Life Care Center Of Grandview
Inspection history, citations, penalties and survey trends for this long-term care facility in Grandview, Missouri.
- Location
- 6301 East 125th St, Grandview, Missouri 64030
- CMS Provider Number
- 265355
- Inspections on file
- 24
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Life Care Center Of Grandview during CMS and state inspections, most recent first.
A resident with dementia and a history of falls was startled by a door opening on a locked memory care unit, fell onto the right side, and exhibited pain responses when the right leg was touched. Facility staff notified hospice, and a hospice nurse later assessed the resident, documented no pain complaints and no new orders, and stated they would inform the family. However, facility records contained no documentation that the resident’s responsible party was notified on the day of the fall, and there was no follow-up by facility staff to verify that hospice had contacted the family, despite staff and leadership acknowledging that nurses are responsible for immediately notifying responsible parties of changes in condition and that this notification should occur regardless of hospice involvement.
Multiple incidents of physical aggression occurred between residents, including one resident striking another in the head after a verbal exchange, another resident punching a peer in the face resulting in injuries, and a third incident where hot sauce was poured on a resident's face. These events involved residents with cognitive and behavioral issues and were not prevented due to lack of supervision and failure to address escalating behaviors.
A resident with diabetes and cognitive impairment was sent to a hospital following two altercations and was subsequently issued an Immediate Notice of Involuntary Discharge. Facility staff, including the administrator and DON, determined the facility could not meet the resident's needs and refused readmission after hospital treatment. The resident was not updated on their status and expressed distress about not being allowed to return, while the social services designee sought alternative placements and notified the Ombudsman. The facility's policy lacked guidance on immediate involuntary discharges, and staff acknowledged noncompliance with regulations regarding reevaluation after treatment.
A resident with a history of epilepsy did not receive the correct dosage of Lamotrigine due to pharmacy delivery issues and staff errors in medication administration. The facility failed to administer the prescribed dose on admission and subsequently gave incorrect doses, leading to the resident experiencing seizure-like activity and requiring hospital transfer. Staff interviews revealed a lack of adherence to medication administration policies.
Two residents, both severely cognitively impaired, were involved in an altercation when one attempted to sit on the other's lap in the dining area. The seated resident said 'No', prompting the other to strike them, causing injuries. Staff witnessed the incident but could not intervene in time. The aggressive resident had a history of mood problems and was care planned for potential aggression. The facility's policy failed to prevent this resident-to-resident abuse.
A facility failed to ensure the safe storage and accountability of a resident's narcotic medication, resulting in 30 missing Oxycodone tablets. RN B signed for a delivery without verifying the contents due to being busy, and the narcotic card was not found in any storage locations. The pharmacy's protocol for verifying and signing for medications was not followed.
The facility failed to maintain a comprehensive infection prevention program, ensure proper hand hygiene during wound care, and screen residents for TB according to policy. Staff did not consistently implement Enhanced Barrier Protection, and several residents lacked documented TB tests or screenings.
The facility failed to maintain cleanliness and proper food safety standards, with debris in storage areas, dirty kitchen utensils, and infrequent changes of deep fryer oil. A refrigerator also lacked a thermometer, making it difficult to confirm adequate temperature ranges for food storage.
The facility failed to provide education and obtain signed consent or refusal for the pneumococcal vaccine for four residents. Interviews revealed that the ADON and DON were responsible for ensuring vaccination processes, but these were not followed for the residents in question.
The facility failed to provide education on the COVID-19 vaccine, obtain signed consent or refusal, and document the vaccination status for three residents. The ADON and DON confirmed these deficiencies, noting the absence of necessary documentation and forms for indicating consent or refusal.
The facility failed to coordinate PASARR assessments for a resident diagnosed with schizophrenia after admission. The resident's initial screening did not indicate a major mental illness, but a subsequent diagnosis should have triggered a referral for a Level II evaluation, which was not documented. Interviews revealed that staff did not follow the expected protocol for PASARR coordination.
The facility failed to complete a PASARR for a resident with depression, bipolar disorder, and dementia. Staff interviews confirmed that the PASARR was not done as required, and the facility had been without a Social Worker for about a month.
The facility failed to update comprehensive care plans for two residents, one with severe cognitive impairment and another with significant dental issues. Despite documented behaviors and conditions, these were not reflected in the care plans, leading to a lack of continuity in care.
