Liberty Health And Wellness
Inspection history, citations, penalties and survey trends for this long-term care facility in Liberty, Missouri.
- Location
- 2201 Glenn Hendren Dr, Liberty, Missouri 64068
- CMS Provider Number
- 265857
- Inspections on file
- 35
- Latest survey
- March 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Liberty Health And Wellness during CMS and state inspections, most recent first.
A resident with cognitive decline and a history of brain cancer left the facility unsupervised after signing out to smoke. Despite being identified as an elopement risk, the facility failed to implement effective interventions or monitor the resident adequately. The resident was later found at a hospital 18 miles away, indicating a failure to follow elopement procedures.
A facility failed to maintain infection control standards during care for three residents. Staff did not perform hand hygiene with glove changes, failed to wear gowns for residents on Enhanced Barrier Precautions, and placed dirty linens on the floor. Observations showed staff not adhering to infection control policies, and interviews revealed gaps in training and awareness.
Facility staff failed to provide complete perineal care for two residents, leading to a deficiency. One resident with paraplegia and bladder incontinence did not receive proper cleaning as staff used a wet hand towel instead of wipes and did not separate perineal folds. Another resident, dependent on staff for personal care, was cleaned with the same wipe for multiple swipes, and staff did not separate perineal folds. Interviews with LPN and DON confirmed the staff did not meet expected care standards.
A resident with an indwelling urinary catheter received improper care, as a CNA was observed cleaning the catheter incorrectly and placing the drainage bag on the mattress, contrary to facility policy. Interviews with staff confirmed the failure to follow proper procedures, leading to a deficiency in preventing UTIs.
Two residents in a LTC facility suffered injuries due to inadequate supervision and improper handling during transfers and physical therapy. One resident, identified as a fall risk, was left unsupervised during therapy and sustained fractures after a fall. Another resident was transferred without a gait belt, resulting in an ankle fracture. The facility's failure to adhere to policies on safe handling and supervision contributed to these incidents.
A resident did not receive the physician-ordered medication, Protonix, for three days due to unavailability in the medication cart. Despite the pharmacy delivering a 30-day supply, the medication was not administered as required, leading to resident frustration and highlighting a lapse in the facility's medication management process.
The facility failed to maintain resident dignity and privacy, as evidenced by incidents where a resident's soiled sheets were not changed, staff entered a room without knocking, and two residents did not receive their meals simultaneously. These actions affected the residents' dignity and privacy, as confirmed by staff interviews.
The facility failed to ensure safe self-administration of medications for two residents. One resident, who is cognitively intact, was found with eye drops at the bedside without a physician's order or care plan reflecting self-administration. Another resident, dependent on staff for various activities, had medications at the bedside without proper orders or care plan documentation. Staff interviews revealed a lack of awareness and documentation regarding self-administration, contrary to facility policy.
The facility failed to address and communicate resolutions to concerns raised by the resident council, as reported by nine out of ten residents. Issues such as door code changes, smoke break arrangements, and CNA conduct were documented, but residents felt there was no effective follow-up or resolution. Interviews revealed that grievances were supposed to be addressed by relevant departments, but residents often received no substantial feedback.
The facility failed to maintain a safe and homelike environment, with observations revealing dirty linens, unpainted patches, chipping paint, and dead bugs in light fixtures. Staff interviews indicated lapses in responsibilities, with a CNA not noticing stained sheets and the maintenance supervisor aware of needed repairs but not addressing them promptly.
The facility failed to provide meaningful activities for several residents, including those with cognitive impairments and physical disabilities. One resident expressed dissatisfaction with the lack of preferred activities like sudoku puzzles, while another, who is legally blind, struggled to participate due to inadequate support and unsuitable activity options. A third resident reported boredom and frustration, as their preferred activities were not offered. Additionally, a resident's activity assessment was not completed, indicating a lack of personalized activity planning.
The facility failed to ensure call lights were within reach for three residents, leading to potential safety hazards. One resident with upper extremity impairments was found with the call light on the floor, out of reach, despite being dependent on staff for mobility. Another resident with severe cognitive impairment also had the call light under the bed, contrary to care plan requirements. A third resident, affected by a stroke, was similarly unable to reach the call light. Staff interviews revealed a lack of adherence to the policy of ensuring call light accessibility.
