoring of completed showers was expected but not consistently documented. These actions and inactions led to the failure to ensure the resident received necessary assistance with ADLs as required.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the State Survey Agency within the required two-hour timeframe. A resident, who was cognitively intact and required assistance with daily activities, reported to facility staff that someone had inserted something into their body while they slept. The resident expressed significant distress and pain, prompting the staff to administer pain medication and arrange for the resident to be sent to the emergency room for evaluation. Despite the resident's clear allegation of sexual abuse, the facility's staff did not report the incident to the Department of Health and Senior Services (DHSS) within the mandated two-hour period. The MDS Coordinator, who was informed of the allegation by a CNA, conducted an assessment and notified the Administrator, the resident's physician, and the corporate Quality Assurance Nurse. However, the Administrator and the corporate QA Nurse advised waiting for the hospital's findings before reporting to DHSS, resulting in a delay in reporting. Interviews with facility staff, including the Administrator, MDS Coordinator, and Director of Nursing, revealed a consensus that the allegation should have been reported immediately. The facility's policy clearly states that any allegations of abuse must be reported to the state agency within two hours if they involve abuse or result in serious bodily injury. The failure to adhere to this policy was acknowledged by the staff involved, who cited miscommunication and reliance on corporate guidance as reasons for the delay.
Accident Hazards and Inadequate Supervision
Penalty
Summary
The report identifies a deficiency related to the presence of accident hazards and inadequate supervision in a nursing home area. The surveyors found that the facility failed to ensure the environment was free from potential accident risks, which could compromise resident safety. Additionally, there was a lack of sufficient supervision to prevent accidents, indicating a lapse in the facility's responsibility to maintain a safe environment for its residents.
Resident Injury Due to Inadequate Securing in Facility Van
Penalty
Summary
The facility failed to ensure the safety of a resident during transportation in the facility's van, leading to an accident. The incident involved a resident with a left leg amputation and other medical conditions, who was dependent on staff for transfers and mobility. During transport back from an event, the resident was not properly secured with a shoulder/lap seat belt due to the obstruction caused by other wheelchairs placed in the van. As a result, the resident slid out of the wheelchair when the van stopped, injuring their knee. The transportation staff, identified as Transportation A and B, did not follow proper procedures for securing the resident in the van. Although the wheelchair was strapped down, the shoulder/lap belt was not fastened because it was obstructed by other wheelchairs. Despite previous training and warnings about the importance of safety restraints, the staff failed to secure the resident adequately, leading to the incident where the resident slid out of the wheelchair and sustained an injury. Interviews with staff and the resident confirmed the sequence of events, highlighting the lack of a specific policy or procedure for transporting residents in the facility van. The facility's internal investigation and employee counseling notices indicated that both transportation staff had been previously warned about safety restraints, yet the deficiency occurred, resulting in the resident's injury.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was on duty for eight consecutive hours on two specific days, 05/05/24 and 05/18/24. Review of the facility's Nurse Monthly Staff Schedule for May 2024 confirmed that no RN was scheduled on these dates. Further examination of the timecards for the Administrator, who is also an RN, the Director of Nursing (DON), and another RN corroborated the absence of RN coverage on the specified dates. During interviews, the DON acknowledged the facility's non-compliance with the RN coverage requirement and mentioned that the facility employs only one RN. The Minimum Data Assessment Coordinator (MDSC) also noted difficulties in hiring RNs despite advertising for the positions. The Administrator confirmed the lack of RN coverage on the mentioned dates and highlighted the ongoing challenges in recruiting RNs.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide an ongoing group or individual activity program to support the physical, mental, and psychosocial well-being of three residents residing on the secure unit. The facility's Activity/Recreational Therapy Manual outlined the need for individualized activity programs and documentation of resident participation, but these protocols were not followed. Specifically, the activity director did not document alternate approaches or one-to-one activities for residents who refused scheduled activities, nor were the residents' strengths and positive aspects identified and discussed as required by the care plan. Resident #15, who had diagnoses including bipolar disorder, anxiety disorder, and Alzheimer's disease, was noted to have refused all activities scheduled on the activity calendar for three consecutive months. Staff did not document any alternate approaches or interventions to engage the resident. Observations showed the resident was alert and personable but was often redirected to his/her room or the TV room without any meaningful engagement. Similarly, Resident #32, with diagnoses including major depressive disorder and moderate dementia, and Resident #44, with diagnoses including senile degeneration of the brain and bipolar disorder, also refused all scheduled activities for three consecutive months. Staff did not document any alternate approaches or one-to-one activities for these residents. Interviews with staff revealed a lack of knowledge and time to provide resident-specific activities, and there were no scheduled activities or specific resident interactions on the secure unit.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure timely provision of a Notice of Medicare Non-Coverage (NOMNOC) for two residents, resulting in a deficiency. Resident #49, admitted with a diagnosis of foot drop, received Medicare Part A skilled services from 03/01/24 to 03/16/24. However, there was no documentation of a NOMNOC or an Advanced Beneficiary Notice of Non-coverage (ABN) provided before the last date of services. During an interview, the resident mentioned that they were not informed about the end of their skilled therapy services or given an option to appeal the decision, which could have potentially improved their condition and reduced pain during transfers. Similarly, Resident #270, admitted with a diagnosis of muscle weakness, received Medicare Part A skilled services from 12/08/23 to 12/13/23, but there was no documentation of a NOMNOC or ABN provided before the last date of services. Interviews with the Business Office Manager (BOM), Administrator, and Social Services Director revealed a lack of awareness and understanding of the ABN process. The BOM stated that NOMNOC forms were issued by the corporate office, but she was unaware of the need to provide an ABN form. The Administrator also confirmed a lack of knowledge about the ABN process, and the Social Services Director mentioned that there was no internal system to track residents being discharged from Part A to ensure timely provision of NOMNOC. The deficiency was attributed to an oversight and lack of communication, as the Social Services Director did not receive the necessary email notifications for the residents in question.
