Lincoln County Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Troy, Missouri.
- Location
- 1145 East Cherry Street, Troy, Missouri 63379
- CMS Provider Number
- 265433
- Inspections on file
- 20
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Lincoln County Nursing & Rehab during CMS and state inspections, most recent first.
A resident with vascular dementia became combative during care, resulting in skin tears, as staff failed to identify behavioral triggers, implement non-pharmacological interventions, or update the care plan. Multiple CNAs and LPNs reported not receiving dementia care training, and key information about the resident's behavioral responses to staff of the same gender was not communicated or documented. The facility did not provide a dementia care policy or evidence of staff training.
The facility failed to provide adequate care for several residents, including maintaining comfortable positioning, nail care, and regular bathing. A resident with hemiplegia was left in an uncomfortable position without repositioning, another had unclean fingernails, and three residents did not receive showers as per their care plans. Staff interviews revealed issues with following up on care refusals and maintaining hygiene standards.
The facility failed to provide adequate staffing, resulting in missed showers and inadequate personal hygiene for residents. Despite an assessment indicating the need for 112 CNA hours per day, the facility consistently fell short, impacting resident care. Interviews with staff confirmed the challenges in maintaining basic care due to insufficient staffing.
A LTC facility failed to maintain a safe medication system, with incidents of tampered morphine and Ozempic insulin, and missing oxycodone from the emergency kit. Policies for storing and handling controlled substances were not followed, with improper documentation of narcotic counts and lack of audits contributing to the deficiencies.
The facility failed to maintain safe and appetizing food temperatures, as residents reported receiving cold meals. Observations confirmed that food temperatures were not within the required range, with soup, milk, tea, and ham sandwich all served at improper temperatures. The Dietary Manager was unsure how to maintain hot food temperatures during service, and beverages were not kept on ice as required.
The facility failed to ensure safe serving of hot beverages, resulting in a third-degree burn for a resident. Additionally, the facility did not adequately implement fall prevention interventions for residents at risk, leading to multiple falls and injuries. Furthermore, residents were unsafely transported in wheelchairs without foot pedals, causing their feet to drag on the floor.
A resident with a history of joint pain and surgical amputation experienced unmanaged pain due to the facility's failure to routinely assess pain and offer PRN medication. Despite being on a pain management program, the resident was not informed about available PRN medication and was not offered it when in pain. Staff interviews revealed a lack of awareness and adherence to pain management protocols, with no documentation of pain scores or PRN medication administration.
A resident with mental illness exhibited inappropriate behaviors, including entering another resident's room without pants and making threatening gestures. The facility failed to implement meaningful interventions or update the care plan to address these behaviors, contributing to ongoing issues. Staff interviews revealed inadequate monitoring and response to the resident's actions.
The facility failed to maintain a clean and homelike environment, with observations of unemptied urinals, poor room maintenance, and a shortage of linens. The DON acknowledged the need for regular urinal checks, but this was not consistently done. Maintenance issues included missing paint, holes, and exposed drywall, while the exterior showed signs of neglect. The facility also faced a linen shortage, impacting resident care.
The facility failed to ensure consistent documentation of residents' code status and proper CPR certification among staff. Multiple residents had discrepancies in their code status across various records, leading to potential confusion in emergencies. Additionally, several shifts lacked staff with valid CPR certifications, and the facility did not have policies to address these issues.
The facility employed an unqualified Activity Director who lacked necessary certifications and training, affecting all 67 residents. The director admitted to having no formal training and was the sole member of the activity department, with no resource person available. The Administrator, new to the facility, was unaware of the director's certification status.
The facility failed to provide adequate nursing staff, resulting in insufficient care for residents, including infrequent showers and delayed response to call lights. A resident reported going without a shower for extended periods, while another did not receive restorative therapy due to the absence of a restorative aide. The facility also lacked consistent RN coverage, relying on agency staff who often did not show up, leading to unmet resident needs.
The facility failed to ensure that CNAs, CMTs, LPNs, and RNs demonstrated competencies in essential care areas as outlined in their facility assessment. Training records for two CNAs showed no evidence of education or competencies in the past year, with only new hire training documented. Interviews revealed confusion and lack of responsibility for tracking and implementing training, with no training schedule or documentation available. The facility's attempt to implement a computer software training system was incomplete, and changes in nursing administration contributed to the lack of documentation.
The facility did not maintain the required RN coverage of at least eight consecutive hours a day, seven days a week, potentially affecting all 67 residents. The facility's assessment highlighted the need for such coverage, but reviews of payroll and staffing sheets showed several days in March, April, and May 2024 without RN hours. The interim DON confirmed reliance on agency RNs for weekends, with instances of no-shows.
The facility failed to ensure the Dietary Manager had the necessary certification and skills to manage food and nutrition services. The DM, hired without the required Certified Dietary Manager certification, lacked training and relevant experience. Interviews with staff, including the Registered Dietitian and Director of Nursing, confirmed the absence of certification. The Administrator was unaware of the DM's certification status, despite expecting compliance with federal requirements.
The facility failed to maintain sanitary conditions in its food service operations, with unlabeled food items, unclean equipment, and improper hand hygiene observed. Staff did not adhere to cleaning schedules, and the ice machine lacked an air gap. The Dietary Manager and Administrator were unaware of these issues, indicating a lack of oversight.
The facility failed to use resources effectively, resulting in numerous deficiencies, including lack of infection control logs, inadequate staff training, and reliance on agency staff. There were inconsistencies in medical records, unsanitary dietary services, and medication errors. The facility also failed to provide adequate care for mobility and range of motion, maintain a homelike environment, and ensure resident rights. Additionally, there was insufficient staffing, lack of oversight for administrative tasks, and failure to conduct thorough investigations of abuse allegations.
The facility did not have a current Quality Assurance and Performance Improvement (QAPI) plan or recent meeting minutes, failing to monitor and evaluate system problems. The Interim Administrator, who began in May, confirmed the absence of a QAPI policy and recent activities, with the last meeting minutes dated January 2023. Staff interviews indicated no recent QAPI committee meetings, and only an outdated outline was found.
The facility failed to implement an effective QAA committee, lacking a QA/QAPI policy and recent meeting minutes. The Interim Administrator, who started recently, found no recent QAPI meetings or active Process Improvement Plans. Staff interviews confirmed the absence of recent QAPI activities, despite expectations for a program with quarterly process improvement activities.
The facility did not maintain an active QAPI committee with required members and quarterly meetings. The Interim Administrator, who started recently, found no QAPI policy or recent meeting minutes, with the last notes dated over a year ago. No staff reported being part of a QAPI committee, and the Interim Administrator had not attended any QAPI meetings since starting.