A resident with hemiplegia and contractures did not have a prescribed hand brace applied as required. Despite a physician's order and multiple observations, staff failed to assist the resident in wearing the brace, and documentation was incomplete. Interviews revealed a lack of adherence to the care plan and physician's order.
The facility failed to accurately complete comprehensive fall investigations for a resident at risk for falls, resulting in multiple incidents without proper documentation of root cause analysis, environmental factors, or fall prevention measures. Staff were unaware of the resident's fall history and specific prevention measures, leading to incomplete and inaccurate incident reports.
The facility failed to ensure that a resident with a feeding tube and oral intake was receiving adequate nutrition by not recording oral intake and not weighing the resident regularly. Staff interviews revealed a lack of clarity on who was responsible for weighing the resident, leading to inconsistent monitoring of the resident's nutritional status.
The facility failed to maintain sanitary oxygen equipment for three residents, including improper storage, lack of water in humidifiers, and failure to change and date oxygen supplies. Staff interviews revealed inconsistencies and lack of knowledge regarding proper procedures.
The facility failed to assess, identify, and provide supportive interventions for a resident diagnosed with PTSD. The resident's care plan lacked specific interventions related to PTSD, and staff were unaware of the diagnosis and potential triggers. Interviews with staff and review of medical records confirmed the deficiency.
The facility failed to address a pharmacy recommendation to discontinue an antipsychotic medication for a resident with Parkinson's Disease and dementia. Staff interviews revealed a lack of clear processes for documenting physician responses to pharmacy recommendations, resulting in the recommendation being missed and not addressed in a timely manner.
The facility failed to ensure that two residents received necessary dental services for broken or missing teeth and did not provide a dental consultation for another resident who had a physician order for dental extractions. Staff members were unaware of the residents' dental needs, and there was a lack of follow-up and documentation for dental appointments.
A resident's debit card and checks were misappropriated, leading to unauthorized transactions and financial loss. The facility's investigation could not identify the perpetrator, and the resident was offered a lock box for safekeeping of personal items. Staff were re-educated on policies following the incident.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party of a significant change in condition following a fall. A resident admitted for a respite stay with a history of falling and dementia was on a locked memory care unit when a staff member opened a door, startling the resident, who then fell to the floor onto the right side. The resident was non-verbal but moaned in pain when the right leg was touched, although some range of motion remained. Facility documentation shows that hospice was notified and a hospice nurse assessed the resident later that evening, noting no complaints of pain, the ability to move the leg without complaint, and no new orders. The hospice nurse indicated they would follow up and inform the resident’s family. The facility’s fall investigation and review of the electronic medical record revealed no documentation that the resident’s responsible party was notified of the fall on the day it occurred. The investigation noted that the hospice nurse stated they would notify the family, and there was no follow-up by facility staff to ensure that this notification actually occurred. Interviews with the Administrator, CMT, RN, LPN, and DON confirmed that nurses were responsible for notifying a resident’s responsible party immediately after a change in condition and that the facility remained responsible for notification even if a hospice nurse said they would notify the family. Staff and leadership acknowledged that the resident’s family was not notified by the facility on the day of the fall and that the family was notified later than expected under facility policy and practice.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect multiple residents from abuse, resulting in several incidents of physical aggression between residents. In one case, a resident with hemiplegia and a history of verbal aggression struck another resident in the back of the head after being called a derogatory name. Both residents involved had cognitive impairments and behavioral histories, and the altercation was preceded by verbal exchanges. Staff and administration were aware of prior verbal altercations but did not implement interventions to prevent escalation to physical abuse. Another incident involved two residents in the dining room, where one resident with dementia and a history of psychosocial issues physically assaulted another resident, causing visible injuries including a laceration and bruising. The altercation was triggered by a dispute at the lunch table, with conflicting accounts from residents and staff about the sequence of events. Staff were not present in the dining room at the time of the incident, and the response to the altercation was delayed, resulting in one resident being struck multiple times before staff intervened. A third incident occurred when a resident with a history of aggressive behavior poured hot sauce on the face of another resident with severe cognitive impairment. The event followed a pattern of playful interactions that escalated into aggression, with both residents initially engaging in mutual teasing. Staff observed the aftermath and intervened to separate the residents and provide care. In all cases, the facility's failure to adequately supervise residents, recognize escalating behaviors, and implement preventive interventions contributed to the occurrence of abuse.