Failure to Complete Significant Change Assessment for Hospice Admission
Penalty
Summary
The facility failed to ensure a significant change assessment was completed within 14 days for a resident who was admitted to hospice services. The Resident Assessment Instrument (RAI) Manual mandates that a Significant Change in Status Assessment (SCSA) must be performed when a terminally ill resident enrolls in a hospice program, with the Assessment Reference Date (ARD) within 14 days from the effective date of the hospice election. Resident #33, who was admitted to hospice services on 08/29/23, did not have a significant change assessment completed within the required timeframe. The resident's quarterly Minimum Data Set (MDS) with an ARD of 02/22/24 did not reflect hospice services received, and the Care Plan dated 05/20/24 showed the resident had chosen hospice services. During an interview, the MDS Coordinator acknowledged that a significant change assessment should have been completed for the resident's hospice admission but was missed. The Director of Nursing (DON) also confirmed that a significant change assessment should be completed within the appropriate timeframe when there is a significant change in a resident's condition. This oversight led to the deficiency noted in the report.
Failure to Update PASARR Screening for Resident with New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to refer a resident who had a negative Level I Preadmission Screen and was later diagnosed with a new mental disorder to the appropriate state designated authority for a Level II PASARR evaluation. This deficiency was identified for one resident out of five reviewed for PASARR among a sample of 24 residents. The resident in question was diagnosed with anxiety disorder, major depressive disorder, and bipolar disorder on different dates, but the facility did not update the PASARR screening to reflect these new diagnoses. The resident's significant change Minimum Data Set (MDS) showed moderately impaired cognition, and the initial PASARR screening indicated no signs or history of major mental illness. During an interview, the Social Worker confirmed that the resident's PASARR Level I screen had been completed earlier and did not trigger any mental illness. However, the Social Worker was unaware of the resident's new diagnoses and verified that a Level II PASARR screening had not been conducted. The regulating authority, Missouri Health and Senior Services, had not been notified for a re-screening to be completed.
Failure to Ensure Ongoing Pre and Post Dialysis Communication
Penalty
Summary
The facility failed to ensure ongoing pre and post dialysis communication for a resident receiving dialysis three times a week. The facility's policy required that all care concerns within the last 24 hours be addressed, and that the dialysis unit complete and return a report including weight, labs, medications, follow-up information, and any new physician's orders. However, the review of the resident's Dialysis Transfer Form for March, April, and May 2024 showed that the forms were only completed on four specific dates, indicating a lack of consistent communication between the facility and the dialysis center. During interviews, an LPN mentioned that the dialysis center often did not return the pre and post dialysis forms, and that staff had contacted the resident's guardian to address the issue with the dialysis center. The LPN also stated that staff did not reach out to the dialysis center to ensure there were no issues with dialysis, assuming the center would contact the facility if there were any concerns. The DON confirmed that she had just become aware of the issue and emphasized the importance of having ongoing communication before and after dialysis services.
Lack of Documented Rationale for Extended PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure there was documented clinical rationale for as-needed (PRN) psychotropic medication orders longer than 14 days for two residents. Resident #6, who was admitted with diagnoses including mood disorder and anxiety disorder, had a PRN order for Xanax 0.25 mg for anxiety. The resident's records showed no documented indication for continued clinical use past 14 days, and the pharmacist did not review or recommend discontinuation of the PRN order after the initial 14-day period. The Director of Nursing (DON) acknowledged the oversight and noted that a stop date was later added, but it did not trigger a review by the pharmacist, leading to the continued PRN order without proper documentation. The pharmacist admitted to missing the regulation requirement during monthly medication reviews. Resident #32, admitted with diagnoses including restlessness, agitation, major depressive disorder, moderate dementia, mood disturbance, and anxiety, had a PRN order for lorazepam 0.5 mg every two hours. The resident's records also lacked a documented rationale for continued use past 14 days, and the pharmacist did not review or recommend discontinuation of the PRN order. The pharmacist stated that the resident was under hospice care and did not require the same rationale for PRN lorazepam. The DON noted that the PRN lorazepam order had a stop date set for several months later, which was not initially noticed, leading to the oversight in documentation and review.
Failure to Address Resident's Bathing Preferences and Behaviors in Care Plan
Penalty
Summary
The facility failed to complete a comprehensive care plan for a resident that addressed the resident's bathing preferences and potential behaviors during showers. The resident, who was admitted with multiple diagnoses including a hip fracture, memory loss, anxiety disorder, chronic pain, major depressive disorder, bipolar disorder, and dementia, was cognitively impaired and required assistance with various activities of daily living, including bathing. Despite the resident's known aversion to showers and documented instances of yelling and screaming during showers, these behaviors and preferences were not included in the resident's care plan. Interviews with various staff members, including nurse aides and certified nurse aides, revealed that the resident's dislike for showers and the calming effect of music during showers were known among the staff. However, this information was not communicated to the MDS Coordinator or included in the resident's care plan. Staff members reported using music to calm the resident during showers, but this intervention was not documented in the care plan. The MDS Coordinator and other nursing staff were unaware of the resident's specific behaviors and preferences related to bathing. The facility's policy required the interdisciplinary care plan team to develop and maintain a comprehensive care plan with input from the resident and family, and to revise the care plan as changes occurred in the resident's condition. However, the care plan for this resident did not reflect the resident's bathing preferences or the behavioral interventions used by staff. The lack of communication and documentation led to a failure in providing consistent and appropriate care for the resident during bathing activities.
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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