The facility failed to follow infection control protocols, including Enhanced Barrier Precautions for a resident with a catheter, proper sanitization of glucometers during blood glucose monitoring, and maintenance of oxygen and nebulizer equipment. Additionally, the facility lacked a comprehensive water management plan and did not adhere to tuberculosis testing requirements for residents and new employees.
The facility failed to ensure the interim DON, acting as the infection preventionist, completed the required specialized training in infection prevention and control. Although partial module certifications were provided, a full program completion certificate was not available. The MDS coordinator, who had completed the certification, was not involved in the IPCP program at the facility.
The facility failed to provide mandatory training for all staff on its QAPI program, as revealed through interviews and record reviews. The facility's assessment and new employee training documentation did not include QAPI training. Interviews with staff showed a lack of clarity and responsibility for training oversight, with the Director of Nursing unaware of facility-wide training tracking and the RN Training Coordinator not conducting CNA education. The Interim Director of Nursing confirmed the absence of a training schedule, contributing to the deficiency.
The facility failed to maintain an effective infection prevention and control training program, as evidenced by the absence of documented training and competencies for CNAs hired in 2017 and 2023. Despite the facility's assessment requiring infection control education for all nursing staff, new employee training records lacked this component. Interviews revealed confusion over training responsibilities, with no established training schedule or system in place.
The facility failed to provide the required 12 hours of annual in-service education for CNAs, with no evidence of training or competencies documented for two CNAs. Interviews revealed confusion over responsibility for training, with no clear tracking or schedule in place. The facility's assessment lacked dementia and abuse prevention training.
The facility failed to provide comprehensive behavioral health training for all staff, as required by its assessment. Training was limited to nursing staff, excluding others, and new employee training lacked behavioral health components. Interviews revealed confusion over training responsibilities, with key staff unaware of facility-wide training efforts. The facility was attempting to implement a software training system but had no schedule in place.
The facility failed to address and respond to Resident Council concerns, as evidenced by recurring issues in food quality, laundry, and maintenance without documented follow-up. Residents reported dissatisfaction with dietary issues, medication management, and housekeeping. Interviews revealed that department supervisors did not consistently provide responses, and meeting minutes were not shared with residents.
The facility failed to ensure residents could voice grievances without fear of reprisal, as some residents experienced negative staff responses after filing complaints. Additionally, several residents were unaware of the grievance process, and the Social Services Director could not locate the grievance book, indicating poor record-keeping and communication.
The facility failed to complete required significant change in status assessments (SCSA) for three residents after notable changes in their conditions. These changes included increased dependency, cognitive improvements, and new medical needs, which were not documented in updated MDS assessments. The acting MDS coordinator, working part-time, was unaware of the residents' needs, leading to this oversight.
The facility failed to create comprehensive care plans for three residents, leading to deficiencies in addressing their individual needs. A resident's care plan did not reflect their DNR status or refusal of care, while another's plan lacked interventions for cognitive loss and diabetes. Additionally, a third resident's plan omitted details on transfer assistance and oxygen therapy. Staff interviews revealed issues with care plan updates due to staffing and communication problems.
The facility failed to update care plans for three residents, leading to deficiencies in care. A resident experienced cognitive decline and medication changes without care plan updates. Another resident had multiple falls due to cognitive impairment, with no care plan revisions for fall risk. A third resident's care plan was not updated after a fall causing injuries and missing hearing aids, impacting communication. Staff confusion over care plan responsibilities contributed to these issues.
The facility failed to adhere to professional standards of practice in medication administration and physician order compliance. Medications were left at the bedside without orders for two residents, necessary lab tests were not conducted for a resident, and another resident received oxygen therapy without a physician's order. Additionally, a resident missed several doses of Victoza due to unavailability and authorization issues.
The facility failed to provide adequate ADL assistance and hygiene care for four residents, leading to unshaven whiskers, improper perineal care, and infrequent showers. Residents with impaired cognition and mobility did not receive necessary grooming and hygiene support, as staff did not follow care plans or provide comprehensive personal care.
The facility failed to provide an adequate activity program for residents, particularly those with dementia, due to a lack of scheduled evening and dementia-specific activities. Observations showed residents with severe cognitive impairments had no involvement in activities, despite care plans indicating preferences. The new, untrained Activity Director struggled to balance responsibilities, leading to frequent cancellations and lack of engagement. The DON acknowledged the absence of specific policies and was unsure of evening and weekend offerings.
The facility failed to provide timely podiatry care for three residents, including two with diabetes, resulting in long and uncomfortable toenails. Despite orders and requests for podiatry consultations, residents had not seen a podiatrist in a long time. Staff interviews revealed issues with obtaining podiatry services and staffing challenges, contributing to the deficiency.
The facility failed to provide restorative services to three residents, impacting their range of motion and mobility. A resident with neck and shoulder limitations did not receive restorative care despite a referral. Another resident with chronic conditions had a restorative plan but no services were provided. A third resident, discharged from therapy, lacked a restorative program in their care plan. Staff interviews revealed the absence of a restorative aide led to the discontinuation of the program.
The facility failed to assess and document bed rail use for several residents, leading to deficiencies in safety and informed consent. A resident did not have a bed rail entrapment assessment or consent before installation, and their care plan lacked mention of bed rails. Another resident used a bed rail for mobility without proper assessment or consent documentation. A third resident's record lacked side rail assessments and physician orders, despite severe cognitive impairment and mobility assistance needs. Staff interviews revealed confusion about responsibilities for assessments and consent.
The facility failed to ensure two nurse aides completed their training and certification within four months of employment. Despite being employed for over six and seven months, neither aide was certified, and there was a lack of clarity and responsibility among staff regarding the tracking and completion of training. The Director of Nursing acknowledged the absence of a specific policy, and various staff interviews highlighted the deficiency in oversight.
The facility failed to provide the required 12 hours of in-service education per year for CNAs, as revealed by interviews and record reviews. Two CNAs lacked documented education hours or competencies, despite the facility's outlined staff education requirements. Interviews with staff indicated confusion over responsibility for tracking and implementing CNA training, contributing to the deficiency.
The facility failed to review or follow up on monthly pharmacy drug regimen recommendations for three residents. Despite the policy requiring comprehensive reviews and reporting, there was no documentation or evidence of addressing the pharmacy consultant's recommendations with the residents' physicians. The director of nursing was unaware of the need to access reports from the pharmacy website, leading to missing documentation and unaddressed recommendations.
The facility failed to comply with regulations for psychotropic medication management, including not limiting PRN orders to 14 days and not attempting gradual dose reductions (GDR) for several residents. The facility's policy lacked specific guidelines for GDRs and 14-day stop dates, and there was a lack of documentation and awareness regarding pharmacy consultant reports, contributing to these deficiencies.