The facility failed to provide fresh water at residents' bedsides and did not date the Styrofoam cups used, affecting three residents with various medical conditions. Observations and interviews revealed that staff did not consistently provide fresh ice water every shift, and the cups were not dated, leading to uncertainty about their usage duration. Staff interviews confirmed the inconsistency in following procedures for hydration care.
The facility failed to provide proper respiratory care by not cleaning oxygen concentrator filters for four residents, leading to dust accumulation. Residents on oxygen therapy for conditions like asthma and COPD were affected. Staff interviews revealed a lack of knowledge and responsibility for cleaning the filters, which were expected to be maintained weekly. The DON and Administrator acknowledged the deficiency.
A long-term care facility reported a 23.08% medication error rate, affecting four residents. Errors included improper administration of Glycolax, Lidocaine patches, Albuterol inhalers, Advair Diskus, Artificial Tears, and Fluticasone Propionate nasal spray. Observations revealed discrepancies between physician orders and actual practices, with staff failing to follow manufacturer guidelines and leaving medications at the bedside.
The facility failed to securely store and properly label medications, with instances of medications left unattended at a resident's bedside, expired medications not discarded, and improperly labeled medications. Staff interviews revealed a lack of clarity on procedures for checking and removing expired medications, and the Director of Nursing's audits did not prevent these deficiencies.
The facility failed to meet food safety standards, with staff not wearing hairnets and multiple sanitation issues in the kitchen, including uncovered light fixtures and mold-like substances. Food trays were transported without proper covers, exposing them to contaminants. The dietary manager and administrator acknowledged these issues, highlighting a need for improved compliance with safety protocols.
The facility failed to accommodate the needs of a paraplegic resident by not providing an escort for physician appointments and not honoring their preference for paper chux. Additionally, a visually impaired resident was not provided with appropriate activities, as they reported difficulty participating due to blindness and arthritis. Staff interviews revealed a lack of clarity regarding the scheduling of escorts and provision of activities for residents with specific needs.
The facility failed to provide adequate hygiene care for several residents, with issues in perineal care and shower frequency. Two residents did not receive complete perineal care, and three residents missed multiple shower opportunities. Staff acknowledged these deficiencies, and residents expressed dissatisfaction with their hygiene care.
A resident with terminal cancer reported that a former Social Services Director sold their possessions, including a 2011 Mercedes, without providing the proceeds. The resident, who was cognitively intact, expressed significant emotional distress over the theft. The facility's investigation confirmed the misappropriation, and the police were notified. The facility's policies on protecting resident property were not effectively enforced.
A resident with multiple diagnoses had medications unsafely stored at their bedside, contrary to the facility's policy. The resident self-administered these medications without staff assistance, and staff confirmed that medications should not be kept at the bedside due to potential hazards.
A facility failed to provide medically related social services for a resident with terminal cancer, who experienced significant distress due to a stolen car and lack of support. The resident's care plan was not followed, and necessary assessments and interventions were not completed, leading to increased anxiety and depression.