Failure to Allow Resident Return After Hospitalization and Involuntary Discharge
Penalty
Summary
The facility failed to ensure that a resident was allowed to return after being sent to a local hospital, resulting in an involuntary discharge that did not meet regulatory requirements. The resident, who had a diagnosis of Diabetes Mellitus Type II and moderately impaired cognition, was involved in two resident-to-resident altercations and was subsequently sent to the hospital. The facility issued an Immediate Notice of Involuntary Discharge, citing endangerment to the safety and health of individuals in the facility, and refused to readmit the resident after hospital treatment. Interviews with facility staff revealed that the administrator and director of nursing did not believe the facility was equipped to care for the resident and made the decision not to allow the resident back. The social services designee sent referrals to other facilities and notified the Ombudsman of the discharge. The resident expressed confusion and distress about not being allowed to return, stating that the facility was their home and they had not been updated on their situation. The facility's policy on transfers and discharges did not address immediate involuntary discharges, and staff acknowledged that regulations were not met by failing to reevaluate the resident after hospital treatment.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Lamotrigine Extended Release (ER) for seizure management. The resident, who had a history of epilepsy and was admitted to the facility from the hospital, did not receive the prescribed dose of Lamotrigine on the day of admission. The medication was not administered because it had not arrived from the pharmacy, and the staff did not utilize the available medication from the Omnicell. On subsequent days, the resident received incorrect doses of the medication. The pharmacy delivered 100 mg tablets instead of the prescribed 200 mg tablets, and the staff failed to administer the correct total dosage of 400 mg at bedtime. This error was compounded by the lack of communication with the physician to clarify the medication order or to address the discrepancy in the dosage provided by the pharmacy. Interviews with the nursing staff and the Director of Nursing revealed a breakdown in the medication administration process, including failure to verify medication orders against the medication administration record (MAR) and the medication cards. The staff did not follow the facility's policy of checking the Omnicell for available medications or notifying the physician when the correct dosage was not available. These actions and inactions led to the resident experiencing seizure-like activity and being transferred to the hospital.
Resident-to-Resident Altercation Due to Cognitive Impairment
Penalty
Summary
The facility failed to protect a resident from abuse when another resident, both of whom were severely cognitively impaired, was involved in an altercation. On the day of the incident, one resident attempted to sit on the lap of another resident who was seated in a wheelchair in the dining area. When the seated resident put up their hands and said 'No', the other resident turned around and struck them in the face, causing a scratch on the lip and a bruise over the left eye. This resulted in the resident sliding out of their wheelchair and being transported to the emergency room for evaluation. The incident was witnessed by several staff members, including CNAs and a CMT, who were unable to intervene in time to prevent the altercation. The staff members reported seeing the resident attempt to sit on the other resident's lap and then strike them when they were told 'No'. The facility's investigation determined that the resident who initiated the aggression had a history of mood problems related to a heightened startled response, which was care planned. The root cause analysis suggested that the resident reacted to being startled by the other resident's verbal refusal. Both residents involved in the incident had diagnoses of dementia and cognitive communication deficits, with the aggressive resident also having a care plan indicating potential for physical aggression. The facility's policy on abuse and neglect emphasizes that residents must not be subjected to abuse by anyone, including other residents. Despite this policy, the incident occurred, highlighting a failure to ensure the safety and protection of residents from abuse by peers.