The facility failed to serve food at a safe and appetizing temperature, with multiple residents reporting cold and unpalatable meals. Observations confirmed low food temperatures, such as hashbrowns at 96 degrees Fahrenheit. Despite staff expectations for hot and flavorful meals, the serving process led to significant cooling before consumption.
The facility did not follow its antibiotic stewardship program, which is part of its infection prevention and control efforts. The interim DON, acting as the IPCP, failed to conduct necessary antibiotic surveillance and tracking due to staffing turnover and time constraints. This resulted in a lack of monitoring and documentation of antibiotic use, despite several residents receiving antibiotic treatments.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails for potential entrapment risks, affecting several residents. Observations showed inconsistencies in bed rail positioning, and interviews revealed confusion among staff about responsibilities for measuring entrapment zones. This lack of adherence to policy compromised resident safety.
The facility failed to maintain resident dignity for two residents. One resident felt like a burden due to staff comments during short-staffed periods, while another reported being scolded by the SSD in front of others, which was humiliating. Both residents were cognitively intact and expressed concerns about the treatment they received.
A facility failed to notify a resident and their representative when the resident's trust account balance exceeded the Medicaid resource limit. The resident's account balance was over the limit, but no notice was given to the responsible party. Interviews revealed a lack of awareness and communication regarding the balance, with the BOM unaware of the excess and the regional fund manager relying on the bookkeeper and family to monitor the balance.
A resident alleged that a CNA slapped them, leading to a fall and a skin tear. The facility failed to conduct a thorough investigation as per its policy, lacking interviews with key staff and other residents. The DON and Administrator admitted that necessary steps were not taken to complete the investigation.
A facility failed to accurately code the MDS for a resident with severe cognitive impairment and multiple diagnoses, leading to discrepancies in documented falls and mobility status. The part-time MDS coordinator completed assessments without full knowledge of residents, relying on staff input and missing interdisciplinary meetings. The DON was unsure of the assessments' accuracy due to the coordinator's limited presence.
A facility failed to document and manage the PASARR process for a resident with significant mental health changes, including suicidal ideations and a new diagnosis of schizophrenia. The resident was admitted without a completed Level I PASARR, and the facility did not file for a Level II PASARR when conditions changed. Interviews revealed confusion among staff regarding PASARR responsibilities.
A facility failed to provide proper care for a resident with a urinary catheter, allowing the drainage bag and tubing to touch the floor, despite the resident's history of UTIs. Another resident with urinary incontinence did not receive proper perineal care, as a CNA failed to wash hands between assisting residents and used the same cloth area multiple times. These actions did not adhere to infection control protocols, increasing infection risk.
Failure to Identify and Address Dementia-Related Behaviors and Provide Staff Training
Penalty
Summary
The facility failed to provide appropriate care and services to maintain the highest practical well-being for a resident with vascular dementia. Staff did not identify or document triggers that led to the resident's aggression and combativeness, nor did they implement or document non-pharmacological interventions to address these behaviors. During an incident, staff continued to provide incontinence care and transferred the resident using a sit-to-stand lift while the resident was actively combative, resulting in the resident sustaining skin tears. The care plan was not updated to reflect the resident's behavioral responses or to provide individualized interventions related to dementia care. Multiple staff interviews revealed that several CNAs and LPNs had not received dementia care training upon hire and lacked direction on how to manage the resident's aggressive behaviors. Some staff were unaware of how to access care plans, and others relied on verbal reports to learn about resident care needs. Staff also reported that the resident was only aggressive with certain staff members, particularly those of the same gender, but this information was not communicated to facility leadership or reflected in the care plan. The psychiatric nurse practitioner was not informed of the resident's behavioral issues, and the care plan coordinator acknowledged that the care plan should have been updated after the incident. The facility did not provide a dementia care policy when requested, and there was no evidence that staff had received or understood dementia care training. The lack of communication, training, and individualized care planning contributed to the failure to address the resident's behavioral symptoms and ensure staff were equipped to manage dementia-related behaviors safely and effectively.
Deficiencies in Resident Care and Hygiene
Penalty
Summary
The facility failed to provide necessary care and services for several residents, leading to deficiencies in maintaining comfortable positioning, nail care, and bathing. Resident #4, who was admitted post-stroke with flaccid hemiplegia, was observed in an uncomfortable position in bed with legs hanging off the foot of the bed and was not repositioned by staff despite expressing discomfort. The resident was also left with a towel to clean up urine spills, indicating inadequate incontinence care. Resident #10, who required setup assistance for personal hygiene, was found with brown debris under the fingernails, which the resident was unaware of and upset about. This indicates a lack of attention to personal hygiene needs by the staff. Additionally, the facility's policy on nail care, especially for diabetic residents, was not adhered to, as there was no evidence of licensed nurses cutting the resident's fingernails. Residents #1, #5, and #14 did not receive showers as per their care plans, which specified twice-weekly showers. The records showed significant gaps between showers, and interviews with residents and staff confirmed that showers were often missed due to staffing issues. Resident #5's roommate noted that showers were infrequent, and Resident #14 reported not receiving showers twice a week. Staff interviews revealed that when residents refused showers, there was no consistent follow-up to ensure they received care, contributing to the deficiency in maintaining hygiene standards.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, particularly in the area of bathing. The facility's assessment indicated that with an average census of 60 residents, 112 certified nurse aide (CNA) hours per day were required. However, a review of the facility's daily staffing sheets from late December to mid-January showed consistent shortfalls in CNA hours, with deficits ranging from 7 to 44 hours per day. This staffing inadequacy directly impacted the care provided to residents, as evidenced by missed showers and inadequate personal hygiene. Three residents were specifically noted to have been affected by the staffing shortages. One resident, who required moderate assistance with showering, did not receive showers twice a week as scheduled, with gaps of up to 11 days between showers. Another resident, who preferred showers to bed baths, was only offered showers sporadically, with refusals noted but also significant gaps between offered showers. A third resident, who required supervision for bathing, also experienced long intervals between showers, sometimes up to nine days. Interviews with staff, including nurse aides and licensed practical nurses, confirmed the staffing issues, with reports of missed showers and difficulty in providing basic care such as hair brushing and incontinence care. The Director of Nursing and other administrative staff acknowledged challenges in filling open slots on the nursing schedule and were unaware of the specific staffing requirements outlined in the facility assessment. The administrator expected sufficient staffing to provide quality care but was uncertain if the responsible staff knew the required hours per discipline.