The facility failed to maintain a complete health record for a resident with pressure ulcers by not documenting wound treatments on the TAR on multiple occasions. Interviews revealed that treatments were sometimes performed but not documented, and the resident's schedule affected the timing of treatments. The DON and Administrator expected documentation after treatment, but the DON was unaware of the lapses.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and identify an elopement risk for a resident who had been deemed incapacitated. The resident, who had a history of brain cancer, cognitive decline, and was at low risk for wandering, left the facility unsupervised after informing staff he was going out to smoke. Despite being identified as an elopement risk with impaired safety awareness, the facility did not implement effective interventions to prevent the resident from leaving the premises. The resident had previously displayed behaviors indicating a desire to leave the facility, such as attempting to exit through various doors and expressing a wish to go to the casino. The facility's staff, including the DON and SSD, were aware of the resident's cognitive decline and the need for supervision while smoking. However, the facility did not complete a smoking assessment or update the resident's care plan with new interventions after the resident's attempts to leave the facility. On the day of the incident, the resident signed out on the smoking log and left the facility. The staff failed to monitor the resident effectively, and the resident was later found at a hospital 18 miles away. The facility did not follow its policy and procedure for elopements, as evidenced by the lack of a police report and the failure to notify the appropriate parties promptly. The resident's DPOA was under the impression that the resident would not leave the property unsupervised, highlighting a communication breakdown between the facility and the resident's representative.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain infection control standards during the provision of care to three residents. Staff did not perform hand hygiene with glove changes while performing perineal care for two residents and did not change gloves when providing urinary catheter care for another resident, as per facility policy. Additionally, staff failed to wear gowns while providing catheter care and perineal care for residents on Enhanced Barrier Precautions (EBP) and while emptying urinary catheter drainage bags. Dirty linens and used incontinence briefs were placed directly on the floor instead of in bags, contrary to facility policy. Resident #2, who had paraplegia and an indwelling urinary catheter, was observed receiving perineal care without staff performing hand hygiene between glove changes. Staff also failed to wear protective gowns and placed dirty linens on the floor. Resident #3, who had a chronic wound and required assistance with personal care, was observed receiving perineal care without staff performing hand hygiene or wearing protective gowns. Staff used contaminated wipes and placed dirty linens on the floor. Resident #4, who had an indwelling urinary catheter, received catheter care without staff performing hand hygiene or wearing protective gowns, and dirty gloves were not changed appropriately. Interviews with staff, including CNAs, LPNs, the Director of Nursing, and the Administrator, revealed a lack of adherence to infection control policies and procedures. Staff acknowledged the need for hand hygiene, proper glove use, and the use of protective gowns, but these practices were not consistently followed. The Director of Nursing and the Administrator expressed expectations for compliance with EBP and infection control protocols, but gaps in training and awareness were evident among staff members.
Deficient Perineal Care for Two Residents
Penalty
Summary
The facility staff failed to provide complete perineal care for two dependent residents, leading to a deficiency in care. Resident #2, who had a BIMS score of 15 indicating no cognitive deficit, was diagnosed with paraplegia, bladder incontinence, and anxiety, and was dependent on staff for personal hygiene and urinary catheter care. During an observation, CNA A and NA A did not perform hand hygiene, used a wet hand towel instead of wipes, and failed to separate the resident's perineal folds while cleaning. They also used a scrubbing motion and wiped back to front, contrary to the facility's policy. Resident #3, with a BIMS score of 13 indicating minimal cognitive deficit, required assistance with personal care and was incontinent of bowel and bladder. During an observation, CNA B and CNA C used the same wipe for multiple swipes and did not separate the resident's perineal folds. CNA B wiped back to front, which was against the expected procedure. Both CNAs acknowledged their failure to follow the correct perineal care procedure during interviews. Interviews with LPN C and the DON revealed that the staff did not meet the expected standards for perineal care. They confirmed that the staff should have used a clean wipe for each swipe, wiped front to back, and separated the perineal folds. The DON reiterated the importance of following the correct procedure to ensure proper hygiene and prevent infection.
Improper Catheter Care Leads to Deficiency in UTI Prevention
Penalty
Summary
The facility failed to provide proper urinary catheter care for a resident, leading to a deficiency in preventing urinary tract infections (UTIs). The resident, who had a BIMS score indicating little cognitive deficit, was diagnosed with a UTI, urine retention, and required assistance with personal care. The resident had an indwelling urinary catheter and needed help with dressing, using the toilet, and bed mobility. The facility's policy required catheter care to be performed by wiping from the body outward and ensuring the urinary drainage bag was below the bladder level to prevent backflow. During an observation, a CNA was seen improperly cleaning the resident's catheter by rubbing back and forth instead of wiping in one direction. The CNA also placed the urinary drainage bag on the resident's mattress, which is against the facility's policy. Interviews with the CNA, an LPN, the DON, and the Administrator confirmed that the staff did not follow the correct procedures for catheter care, as they were expected to swipe once from top to bottom and keep the drainage bag below the bladder level. This improper handling of catheter care was identified as a deficiency affecting the resident's care.