Failure to Verify and Store Narcotic Medication
Penalty
Summary
The facility staff failed to ensure the safe storage and accountability of a resident's narcotic medication, specifically 30 tablets of Oxycodone HCL 10 mg, which were reported missing. The incident involved a failure to verify and sign for the delivery of medications to the East Nurses Station. RN B, who was responsible for receiving the medications, signed for a delivery without verifying the contents, which included the missing narcotic medication for a resident with a history of chronic pain and other significant medical conditions. RN B admitted to signing for a blue bag from the pharmacy without opening it or checking the contents due to being busy. The pharmacy's delivery manifest indicated that two narcotic medications were delivered, but RN B did not check off the medications as received. The pharmacy driver also signed the delivery receipt, but there was no documentation of the time or date of delivery. The facility's investigation revealed that the narcotic card was not found in any of the usual storage locations, and RN B was suspended pending the investigation. Interviews with other staff members highlighted the protocol for receiving and storing narcotic medications, which was not followed in this instance. The pharmacy's General Manager confirmed that controlled substances are typically delivered in a red sealed bag, and the receiving nurse is expected to verify and sign for each medication. However, in this case, the verification process was not completed, leading to the unaccounted narcotic medication.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program, which included the prevention and transmission of water-borne pathogens. The facility's water management program lacked a diagram or flowchart identifying specific potential risk areas, a facility-specific risk assessment, and a completed CDC toolkit with control measures. Additionally, there was no documented infection prevention program or plan to deal with outbreaks of Legionella and other waterborne pathogens, including testing protocols and acceptable ranges for control measures. The Maintenance Supervisor and Administrator acknowledged the deficiencies during interviews, and the in-service sign-in sheets provided lacked educational materials attached. The facility also failed to ensure proper hand hygiene and infection control practices during wound care for two residents. One resident with open wounds on the thighs did not have Enhanced Barrier Protection (EBP) in place, and the wound care nurse did not change gloves or cleanse hands between treating different wounds, leading to potential cross-contamination. Another resident with a suprapubic catheter had the catheter drainage bag touching the floor multiple times, and the nurse did not wear a gown during catheter irrigation, contrary to EBP protocols. Staff interviews confirmed that the facility had recently provided education on EBP, but the implementation was inconsistent. Furthermore, the facility did not ensure that all residents were screened for tuberculosis (TB) according to the facility policy. Several residents did not have documented two-step TB skin tests or chest x-rays upon admission, and there was no annual screening for TB symptoms. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the lapses in TB screening and testing, attributing the deficiencies to incomplete orders and documentation by the nursing staff.
Failure to Maintain Cleanliness and Food Safety Standards
Penalty
Summary
The facility failed to maintain cleanliness and proper food safety standards in the kitchen and food storage areas. Observations revealed that the dry storage room and walk-in freezer floors were littered with various debris, including plastic, paper, and food packets. The manual can opener had an unknown residue on its blade, and several cutting boards were excessively scored, posing a risk of cross-contamination. Additionally, the deep fryer oil was not changed frequently enough, resulting in oil that was black and filled with crumbs. A white-handled spatula was found with chipped edges, further indicating poor maintenance of kitchen utensils. During inspections, it was also noted that a refrigerator in the galley between the locked unit dining room and the rehab unit dining room lacked a thermometer, making it difficult to confirm adequate temperature ranges for food storage. Interviews with the Dietary Services Manager (DSM) and the Administrator confirmed these deficiencies, with the DSM acknowledging that the deep fryer oil was changed only every other week and that all refrigerators should have thermometers. Despite these acknowledgments, follow-up inspections showed that the issues persisted, with the deep fryer oil remaining in poor condition and debris still present in the storage areas.
Failure to Provide Pneumococcal Vaccine Education and Documentation
Penalty
Summary
The facility failed to provide education to residents or their representatives and obtain signed consent or refusal for the pneumococcal vaccine for four residents. Specifically, two residents had no evidence of being offered or administered the vaccine, nor any signed consent or refusal documented. Another resident had a status of consent refused for the vaccine but lacked a signed refusal form. Additionally, one resident had verbally consented to the vaccine, but there was no evidence of education provided or the vaccine being administered. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the ADON was responsible for ensuring the completion of pneumococcal vaccinations, including reviewing vaccine history on admission and offering the vaccine to residents. The DON confirmed that the ADON was tasked with infection control and ensuring the completion of vaccinations, while the DON was ultimately responsible for ensuring education, obtaining signed consents/refusals, administering the vaccine, and documenting the vaccination status in the medical records. However, these processes were not followed for the residents in question.
Failure to Provide COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to provide education on the COVID-19 vaccine, obtain signed consent or refusal, and document the vaccination status for three residents out of five sampled residents. Specifically, Residents #48, #61, and #166 had no evidence in their medical records of COVID-19 vaccination history, education provided, or signed consent or refusal forms. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed these deficiencies during interviews, noting that the facility did not have a form for residents to sign indicating consent or refusal for the COVID-19 vaccine. The ADON was responsible for ensuring the completion of COVID-19 vaccinations for residents, including reviewing vaccine history on admission and offering the vaccine to residents or their medical representatives. Despite these responsibilities, the facility failed to document the necessary information in the medical records of the affected residents. The DON acknowledged that the ultimate responsibility for ensuring residents received education, signed consents, and proper documentation of vaccination status rested with the facility's administration.