Medication Tampering and Documentation Failures in LTC Facility
Penalty
Summary
The facility failed to maintain a safe and effective medication system, as evidenced by several incidents involving tampered medications and improper documentation of narcotic counts. Morphine prescribed for two residents was found to have unusual smells, indicating tampering, and a card of oxycodone was missing from the facility's emergency medication kit. Additionally, an Ozempic insulin pen for another resident was tampered with and replaced with a different type of insulin. These incidents highlight significant lapses in medication security and monitoring. The facility's policies for storing and handling medications, particularly controlled substances, were not adequately followed. Controlled substances were not consistently stored under double lock and key, and the required narcotic counts at shift changes were not properly documented. Interviews with staff revealed that medication counts were often not conducted due to the absence of available personnel to perform the task together, leading to discrepancies in the controlled substance shift change log. The facility's failure to audit medication carts and the Stat Safe emergency medication kit contributed to the deficiencies. The consultant pharmacist discovered the missing oxycodone during a routine visit, and it was noted that a nurse could access the Stat Safe without a witness. The lack of oversight and adherence to policies for medication administration and documentation resulted in multiple instances of medication tampering and missing narcotics, compromising resident safety.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to provide food items at a safe and appetizing temperature, as observed during a survey. The facility's policy requires hot foods to be served at no less than 120 degrees Fahrenheit and cold foods at no greater than 40 degrees Fahrenheit. However, during meal service, residents reported receiving cold meals, and observations confirmed that food temperatures were not maintained within the required range. Specifically, a test tray showed soup at 118 degrees Fahrenheit, milk at 62 degrees Fahrenheit, tea at 60 degrees Fahrenheit, and ham on a sandwich at 52 degrees Fahrenheit. These temperatures were below the facility's standards for hot foods and above the standards for cold foods. Interviews with residents revealed consistent complaints about receiving cold meals, particularly when meals were served in their rooms. The Dietary Manager acknowledged the issue, noting that the soup was initially at 165 degrees Fahrenheit before service but was unsure how to maintain the temperature during service. Additionally, beverages were not kept on ice as required, contributing to the improper temperatures. The Administrator confirmed that beverages should be kept on ice and meals should be served in a timely manner to ensure proper temperatures.
Deficiencies in Hot Beverage Service, Fall Prevention, and Wheelchair Transport
Penalty
Summary
The facility failed to ensure the safe serving of hot beverages, resulting in a third-degree burn for a resident. The resident, who was cognitively intact but had limited range of motion, was served hot water in a large Styrofoam cup, which was placed out of reach. As the resident attempted to pull the overbed table closer, the cup tipped over, spilling hot water onto the resident's leg. The facility did not have a policy for hot liquid service, and staff training did not include instructions on placing trays or allowing drinks to cool before serving. The facility also failed to implement and modify fall prevention interventions for residents at risk of falls. One resident with a history of falls and moderate cognitive impairment experienced multiple falls, resulting in injuries such as a dislocated shoulder and lacerations. Despite these incidents, the resident's care plan was not updated to address the fall risk adequately. Another resident with severe cognitive impairment and a history of falls was not provided with a care plan that addressed their fall risk, leading to multiple falls and injuries. Additionally, the facility did not safely transport residents in wheelchairs, as staff pushed residents without foot pedals, causing their feet to drag on the floor. This practice was observed with multiple residents, and staff were unaware of the location of the foot pedals. The facility's policy on wheelchair use did not address the importance of using foot pedals during transport, contributing to the unsafe transportation of residents.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident with a history of joint pain, surgical amputation, and phantom leg pain. The resident was on a pain management program that included scheduled and PRN opioids, but the facility did not routinely assess the resident's pain as ordered. The resident frequently experienced pain that interfered with daily activities and expressed agitation and difficulty sleeping due to pain. Despite having PRN pain medication available, the resident was not informed of this option and was not offered additional medication when complaining of pain. Interviews with the resident revealed that their pain was never controlled, and they were unaware of the availability of PRN medication. Observations showed the resident in distress, rocking back and forth in their wheelchair, and expressing frustration about their unmanaged pain. The facility's medication administration record (MAR) lacked documentation of PRN medication administration and pain scores, indicating a failure to follow physician orders for pain assessment every shift. Staff interviews highlighted a lack of awareness and adherence to pain management protocols. Certified Medication Technicians (CMTs) responsible for the resident's care did not document pain scores or offer PRN medication, as they believed the resident was simply agitated and did not request it. The Director of Nursing (DON) acknowledged the expectation for staff to follow physician orders and assess pain, but was unaware of the resident's ongoing pain issues and inability to sleep.
Failure to Provide Appropriate Behavioral Interventions for Resident with Mental Illness
Penalty
Summary
The facility failed to provide appropriate person-centered and individualized treatment and services to a resident with mental illness, resulting in multiple incidents of inappropriate behavior. The resident, who had a history of schizoaffective disorder, major depressive disorder, anxiety disorder, and a history of trauma, exhibited behaviors such as entering another resident's room without pants, lighting a cigarette indoors, and making threatening gestures towards other residents. Despite these behaviors, the facility did not implement meaningful interventions or ensure the resident received services to address these behaviors. The resident's care plan was not adequately updated to address ongoing inappropriate sexual behaviors and aggressive actions towards peers. The facility's interventions were insufficient, as evidenced by the resident's continued inappropriate actions, including touching other residents inappropriately and attempting to choke a roommate. The facility's lack of a comprehensive behavior management policy and failure to implement non-pharmacological interventions contributed to the deficiency. Interviews with staff revealed that the resident's behaviors were often triggered by urinary tract infections, yet the facility's response was limited to encouraging fluid intake. The facility did not consistently monitor the resident's interactions with peers, and staff were not always present to redirect the resident during negative behaviors. The facility's failure to provide a structured environment and consistent routines, as recommended in the resident's PASRR II assessment, further contributed to the deficiency.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of poor housekeeping and maintenance practices. In several resident rooms, urinals were not emptied or replaced as per physician orders, leading to unpleasant odors. The Director of Nursing acknowledged that urinals should be checked and emptied regularly by staff, but this was not consistently done. Additionally, the facility lacked a homelike environment policy, and the housekeeping department was short-staffed, contributing to the inadequate cleanliness and maintenance of resident rooms. Numerous observations revealed significant maintenance issues throughout the facility. Resident rooms had walls with missing paint, holes, and exposed drywall, while bathroom fixtures were stained and in disrepair. The facility's exterior also showed signs of neglect, with rotted trim boards, missing paint, and loose siding. The maintenance director admitted to being aware of some issues but was unable to address them due to budget constraints and lack of resources. The housekeeping supervisor noted that vents were cleaned monthly, but the buffer machine needed for floor maintenance was broken, further hindering cleaning efforts. The facility also faced a shortage of linens, impacting the ability to provide adequate resident care. Linen carts and closets were often empty or contained insufficient supplies, forcing residents to wait for bed changes or use their own linens. The laundry supervisor reported a decrease in available linens, suspecting that agency staff might be discarding them. Despite notifying the previous administrator about the shortage, no action was taken to address the issue. The current administrator acknowledged the lack of a linen policy and was unaware of any requests for additional linens from the supplier.