Inadequate Supervision and Handling During Transfers and Therapy
Penalty
Summary
The facility failed to provide adequate supervision and safe handling during physical therapy sessions, resulting in injuries to two residents. Resident #4, who had no cognitive impairment and required substantial assistance for mobility, was left unsupervised while performing standing exercises at the parallel bars. Despite being identified as a fall risk, the resident was not closely monitored, and staff were not in a position to prevent the fall. The resident fell, sustaining a displaced hip fracture and a tibia fracture, which required hospitalization. The care plan for Resident #4 did not adequately address the resident's mobility needs, fall risk, or the necessity for close supervision during therapy. In another incident, Resident #6, who had cognitive skills intact but required substantial assistance for transfers, was improperly transferred from bed to a wheelchair without the use of a gait belt, contrary to the facility's policy. During the transfer, the resident was lowered to the floor, resulting in an acute medial malleolar fracture. The staff involved did not follow the proper protocol for using a gait belt, and the resident's care plan did not adequately address the risk of falls or the need for specific transfer assistance. Both incidents highlight a lack of adherence to the facility's policies on safe resident handling and supervision, particularly during transfers and physical therapy sessions. The failure to ensure proper supervision and use of assistive devices like gait belts contributed to the injuries sustained by the residents. The facility's policies were not effectively implemented, and staff were not adequately informed or attentive to the residents' needs during these critical activities.
Medication Unavailability for Resident
Penalty
Summary
The facility failed to ensure that a physician-ordered medication, Protonix, was available and administered to a resident for three consecutive days. The resident, who was cognitively intact and had multiple diagnoses including cancer, heart disease, high blood pressure, stroke, and lung disease, did not receive the medication on 12/24/24, 12/25/24, and 12/26/24 as per the Medication Administration Record. The facility's Medication Administration Policy requires staff to keep the medication cart stocked with adequate supplies, but this was not adhered to in this instance. On 12/26/24, a Certified Medical Technician (CMT) was observed searching for the medication but could not find it in the cart. The resident expressed frustration about having to track down a nurse to receive the medication. Interviews with staff revealed that the pharmacy had delivered the medication on 12/17/24, but it was not available on the cart when needed. The Director of Nursing confirmed that the medication had been requested again from the pharmacy on 12/26/24. The pharmacy later confirmed that a 30-day supply had been delivered and signed for by staff, indicating a lapse in the facility's medication management process.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain resident dignity and privacy, as evidenced by several incidents involving different residents. One resident, who was incontinent of urine and bowel, reported that the night shift nurse did not change their soiled bed sheets on two consecutive nights, leaving them embarrassed and angry. The resident was forced to either sleep on the wet sheets or endure the smell of urine. Interviews with staff confirmed that the night shift was expected to change soiled sheets, but this was not done for the resident in question. Another incident involved a resident whose privacy was compromised when staff entered their room without knocking, despite a 'Do Not Disturb' sign on the door. The resident expressed a desire for staff to knock and announce themselves before entering. The dietary manager admitted to not knocking before entering the resident's room, and the Director of Nursing stated that all staff were expected to knock and announce themselves before entering a resident's room. Additionally, two residents in the dining room did not receive their meals at the same time as others sharing their table, further indicating a lack of attention to resident dignity.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that staff obtained physicians' orders and assessed residents for safe self-administration of medications to be kept at the bedside for two residents. Resident #41, who is cognitively intact and independent with most activities of daily living but requires supervision for walking, was found with an unexpired bottle of eye drops at the bedside without a physician's order to self-administer or keep the medication at the bedside. The resident's care plan did not reflect the ability to self-administer medications or keep them at the bedside. Similarly, Resident #76, who is cognitively intact but dependent on staff for various activities, was found with a bottle of Artificial Tears Ophthalmic Solution and a tube of Zinc Oxide on the bedside table. There was no physician's order for the resident to self-administer these medications or keep them at the bedside. The care plan did not reflect the resident's ability to self-administer medications. Interviews with facility staff, including a Certified Medication Tech and an LPN, revealed a lack of awareness and documentation regarding residents' self-administration of medications, contrary to the facility's policy.