Failure to Coordinate PASARR Assessments for Resident with New Mental Disorder
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for a resident with a newly diagnosed mental disorder. Specifically, the facility did not refer Resident #48, who was diagnosed with schizophrenia after admission, for a Level II PASARR evaluation. The resident's initial Level One screening did not indicate a major mental illness, but a subsequent diagnosis of schizophrenia was made, which should have triggered a referral to the appropriate state-designated mental health authority for further review. However, there was no documentation of such a referral or evaluation in the resident's medical record. Interviews with the Social Services Director and the Regional Director of Nursing revealed that the facility's staff did not follow the expected protocol for PASARR coordination. The Social Services Director acknowledged that an evaluation should have been completed following the new diagnosis to ensure the resident's needs could be met by the facility. The Regional Director of Nursing confirmed that the facility social worker was responsible for PASARR coordination and should have conducted a follow-up after the new diagnosis of schizophrenia. This oversight resulted in a failure to comply with federal requirements for appropriate placement and care of residents with mental impairments.
Failure to Complete PASARR for Resident
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) for one resident out of 23 sampled residents. The resident, who had diagnoses of depression, bipolar disorder, and dementia, was admitted to the facility without a Level I PASARR being completed. The facility's policy mandates that a PASARR should be completed prior to admission, but this was not done for the resident in question. The resident's medical record showed no documentation of a Level I PASARR, and interviews with staff confirmed that the PASARR was not completed as required. The Social Service Director and Social Service Assistant both acknowledged that the PASARR for the resident was not done and should have been completed within 72 hours of admission. The Director of Nursing (DON) also confirmed that the PASARR should have been completed at the time of admission and that the Social Worker was responsible for ensuring its completion. The facility had been without a Social Worker for about a month, and the MDS Coordinator was assisting in ensuring all residents had a PASARR. However, this particular resident's PASARR was missed.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to provide continuity of resident care by not reviewing and revising comprehensive care plans for two residents. Resident #114, who was severely cognitively impaired, exhibited multiple instances of refusing care, medication, and food. Despite these behaviors being documented in progress notes, they were not reflected in the resident's care plan. Interviews with staff revealed that behaviors were reported and documented on the Medication Administration Record (MAR) and Treatment Administration Record (TAR), but the care plan was not updated accordingly. The Director of Nursing confirmed that these refusals should have been documented in the care plan. Resident #9 had broken teeth and was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS). Despite the resident's dental issues being noted during an admission assessment and a subsequent dental visit, these issues were not included in the resident's care plan. Interviews with various staff members, including a Certified Nursing Assistant (CNA), Certified Medication Technician (CMT), Registered Nurse (RN), and Social Service Assistant (SSA), revealed a lack of awareness about the resident's dental issues and confirmed that these should have been documented in the care plan. The Director of Nursing acknowledged that both residents' care plans should have been updated to reflect their current needs and issues. The facility's policy required comprehensive care plans to be updated periodically and with each Minimum Data Set (MDS) assessment. The failure to update the care plans resulted in a lack of continuity in resident care, as the care plans did not accurately reflect the residents' current conditions and needs.
Failure to Apply Prescribed Hand Brace
Penalty
Summary
The facility failed to ensure that staff applied a brace to a resident's hand as prescribed. Resident #13, who was admitted with diagnoses including hemiplegia, hemiparesis, muscle weakness, and contractures, had a physician's order for a splint/brace to be applied to the left hand for six to eight hours daily. Despite this order, multiple observations over several days showed that the resident was not wearing the brace, and interviews with the resident and staff confirmed that the brace was not being applied as required. The resident reported being unable to put the brace on independently and stated that staff had not assisted despite requests. Interviews with various staff members, including CNAs, RNs, and the Director of Nursing, revealed a lack of awareness and adherence to the physician's order. Staff members admitted they had not seen the resident with the brace on and acknowledged that it should have been applied during morning care. Documentation in the Treatment Administration Record (TAR) was incomplete, with no records indicating that the brace had been applied or removed, only assessments of pain and skin integrity. The Director of Nursing and other staff members confirmed that the responsibility for ensuring the brace was applied fell on the CNAs, RAs, and ultimately the Charge Nurse. However, the failure to document and follow through with the physician's order resulted in the resident not receiving the necessary treatment to manage their condition effectively.