Inconsistent Code Status Documentation and CPR Certification Deficiencies
Penalty
Summary
The facility failed to ensure systems were in place to clearly document residents' code status and communicate this information to direct care staff. This deficiency was identified for multiple residents, where inconsistencies were found between the residents' face sheets, care plans, physician order sheets (POS), paper charts, and the facility's 24-hour daily nursing reports. For instance, one resident's face sheet did not indicate a code status, while their care plan and POS showed a full code status, yet the 24-hour daily nursing report indicated a DNR status. Such discrepancies were prevalent across several residents, leading to potential confusion about whether to perform CPR in emergencies. The facility also failed to ensure that a staff member with the required CPR certification was scheduled for each shift. The survey revealed that several shifts lacked staff with valid CPR certifications, and some staff members' CPR certifications did not meet the requirements for basic life support (BLS) for healthcare providers. Interviews with staff members highlighted a lack of clarity and consistency in identifying residents' code status, with some relying on outdated or incorrect documentation. Additionally, the facility did not have policies regarding staff CPR certification, scheduling for CPR coverage, or code status documentation. The Director of Operations confirmed the absence of such policies, and the Director of Nursing acknowledged the inconsistencies in code status documentation and the lack of verification of agency staff CPR credentials. This lack of policy and oversight contributed to the deficiencies observed during the survey.
Unqualified Activity Director Lacks Certification and Training
Penalty
Summary
The facility failed to employ a qualified activity professional to oversee its activity program, affecting all 67 residents. The current Activity Director had not completed an approved activity professional training program and lacked both state certification and certification in therapeutic recreation or activities. The facility was unable to provide job title responsibilities and qualifications for the Activity Director, only providing a job description for an assistant activity director. The employee list confirmed that the department head was the Activity Director, yet her file showed no relevant certifications. Interviews revealed further deficiencies in the activity program. The Activity Director admitted to having no formal training in activities and split her time between activities and resident transportation. She was the sole member of the activity department and had no resource person to assist her. She also expressed a lack of knowledge regarding appropriate activities for residents with dementia. The Director of Nursing indicated that the administrator was responsible for ensuring staff certifications. However, the Administrator, who was new to the facility, was unaware of the Activity Director's certification status and expected a certified director to oversee and train her until certification was obtained.
Staffing Shortages and Inadequate Care in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by the lack of routine showers and timely response to call lights for certain residents. Specifically, Resident #61 did not receive regular showers, leading to poor personal hygiene and body odor. The resident expressed dissatisfaction with the infrequency of showers and the lack of staff to change bed sheets. Additionally, Resident #41 reported delays in receiving assistance, including waiting an hour for help and not receiving restorative therapy due to the absence of a restorative aide. The facility also did not maintain the required staffing levels, including the absence of a Registered Nurse (RN) for eight consecutive hours a day, seven days a week. The facility's staffing records showed multiple days without RN coverage, and the Director of Nursing (DON) confirmed that the facility relied heavily on agency staff, who often did not show up for work. This staffing shortage affected the delivery of care, as residents reported delays in receiving medications and assistance with activities of daily living. Furthermore, the facility's restorative nursing program was discontinued after the restorative aide left, leaving residents without necessary therapy. The therapy director and DON confirmed that the program was halted due to the lack of trained staff. The facility's failure to maintain adequate staffing and provide necessary care and services as outlined in the facility assessment contributed to the deficiencies observed during the survey.
Failure to Ensure Staff Competency and Training
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had the appropriate competencies to care for residents, as outlined in their facility assessment. The assessment, updated on 5/20/24, specified that all Certified Nurse Assistants (CNAs), Certified Medication Technicians (CMTs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs) were required to demonstrate competencies in various areas such as activities of daily living, mobility, fall prevention, bowel and bladder care, skin integrity, mental health, medication and pain management, infection control, management of medical conditions, therapy, special care needs, nutrition, and person-centered care. However, the facility did not provide evidence of education, testing, or return demonstrations for these competencies. The report highlighted specific deficiencies in the training records of two CNAs. CNA C, hired on 12/5/17, and CNA PP, hired on 4/17/23, both lacked documentation of education hours or competencies in the past year. The only training documented for both was their new hire training, which did not include any competencies. Interviews with the Interim Director of Nursing, Social Service Director (SSD), RN Training Coordinator/MDS Coordinator, and Business Office Manager revealed a lack of clarity and responsibility regarding the tracking and implementation of training and competencies for CNAs and other staff. The Interim Director of Nursing admitted that the facility was attempting to implement a computer software training system, but it had not been accomplished. There was no training schedule in place, and the documentation of training and competencies was either missing or could not be located. The facility had undergone changes in nursing administration, which contributed to the confusion and lack of documentation. The report indicates a systemic failure in maintaining and verifying staff competencies, which is crucial for ensuring the well-being of residents.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, which had the potential to affect all 67 residents. The facility's assessment, updated on May 20, 2024, indicated the necessity of RN coverage for eight hours daily. However, a review of the facility's RN payroll and agency staffing sheets revealed multiple instances in March, April, and May 2024 where there was no evidence of RN hours, specifically on March 4, 9, 10, and 31, April 19, and May 18, with insufficient hours on April 5. During an interview, the interim Director of Nursing stated she was the only full-time RN, and the facility relied on agency RNs for weekends, but there were occasions when agency RNs did not show up.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the necessary competencies and skills to fulfill the responsibilities of the food and nutrition services department. The DM, hired on January 23, 2023, lacked the required certification as a Certified Dietary Manager, a federal requirement for long-term care facilities. Additionally, there was no evidence of certification as a certified food service manager, national certification for food service management, or documentation of an associate's or higher degree in food service management or hospitality. The DM also did not have two or more years of experience in the position of director of food and nutrition services in a nursing facility setting. The only certification present was a State Food Safety Food Protection Manager Certification, which does not meet the dietary manager certification requirements. Interviews with facility staff revealed that the DM had not received any training related to the position and had only attended a food safety course. The Registered Dietitian, who visits the facility monthly, confirmed that the DM was not certified. The Director of Nursing acknowledged the lack of certification, stating that it was the administrator's responsibility to ensure staff certifications. The Administrator expressed an expectation for the DM to be certified and, if not, to be supervised by a certified Dietary Manager or Dietitian until certification was obtained. However, the Administrator admitted to not being aware of the DM's certification status due to his short tenure at the facility.