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to adequately address and communicate the concerns and recommendations of the resident council members, as reported by nine out of ten residents who attended a group meeting. The residents expressed that while their grievances were noted during council meetings, there was no effective follow-up or resolution communicated to them. This lack of communication and resolution was evident in the resident council minutes, which did not indicate whether the issues raised were resolved or if the residents still considered them to be ongoing problems. The resident council minutes from meetings held on two separate occasions highlighted several issues, including door code changes, smoke break arrangements, courtyard maintenance, and concerns about laundry, housekeeping, and CNA conduct. Despite these issues being documented, the residents reported that during follow-up meetings, staff only read the old business without providing updates on resolutions or addressing whether the residents still perceived these issues as unresolved. Interviews with the Activity Director and the Director of Nursing revealed that grievances voiced during meetings were supposed to be written up and addressed by the appropriate departments. However, the residents felt that the process was ineffective, as they were often told to fill out a grievance form without receiving any substantial feedback or resolution. This lack of effective communication and follow-up on grievances contributed to the deficiency identified in the facility's handling of resident council concerns.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to uphold the residents' right to a safe, clean, comfortable, and homelike environment. Observations over several days revealed multiple deficiencies, including dirty and stained bed linens in several rooms, unpainted patches on walls, chipping paint on ceilings, dead bugs in light fixtures, and unpatched holes in walls and ceilings. The facility's policy mandates maintaining a sanitary and orderly environment, but these observations indicate a failure to adhere to these standards. Interviews with staff, including a CNA, the Director of Nursing, and the housekeeping and maintenance supervisors, highlighted lapses in responsibilities. The CNA admitted to not noticing the stained sheets, despite being responsible for changing them. The Director of Nursing expected CNAs to ensure clean linens, while the housekeeping supervisor mentioned a rotating cleaning schedule that was not effectively addressing the issues. The maintenance supervisor acknowledged awareness of the need for repairs and painting, indicating a lack of timely action to address these environmental deficiencies.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities for five residents, as observed through interviews and record reviews. Resident #55, with moderately impaired cognition and various health conditions, expressed dissatisfaction with the activities offered, stating a preference for sudoku puzzles, which were not provided. The resident's activity evaluation indicated interests in cooking, religious activities, and music, but these preferences were not reflected in the activities offered. Resident #419, who is legally blind and has multiple health issues, reported difficulties in participating in activities due to blindness and arthritis. The resident was unable to operate the television and had not been offered suitable alternatives, such as audio books, despite expressing interest in educational programs and music. The resident's participation record showed repetitive activities that did not align with their preferences or abilities. Resident #95, who is cognitively intact but has a seizure disorder and depression, expressed boredom and frustration with the lack of engaging activities. Despite having a detailed list of preferred activities, such as arts and crafts and social events, the resident reported that these preferences were not being met. Additionally, Resident #76's records showed no completed activity assessment, and the Activities Supervisor admitted that assessments were not consistently conducted, leading to a lack of personalized activity planning.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for three residents, as their call lights were not within reach. Resident #6, who had no cognitive impairment but had upper extremity impairments and was dependent on staff for bed mobility and toileting, was observed on two occasions with the call light on the floor, out of reach. Despite being in bed and calling for assistance, staff failed to place the call light within reach during their interactions. Resident #23, with severe cognitive impairment and upper extremity impairments, was also found with the call light under the bed and out of reach. This resident was dependent on staff for all activities of daily living and was at risk for falls. The care plan specifically required staff to ensure the call light was accessible, yet observations showed this was not adhered to. Similarly, Resident #75, who had no cognitive impairment but had impairments due to a stroke, was observed with the call light on the floor and out of reach. Interviews with staff, including CNAs and the LPN, revealed a lack of awareness and adherence to the policy of ensuring call lights are within reach. Additionally, a call light cord in a restroom was found to be shortened, further indicating a failure to maintain accessible call lights for residents.