Failure to Complete Comprehensive Fall Investigations
Penalty
Summary
The facility failed to accurately complete comprehensive fall investigations for a resident at risk for falls. The resident, diagnosed with dementia and severe cognitive impairment, experienced multiple falls, including an unwitnessed fall that resulted in a head injury. The facility's documentation lacked details on the root cause analysis, environmental factors, and fall prevention measures in place at the time of the incidents. On one occasion, the resident fell out of bed and was sent to the hospital for evaluation. Upon return, no new preventative fall interventions were documented. Another fall occurred, and the incident report did not include comprehensive details such as the resident's positioning, the bed's position, or the presence of fall mats. Interviews with staff revealed a lack of awareness of the resident's fall history and the specific fall prevention measures required. The facility's fall management policy was not followed, as evidenced by incomplete and inaccurate incident reports and a lack of detailed investigations. The Director of Nursing and other staff members acknowledged the deficiencies in the fall investigation process, including the absence of a detailed root cause analysis and follow-up documentation.
Failure to Ensure Adequate Nutrition and Regular Weighing of Resident
Penalty
Summary
The facility failed to ensure that a resident with a feeding tube and oral intake was receiving adequate nutrition by not recording the amount of food taken orally and not weighing the resident regularly. The resident, who had diagnoses including gastrostomy status, anoxic brain damage, autistic disorder, and dysphagia, was admitted with specific dietary and feeding instructions. However, there was no physician's order or care plan documentation specifying the frequency of weighing the resident, and the last recorded weight was on 4/9/24, despite the resident being on tube feedings and requiring regular monitoring of nutritional status. Interviews with facility staff, including a CNA, CMT, RN, and the DON, revealed a lack of clarity and communication regarding who was responsible for weighing the resident. The staff indicated that the Restorative Aide was typically responsible for weighing residents, but this individual had been sick, and there was no clear protocol for ensuring that other staff members took over this responsibility. The staff also confirmed that the resident should have been weighed weekly, but this was not consistently documented or communicated. The facility's policy required consistent methods for weighing residents and monitoring their nutritional status, but these procedures were not followed for the resident in question. The lack of documentation and clear responsibility led to the resident not being weighed regularly, which could have impacted their nutritional management and overall health status. The deficiency highlights a breakdown in communication and adherence to established protocols within the facility.
Failure to Maintain Sanitary Oxygen Equipment
Penalty
Summary
The facility failed to ensure that oxygen equipment for three residents was stored and maintained in a sanitary condition. Resident #5's oxygen humidifier had less than 1/4 inch of water, was not dated, and the oxygen tubing was not dated. The nebulizer mask was left on the bedside tray table without a bag or date. The resident was unaware of when the tubing was last changed, estimating it had been a couple of weeks. Resident #9's oxygen humidifier was empty, and the water container was not dated. The CPAP mask was in a bag dated 4/18/24, and the resident reported that staff did not regularly change the oxygen supplies or assist with the CPAP mask at night. Observations on 5/3/24 confirmed the humidifier was still empty, and the CPAP mask remained in the same dated bag. Resident #51's oxygen tubing was dirty and improperly stored, with the humidifier also lacking water. The tubing was observed on a bloody incontinent pad, and the resident indicated that the tubing was changed infrequently, possibly monthly. The wound care nurse confirmed the improper storage and changed the tubing but did not date the new water container. Interviews with staff revealed a lack of knowledge and consistency in changing and dating oxygen supplies, with the Director of Nursing acknowledging the deficiencies and attributing them to missed responsibilities by the night shift charge nurse.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to assess, identify, and provide supportive interventions for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident's admission record indicated multiple diagnoses, including PTSD, dementia with mood disturbances, major depressive disorder, borderline personality disorder, and hemiplegia. However, the Trauma Informed Care assessment did not include any detailed information about the resident's PTSD, triggers, or events. The care plan also lacked specific interventions related to the PTSD diagnosis, and there was no documentation of psychiatric consultations or further assessments for PTSD in the resident's medical records. Interviews with staff revealed a lack of awareness regarding the resident's PTSD diagnosis and potential triggers. The Certified Nursing Assistant (CNA) and Registered Nurse (RN) interviewed were unaware of the PTSD diagnosis and any associated triggers. The Director of Social Services and the Director of Nursing (DON) acknowledged that the care plan should have included the PTSD diagnosis, triggers, and interventions, and that staff should have been informed about the resident's PTSD status. The deficiency was identified as a failure to provide trauma-informed care as per the facility's policy.