Sanitation and Hygiene Deficiencies in Food Service Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in its food service operations, as observed during a survey. Staff did not label and date opened food items in the kitchen refrigerator, including sandwiches and pudding, which is against the facility's food storage guidelines. Additionally, the ice machine was not properly cleaned, with scaly material and slime observed, and lacked an appropriate air gap at the drain, which is necessary for sanitary conditions. The Maintenance Director was unaware of the missing air gap and the Dietary staff were behind on checking items for labeling and dating. The kitchen and food preparation areas were found to be in unsanitary conditions, with slime and debris in the steam table, oil and debris on the sneeze guard, and a buildup of oily material on various kitchen surfaces and equipment. The cleaning schedules were not adhered to, as evidenced by the presence of dust, debris, and oily material on kitchen hoods, fire suppression systems, and other surfaces. Dietary staff admitted to not completing cleaning tasks due to time constraints, and the Dietary Manager was unaware of the extent of the cleanliness issues due to a recent absence. Improper hand hygiene and glove use were also observed, with staff failing to wash hands before putting on gloves and using the same gloves for multiple tasks. Staff entered the kitchen without hairnets and handled food without washing hands, which is against the facility's handwashing and glove use guidelines. The Dietary Manager and Administrator were not fully aware of these issues, indicating a lack of oversight and adherence to sanitary practices in the facility's food service operations.
Facility Fails to Use Resources Effectively, Leading to Multiple Deficiencies
Penalty
Summary
The administration of the facility failed to effectively use its resources to ensure the highest practicable well-being of its residents. Observations during the survey period revealed numerous deficiencies, including the absence of infection control logs, lack of yearly staff education on dementia care, abuse, and neglect, and failure to provide required training hours for certified nursing assistants. The facility also lacked an organized Quality Assurance and Performance Program (QAPI) and relied entirely on agency staff for licensed nursing positions, with no permanent licensed nursing staff hired. Additionally, there were inconsistencies in residents' cardiopulmonary resuscitation status across medical records, unsanitary dietary services, and medication administration errors. Further deficiencies included inadequate management of foot care, failure to prevent decline in mobility and range of motion, inconsistent protective oversight, and insufficient supplies such as linens. The facility did not consistently provide assistance with activities of daily living, follow infection control measures, or offer an activities program that met the needs of all residents. There was a lack of proper certification for key staff roles, failure to ensure resident rights, and grievances were not being addressed. The facility also failed to provide oversight for various administrative tasks, such as completing Advance Beneficiary Notices and notifying residents about trust account balances. The physical environment was not maintained, and there was insufficient staffing to meet residents' needs. Additionally, the facility did not conduct thorough investigations of abuse allegations or ensure timely and accurate assessments. Pharmacy reviews were not being received or followed up on, and the facility had experienced significant turnover, relying heavily on agency staffing.
Lack of QAPI Plan and Implementation
Penalty
Summary
The facility failed to establish and implement a Quality Assurance and Performance Improvement (QAPI) plan to monitor and evaluate system problems, as evidenced by the absence of a current QAPI policy or recent meeting minutes. The facility, with a census of 67, did not provide a QAPI policy when requested by the state agency. The last available QAPI meeting minutes were dated January 2023, and no current, facility-specific QAPI plan was found in the provided binder. The Interim Administrator, who started on May 7, 2024, confirmed that the facility lacked a QAPI policy, recent minutes, or completed QAPI information. Interviews with current staff revealed that no one recalled recent QAPI committee meetings, and the Interim Administrator only found an outline of what to do, which he was unsure was current. He expected the facility to have a QAPI program with process improvement activities meeting quarterly with appropriate team members.
Failure to Implement Effective QAA Committee
Penalty
Summary
The facility staff failed to implement an effective Quality Assessment and Assurance (QAA) committee to address and resolve identified concerns. The facility, with a census of 67, did not provide a Quality Assurance (QA)/QAPI policy when requested. A binder labeled QAPI, reviewed on May 23, 2024, contained meeting minutes last dated January 2023. The Interim Administrator, who began on May 7, 2024, confirmed that the facility lacked a QAPI policy and recent meeting minutes. Interviews with current staff revealed no recent QAPI meetings or active Process Improvement Plans. The Interim Administrator expected the facility to have a QA/QAPI program with quarterly process improvement activities involving appropriate team members.
Lack of Active QAPI Committee and Meetings
Penalty
Summary
The facility failed to maintain an active Quality Assurance and Process Improvement (QAPI) committee with the required members and quarterly meetings. The facility, with a census of 67, did not provide documentation of a QAPI policy or recent meeting minutes. The last available QAPI meeting notes were dated over a year ago. The Interim Administrator, who started on 5/7/24, confirmed that no QAPI policy or recent minutes were available and that no staff reported being part of a QAPI committee. The Interim Administrator expected the QAPI program to include the Administrator, Director of Nursing, several floor staff, department heads, medical director, pharmacist, and dietitian, meeting at least quarterly. However, he had not participated in any QAPI meetings since his tenure began.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols for multiple residents, leading to several deficiencies. For Resident #20, who had an indwelling urinary catheter, staff did not follow Enhanced Barrier Precautions (EBP), as they were unaware of what EBP entailed and did not use gowns during care. This resident had a history of urinary tract infections and returned from the hospital with antibiotics, yet the staff did not implement the necessary precautions to prevent further infections. Additionally, the facility did not follow proper infection control practices during blood glucose monitoring for several residents. The staff failed to sanitize the glucometer appropriately and did not place it on a clean surface after use. This oversight occurred repeatedly across different residents, indicating a systemic issue with the procedure for blood glucose monitoring. The facility also neglected to maintain proper infection control regarding oxygen and nebulizer equipment. Oxygen tubing was not changed as ordered, and nebulizer equipment was not cleaned according to facility policy. Furthermore, the facility did not have a comprehensive water management plan to prevent Legionella, and there were lapses in tuberculosis testing for both residents and new employees, with some tests not being administered or documented correctly.
Inadequate Training for Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated infection preventionist (IP) completed the required specialized training in infection prevention and control. The interim Director of Nursing (DON) was serving as the IP after the departure of the previous DON and assistant director of nursing (ADON). Although the interim DON claimed to have completed the Infection Prevention Control Program (IPCP), the facility was unable to provide a certificate of completion for the entire program, only partial module certifications were available. This deficiency affected all 67 residents in the facility. Additionally, the facility's policy required the selection of an Antibiotic Stewardship Champion (ASC) who would be responsible for implementing and maintaining the antibiotic stewardship program, with certification through the CDC. However, the MDS coordinator, who had completed the IPCP certification, was only employed part-time for MDS assessments and had not been involved in the IPCP program at the facility. The MDS coordinator provided her certificate to the facility for potential future assistance, but no direct involvement in the IPCP was noted at the time of the survey.