Failure to Provide Fresh Water and Date Cups
Penalty
Summary
The facility failed to ensure that residents had fresh water at their bedside that was easily accessible and failed to date the Styrofoam cups used for fresh water. This deficiency affected three residents, each of whom had intact cognitive skills and required assistance with eating. The residents had various diagnoses, including COPD, CHF, diabetes mellitus, anxiety, depression, and unsteadiness on feet. Observations and interviews revealed that the staff did not consistently provide fresh ice water every shift, and the Styrofoam cups were not dated, making it difficult to determine how long they had been in use. Interviews with staff, including an LPN, CNAs, and the DON, confirmed that fresh ice water should be provided every shift and that the Styrofoam cups should be dated and changed regularly. However, there was inconsistency in the staff's understanding and execution of these procedures. The residents expressed a desire for fresh ice water every shift, and one resident noted that the staff only provided fresh water because the State was in the building. The lack of adherence to the facility's policy for assisted nutrition and hydration contributed to the deficiency.
Failure to Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to ensure proper respiratory care for four residents by not effectively cleaning the oxygen concentrator filters. The facility's Oxygen Administration Policy did not address the cleaning of concentrator filters, leading to neglect in maintaining these essential components. Observations revealed that the filters on the oxygen concentrators for the residents were thick with built-up dust and gray lint, indicating a lack of regular cleaning. Resident #74, who had no cognitive impairment and required supervision for activities of daily living (ADLs), was observed with a dusty oxygen concentrator filter. The resident was on oxygen therapy due to diagnoses including cancer, asthma, and respiratory failure. Similarly, Resident #103, also without cognitive impairment and requiring supervision for ADLs, had a concentrator filter covered in dust. This resident was on oxygen therapy for asthma, respiratory failure, and anxiety. Interviews with staff, including CNAs and an LPN, revealed a lack of knowledge and responsibility regarding the cleaning of oxygen concentrator filters. The CNAs were expected to clean the filters weekly, but some staff members were unaware of how to perform this task. The Director of Nursing and the Administrator acknowledged that the filters should be cleaned at least monthly and expressed that they should not be caked with dust and dirt.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 23.08% error rate. This affected four residents, with errors observed in the administration of medications such as Glycolax, Pulmicort, Lidocaine patches, Albuterol inhalers, Advair Diskus, Artificial Tears, and Fluticasone Propionate nasal spray. The errors were identified through observations, interviews, and record reviews, highlighting discrepancies between physician orders and actual administration practices. For Resident #28, the errors included improper administration of Glycolax, failure to change a Lidocaine patch since 10/20/24, and incorrect use of an Albuterol inhaler without a documented physician's order. The resident experienced severe back/hip pain, and the CMT left the Glycolax medication at the bedside, which was not consumed by the resident. The CMT also admitted to being unfamiliar with the Albuterol inhaler and failed to administer the correct dosage. Other residents experienced similar issues. Resident #8 did not rinse their mouth after receiving Advair Diskus, contrary to manufacturer guidelines. Resident #11 did not receive proper pressure application after receiving Artificial Tears, and Resident #42's Fluticasone Propionate nasal spray was administered without closing one nostril as required. The Director of Nursing confirmed that medications should be administered as ordered and according to manufacturer guidelines.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored securely and properly labeled, leading to several deficiencies. Medications were found left unattended at a resident's bedside, including a bottle of Zinc Oxide paste, Antifungal Ointment, hair and skin spray cleanser, Genteal Tears liquid drops, and an unlabeled bottle containing an unknown green fluid. These items were not labeled with the resident's name, and the resident was not present in the room at the time of observation. The facility's policy requires that medications not authorized for bedside storage be reported and returned to the charge nurse, but this was not adhered to. Additionally, the facility did not discard expired medications, affecting two residents and house stock items. Expired medications found included a bottle of Eliquis, Losartan, and Donepezil for one resident, and Carbamazepine for another. House stock items such as lubricating eye drops and Insta-glucose were also expired. The facility's policy mandates that expired medications be removed and destroyed, but this was not followed, as confirmed by interviews with staff who were unsure of the procedures for checking and removing expired medications. Furthermore, medications were not properly labeled, as observed with an opened tube of Mupirocin ointment with a faded label. The facility's policy requires that all medications be clearly labeled, but this was not the case. Interviews with staff revealed a lack of clarity on who was responsible for checking medication carts and ensuring labels were legible. The Director of Nursing was noted to perform audits, but expired and improperly labeled medications were still present, indicating a lapse in adherence to the facility's medication storage and labeling policies.