Failure to Address Pharmacy Recommendation in a Timely Manner
Penalty
Summary
The facility failed to address the pharmacy's recommendation to the physician in a timely manner for one resident. The resident, who had been diagnosed with Parkinson's Disease and dementia, was on three medications for Parkinson's. The pharmacy recommended discontinuing Nuplacid, an antipsychotic medication, but there was no documentation from the physician responding to this recommendation. Interviews with various staff members, including RNs, LPNs, the ADON, and the DON, revealed that there was no clear process for documenting the physician's response to pharmacy recommendations, especially when the physician disagreed with the recommendation. The DON admitted that the recommendation was missed and not addressed in a timely manner. The facility's policy required that the pharmacist's recommendations be addressed by the attending physician, Medical Director, and DON, and that any actions or rejections be documented in the resident's health record. However, in this case, the policy was not followed, and there was no documentation of the physician's decision regarding the pharmacy's recommendation. The staff interviews indicated a lack of clarity and consistency in handling and documenting pharmacy recommendations, leading to the deficiency in addressing the resident's medication regimen review in a timely manner.
Failure to Provide Necessary Dental Services and Consultations
Penalty
Summary
The facility failed to ensure that two residents received necessary dental services for broken or missing teeth and did not provide a dental consultation for another resident who had a physician order for dental extractions. Resident #9 had broken teeth and was at risk for malnutrition. Despite a dental visit recommending extractions and dentures, there was no follow-up appointment scheduled, and the resident expressed frustration about the delay. Staff members were unaware of the resident's dental issues, and there was no documentation of a scheduled appointment for the extractions. Resident #13 had missing teeth and dentures upon admission but lost the dentures while at the facility. The resident expressed a desire for new dentures, but there was no documentation of a dental visit or follow-up. Staff members were unaware of the resident's dental needs, and the Social Services department failed to ensure the resident saw a dentist. The resident's care plan did not address the dental issues, and there was no annual assessment to determine the need for dentures. Resident #27 had multiple missing and broken teeth and a physician order for a referral to an oral surgeon for extractions. Despite the order, there was no progress in scheduling the appointment, and the resident had not received an update. The Social Services department and the Assistant Director of Nursing were both involved in the process but failed to coordinate effectively, resulting in a lack of follow-up and documentation. The Director of Nursing acknowledged the responsibility of the Social Services department to make dental appointments and the need for proper documentation.
Failure to Protect Resident's Belongings
Penalty
Summary
The facility failed to protect a resident's belongings, resulting in the misappropriation of the resident's debit card and checks. The resident, who had a history of memory deficit following a stroke, bilateral hearing loss, and depression, reported the missing items on 10/12/23. The facility's Social Service Assistant (SSA) and Director of Nursing (DON) initiated an investigation and found the checkbook but not the debit card. Unauthorized transactions were identified, including a declined purchase of $11.60, a $60.00 gas bill payment, and two checks cashed for $875.00 and $1000.00, respectively. The resident did not authorize these transactions and was unaware of who took the items. The facility's investigation revealed that the resident's debit card was used without authorization on multiple occasions, and the checks were cashed with forged signatures. The police were notified, and a report was filed on 10/12/23. The SSA assisted the resident in contacting the bank to cancel the debit card and close the compromised account. The bank confirmed the fraudulent transactions and provided copies of the cashed checks, which were not signed by the resident. The facility interviewed relevant staff and the resident but could not identify the perpetrator. The resident was offered a lock box for safekeeping of personal items, and the bank refunded the stolen money. Despite these measures, the facility's failure to protect the resident's belongings led to significant financial loss and distress for the resident. The facility's policies on abuse, neglect, and misappropriation of resident property were reviewed, and staff were re-educated on these policies following the incident.
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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