Failure to Provide Mandatory QAPI Training for Staff
Penalty
Summary
The facility failed to provide mandatory training for all staff on its Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified through interviews and record reviews, revealing that the facility did not include QAPI training in its new employee training or ongoing staff education. The facility's assessment, updated on 5/20/24, outlined various staff education and competencies but did not address QAPI training. Additionally, the new employee training documentation lacked any mention of QAPI training, focusing instead on topics like resident rights, abuse prevention, and company policies. Interviews with facility staff highlighted a lack of clarity and responsibility regarding training oversight. The Director of Nursing was unaware of any facility-wide training tracking beyond new hire training. The Social Service Director, who previously tracked CNA and NA training, no longer did so, and the RN Training Coordinator/MDS Coordinator stated she did not conduct CNA education or competencies. Furthermore, the Business Office Manager confirmed the absence of QAPI training records for specific employees. The Interim Director of Nursing acknowledged the facility's attempt to implement a computer software training system, which had not yet been accomplished, and confirmed the absence of a training schedule. This lack of structured training and oversight contributed to the facility's failure to ensure all staff received mandatory QAPI training, as required.
Deficiency in Infection Control Training Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control training program for its staff, as evidenced by the lack of documented training and competencies in the employee education files of two Certified Nurse Assistants (CNAs) hired in 2017 and 2023. The facility's assessment indicated that all CNAs, Certified Medication Technicians (CMTs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs) were required to undergo education and return demonstrations to assess their abilities in infection prevention and control. However, the new employee training records reviewed did not include infection control training, despite the facility's stated requirements. Interviews with various staff members revealed a lack of clarity and responsibility regarding the tracking and implementation of infection control training. The Director of Nursing was unaware of who was responsible for facility-wide training beyond new hires, while the Social Service Director and RN Training Coordinator/MDS Coordinator both indicated they did not track or conduct CNA training or competencies. Additionally, the facility was in the process of implementing a computer software training system, but this had not yet been accomplished, and there was no established training schedule in place.
Deficiency in CNA Training and Competency Documentation
Penalty
Summary
The facility failed to ensure that Certified Nurse Assistants (CNAs) received the required 12 hours of in-service education annually. This deficiency was identified through interviews and record reviews, which revealed that two CNAs, hired on different dates, did not have any documented evidence of education hours or competencies in the past year. The facility's assessment, updated in May 2024, outlined various staff education and competencies but did not address dementia training or annual abuse and neglect prevention training. Interviews with facility staff highlighted a lack of clarity and responsibility regarding the tracking and provision of CNA training. The Director of Nursing initially indicated that the Social Service Director was responsible for tracking training hours and competencies, but the Social Service Director stated that the RN Training Coordinator was handling CNA training. However, the RN Training Coordinator confirmed that she did not conduct any CNA education or competencies, nor did she perform annual training for CNAs. Further interviews revealed that the facility was attempting to implement a computer software training system, but this had not been accomplished. The Interim Director of Nursing mentioned that there was no training schedule in place and that while some training documentation was completed earlier in the year, changes in nursing administration led to uncertainty about the current status of training records and staff attendance.
Deficiency in Behavioral Health Training for Facility Staff
Penalty
Summary
The facility failed to maintain a comprehensive training program for all staff, specifically lacking in behavioral health care and services training. The facility's assessment, updated in May 2024, outlined the need for staff education in managing mental health and behavioral issues, including psychiatric symptoms, cognitive impairments, and other psychiatric diagnoses. However, the training was only identified for nursing staff, excluding other facility staff. The new employee training program also did not include behavioral health training, which was a requirement according to the facility assessment. Interviews with various staff members, including the Director of Nursing, Social Service Director, and RN Training Coordinator, revealed a lack of clarity and responsibility regarding the tracking and implementation of training programs. The Director of Nursing was unaware of any facility-wide training beyond new hire training, and the Social Service Director no longer tracked CNA training. The RN Training Coordinator confirmed that she did not conduct CNA education or competencies, nor did she handle annual training for all employees. The Business Office Manager confirmed the hire dates of CNAs but did not have additional training information. The Interim Director of Nursing acknowledged the absence of a training schedule and the ongoing attempt to implement a computer software training system.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to consistently address and respond to concerns brought forth by the Resident Council, as evidenced by the lack of documentation and follow-up on issues raised during council meetings. The facility's grievance protocol, which outlines the responsibilities of the Social Services Director (SSD) and the administrator in handling grievances, was not effectively implemented. The Resident Council Meeting Minutes from February, March, and April 2024 highlighted recurring issues such as inadequate food quality, unresolved laundry problems, and maintenance concerns, with no documented follow-up or resolution. Interviews with residents and staff revealed that department supervisors did not consistently provide responses to the Resident Council's questions or recommendations, and meeting minutes were not shared with the residents. Residents expressed dissatisfaction with various aspects of their care, including dietary issues, medication management, and housekeeping. Specific grievances included bland and improperly cooked food, missing laundry items, and insufficient housekeeping staff. Additionally, maintenance issues such as broken beds and wheelchairs, and the need for air conditioner filter replacements were reported. Despite these ongoing concerns, the facility did not maintain a consistent process for addressing and resolving grievances, as the Activities Director did not follow up for responses from department supervisors, and the administrator's expectations for timely responses were not met.
Failure to Ensure Safe Grievance Process
Penalty
Summary
The facility failed to ensure that residents could voice grievances without fear of discrimination or reprisal. Two residents expressed concerns about the negative response from staff after filing grievances. One resident reported that staff made derogatory comments after a grievance was filed, and another resident expressed fear of retaliation, indicating a lack of a safe environment for voicing concerns. Additionally, the facility did not adequately inform residents about the grievance process. Several residents were unaware of how to file a grievance or that they could file directly with the state agency. This lack of information suggests that the facility did not effectively communicate the grievance procedures to its residents, which is a critical component of ensuring residents' rights are upheld. The Social Services Director, responsible for managing grievances, was unaware of certain grievances and could not locate the grievance book, which was found damaged and unreadable. This indicates a failure in maintaining proper records and oversight of the grievance process, further contributing to the deficiency in handling resident grievances appropriately.