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as observed during a survey. Staff did not comply with hairnet requirements, allowing two visitors to walk through the kitchen without hairnets and a dietary aide working without a hairnet on multiple occasions. Additionally, the kitchen had several sanitation issues, including uncovered light fixtures, mold-like substances on water-damaged documents, old food debris on refrigerator racks, and congealed liquid in a machine drip tray. The ceiling paint was chipping, and dust was hanging from the fire suppression system, indicating a lack of cleanliness and maintenance. Furthermore, food trays were transported through the facility without proper covers, exposing them to environmental contaminants. The facility's policy required food containers to be covered to retain heat and prevent contamination, but the staff believed that individual covers and plastic wrap sufficed. The dietary manager and dietician acknowledged the need for light fixture covers and stated that deep cleaning was performed twice a month. The administrator confirmed the expectation for meals to be served promptly and covered, and for hairnets to be worn by anyone in the kitchen.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of Resident #24 by not providing an escort for physician appointments and not honoring the resident's preference for paper chux. Resident #24, who is paraplegic and has multiple medical conditions including anxiety and chronic pain, expressed concerns about attending appointments alone due to social anxiety and the potential need for assistance with his colostomy and drainage bags. Despite the resident's preference and the wound physician's recommendation for paper chux and an escort, the facility did not have a physician's order for these accommodations, and staff were unaware of the resident's preference for paper chux. Additionally, the facility did not provide appropriate activities for Resident #419, who is visually impaired. Although the resident expressed interest in various activities such as reading, writing, and music, they reported not participating in activities due to blindness and difficulty operating the television. The resident also mentioned not being offered activities other than audio books and not attending puzzle activities due to arthritis and blindness. The facility's activity records showed limited participation, and staff failed to assist the resident in accessing desired activities or turning on the television. Interviews with facility staff revealed a lack of clarity and communication regarding the scheduling of escorts for appointments and the provision of activities for residents with specific needs. The Social Services Director and LPNs were unsure about the process for determining the need for escorts, and the Director of Nursing stated that no residents had physician's orders for escorts. The Administrator expected staff to assist residents with blindness in participating in activities, but this was not consistently documented or executed.
Deficiencies in Resident Hygiene Care
Penalty
Summary
The facility failed to ensure that dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene. This deficiency affected five residents, with specific issues in perineal care and shower frequency. For two residents, staff did not provide complete perineal care, failing to clean all necessary areas, including the perineal folds and urethral opening, as required by the facility's policy. This was observed during interactions with the residents, and staff admitted to not following the proper procedures. Additionally, three residents did not receive showers at least twice a week as required. The facility's records showed that these residents missed several shower opportunities over multiple months. One resident expressed feeling better after being cleaned, indicating the importance of regular hygiene care. Another resident frequently refused showers due to feeling unsafe, and there was an incident where a staff member inadvertently caused distress by entering the shower area. Interviews with staff, including CNAs and the DON, confirmed the issues with shower frequency and perineal care. Staff acknowledged the residents' complaints about not receiving showers as per their preferences. The facility's policy mandates that residents should receive the necessary services to maintain good personal hygiene, but the observations and interviews revealed a failure to adhere to these standards.
Misappropriation of Resident Property by Former Social Services Director
Penalty
Summary
The facility failed to protect a resident from misappropriation of property, specifically involving a former Social Services Director (PSSD) who was reported to have sold the resident's possessions, including a 2011 Mercedes, without providing the resident with the money received from the sales. The resident, who had terminal cancer, reported being devastated by the theft, as the car was a significant personal achievement. The resident's cognitive status was intact, as indicated by a BIMS score of 15, and they had expressed the importance of having a place to lock their belongings to keep them safe. The deficiency was identified when the resident reported to the Admissions Director that the PSSD had been helping them sell their car and personal belongings, but the items were now missing, and the resident had not received any money. The facility's investigation revealed that the PSSD had picked up the resident's car from the hospital, sold it, and paid off the car loan using their personal bank account. However, the resident did not receive any proceeds from the sale. The PSSD was terminated from their position for unrelated reasons, and the police were notified of the incident. Interviews with various staff members and the resident confirmed the misappropriation of property. The resident expressed significant emotional distress and frustration over the situation, feeling that the facility had not provided a resolution or kept them updated on the investigation. The resident's behavior and mood were notably affected by the incident, leading to outbursts and increased seclusion. The facility's policies on abuse, neglect, and exploitation, as well as the protection of resident personal belongings, were not effectively implemented or enforced in this case, resulting in the misappropriation of the resident's property.
Unsafe Medication Storage at Resident's Bedside
Penalty
Summary
The facility failed to ensure the environment for one resident remained free of accident hazards, specifically by allowing medications to be unsafely stored at the resident's bedside. The facility's Medication Storage policy mandates that all medications be stored in locked compartments and only accessible to authorized personnel. However, observations revealed that Resident #58 had an inhaler and sulfadiazine cream at the bedside, which the resident had been self-administering without staff assistance. Additionally, the resident had antifungal powder and hydrocortisone cream at the bedside without a physician's order for these medications. Interviews with staff confirmed that medications should not be kept at the bedside due to the risk of other residents potentially ingesting them. Resident #58, who had diagnoses including encephalopathy, bipolar disorder, diabetes, chronic obstructive pulmonary disease, and osteoarthritis, was admitted to the facility on 08/18/2022. The resident had a BIMS score of 15, indicating intact cognition, and had a care plan that did not address self-administration of medications or safe storage of medications in the resident's room. Despite the facility's policy and staff assertions that medications should not be kept at the bedside, the resident had multiple medications accessible, posing a potential hazard. The Director of Nursing confirmed that medications should not be kept at the bedside and noted that the resident was an online shopper who bought medication online.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services for a resident who had recently been diagnosed with terminal cancer, lost their job, and became homeless due to their health condition. The resident, who had a history of trauma, showed signs of mental and psychosocial distress, including anxiousness and depression. The resident also reported that a previous social worker had stolen their car, which added to their distress. Despite these significant issues, the facility did not provide adequate follow-up or support to address the resident's needs. The resident's care plan indicated a need for psychiatric evaluation and referral to social services, but there was no documentation of a trauma-informed care assessment or follow-up after the incident with the stolen car. The Social Services Director (SSD) acknowledged that they had not completed the necessary assessments or provided the required support. The resident expressed feelings of being neglected and unsupported by the facility staff, who did not check in on them or offer updates regarding the stolen car. Interviews with the resident and staff revealed that the resident's behavior had changed significantly due to the distress caused by the stolen car and their terminal diagnosis. The resident had outbursts and expressed feelings of devastation and extreme stress. Despite these clear signs of distress, the facility did not take appropriate steps to address the resident's psychological and social needs, failing to provide the necessary support and interventions as required by their care plan and facility policies.
Failure to Document Wound Treatments
Penalty
Summary
The facility failed to maintain a complete health record for one resident reviewed for pressure ulcers. Specifically, the staff did not document wound treatments on the Treatment Administration Record (TAR) for Resident #35 on multiple occasions across January, February, and March 2024. The resident had diagnoses including type 2 diabetes mellitus, chronic combined congestive heart failure, end-stage renal disease, and dependence on renal dialysis. The resident's care plan included instructions for wound treatment, but the TAR revealed missing documentation for several dates when treatments were supposed to be administered. Interviews with nursing staff indicated that treatments were sometimes performed but not documented, and in some cases, the resident's preferences or schedule (such as dialysis) affected the timing of treatments. The Director of Nursing (DON) and the Administrator both stated that they expected all treatments to be documented after completion. However, the DON was not aware that staff had failed to document treatments for Resident #35 on some days. The failure to document wound treatments as required by the facility's policy and physician orders led to the deficiency identified in the report.
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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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