Failure to Complete Significant Change Assessments
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) for three residents within the required 14-day period after a significant change in their condition was identified. This deficiency was observed in a review of 24 sampled residents. The facility did not perform the necessary assessments to document changes in the residents' physical or mental conditions, which impacted multiple areas of their health status and required an interdisciplinary review and revision of their care plans. For Resident #54, the facility did not complete an SCSA despite significant changes in the resident's condition, including a decline in cognitive and physical abilities, the need for oxygen therapy, and a shift to comfort care only. The resident, who previously exhibited independence in certain activities, became dependent on staff for all care and was placed on oxygen therapy. These changes were not reflected in an updated MDS, indicating a failure to reassess and adjust the care plan accordingly. Resident #42 experienced a significant increase in cognitive ability, a decrease in pain, and changes in mobility and restraint use, yet the facility did not complete an SCSA to document these improvements. Similarly, Resident #52 showed increased dependency in activities of daily living, a rise in incontinence and falls, and new diagnoses, but the facility failed to conduct an SCSA. The acting MDS coordinator, who was only present part-time, admitted to not being fully aware of the residents' needs and not completing the necessary assessments, contributing to the oversight.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for three residents, leading to deficiencies in meeting their individual needs. For Resident #20, the care plan did not reflect the resident's preferred Do Not Resuscitate (DNR) status, despite it being documented in the resident's out-of-hospital DNR form. Additionally, the care plan lacked documentation of the resident's repeated refusals of catheter and peri-care, which were noted in multiple progress notes. Interviews with staff revealed that the resident often refused care from certain staff members, yet this was not addressed in the care plan. Resident #68's care plan was found lacking in addressing the resident's cognitive loss/dementia and diabetes, despite these conditions being documented in the resident's medical records and physician orders. The resident's admission and quarterly Minimum Data Set (MDS) assessments indicated severe cognitive impairment and diabetes, yet the care plan did not include any problems, goals, or interventions related to these diagnoses. This oversight suggests a failure to incorporate critical health information into the care planning process. For Resident #4, the care plan did not include necessary details on how the resident was to transfer, despite requiring substantial assistance for transfers as indicated in the MDS. Furthermore, the care plan did not document the resident's need for oxygen therapy or the discontinuation of restorative nursing services, which were noted in the physician orders. Interviews with facility staff revealed a lack of clarity and responsibility in updating care plans, with the Director of Nursing acknowledging that care plans were not being updated due to staffing issues and lack of communication.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update the comprehensive care plans for three residents, leading to deficiencies in their care. Resident #17 experienced a significant decline in cognitive function, increased assistance needs, and changes in medication, including the addition of an antidepressant and pain management drugs. Despite these changes, the resident's care plan was not updated to reflect the new cognitive status, medication regimen, or the removal of an indwelling urinary catheter. Observations showed the resident's condition had changed, yet the care plan remained outdated. Resident #52 had multiple falls, some resulting in injuries, due to severe cognitive impairment and attempts to assist a family member who was also a resident. The care plan did not address the resident's fall risk or the need for increased supervision and assistance. Despite several falls and changes in the resident's condition, including increased assistance needs and the use of a walker, the care plan was not revised to include these critical interventions. Resident #42's care plan was not updated after improvements in transfer, ambulation, continence, and cognition. The resident experienced a fall resulting in a dislocated shoulder and facial lacerations, yet the care plan did not reflect these injuries or the need for increased pain management. Additionally, the resident's missing hearing aids were not addressed in the care plan, impacting communication with staff. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans, contributing to the deficiencies.
Medication Administration and Physician Order Compliance Deficiencies
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards of practice, as evidenced by several incidents involving multiple residents. For Resident #38, medications were left at the bedside without a physician's order permitting self-administration. The resident had various medications, including an inhaler and pain medication, left unattended, which the resident claimed to use as needed. The Certified Medication Technician (CMT) acknowledged that medications should not be left at the bedside unless ordered by a physician, yet the resident's medications were found unattended. Resident #59 also had medications left at the bedside without the appropriate order. The resident was unsure about the medication left and when it was brought to them. The Licensed Practical Nurse (LPN) and CMT both confirmed that the resident should not have medications left at the bedside, yet the medication was found and later taken by the resident without supervision. This indicates a lapse in following the facility's medication administration policy. Additionally, the facility failed to obtain necessary laboratory tests and maintain medication availability. Resident #1 did not have a required Dilantin level drawn, and the Director of Nursing (DON) could not explain how the order was missed. Resident #25 was on oxygen therapy without a physician's order, and Resident #45 experienced multiple days without receiving the prescribed Victoza due to unavailability and issues with prior authorization. These incidents highlight a pattern of non-compliance with physician orders and facility policies, leading to potential risks for the residents involved.
Inadequate ADL Assistance and Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate care and assistance for activities of daily living (ADLs) to four residents who were unable to perform these tasks independently. Resident #4, with severely impaired cognition and dependent on staff for personal hygiene, was observed with unshaven whiskers despite expressing a preference for a clean-shaven appearance. The resident's care plan indicated a need for assistance with ADLs due to dementia progression, yet staff did not meet these needs as evidenced by the resident's unkempt appearance. Resident #26, who was incontinent of bowel and bladder and at high risk for urinary tract infections, did not receive proper perineal care. Observations showed that CNAs failed to clean all necessary areas during incontinence care, leaving the resident's skin in contact with urine and feces. The care plan required assistance with toileting and hygiene, but the staff did not adequately perform these tasks, compromising the resident's hygiene and comfort. Resident #28, with moderately impaired cognition and limited mobility, did not receive comprehensive personal care. The CNA did not clean all areas during perineal care, and the resident was left with unkempt hair and dried matter around the eyes. Additionally, Resident #61, who required assistance with bathing and personal hygiene, went extended periods without showers, leading to body odor and long facial hair. The facility's policies lacked specific guidelines on the frequency of showers and personal grooming, contributing to the deficiencies observed.
Inadequate Activity Program for Dementia Residents
Penalty
Summary
The facility failed to design an activity program that met the needs, interests, and well-being of its residents, particularly those with dementia. Observations and interviews revealed that there were no scheduled evening activities or activities specifically tailored for dementia residents. The activity calendar showed limited weekend activities, primarily consisting of bingo and devotionals, with no evidence of one-on-one activities or engagement for residents with cognitive impairments. Resident #22, diagnosed with dementia and severely impaired cognitive skills, was observed to have no involvement in activities despite a care plan that encouraged socialization and participation in favorite activities. Similarly, Resident #44, also with severe cognitive impairment, expressed the importance of religious services and music but had no documented activity assessments or participation. Resident #52, with a diagnosis of dementia, had preferences for reading, music, and outdoor activities, yet there was no evidence of activity engagement or assessments in their medical record. Interviews with staff and residents highlighted systemic issues in the activity program. The Activity Director, who was new and untrained, struggled to balance her responsibilities between activities and transportation, resulting in frequent cancellations and lack of enthusiasm. The Director of Nursing acknowledged the lack of specific policies for activities and was unsure of the evening and weekend offerings. The facility's failure to provide adequate activities for dementia residents and ensure consistent programming contributed to the deficiency.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to provide appropriate foot care for three residents, including two with diabetes, in a sample of 24 residents. Resident #36, who has congestive heart failure, end-stage kidney disease, and diabetes, had orders from a dialysis clinic to have their toenails trimmed, which were not followed. Observations showed that the resident's toenails were long, uneven, and causing discomfort. Despite multiple reminders from the dialysis clinic, the resident had not seen a podiatrist in a long time. Resident #9, diagnosed with heart failure and requiring assistance with personal hygiene, had an order for a podiatry consult that was not fulfilled. The resident expressed a desire to see a podiatrist, indicating it had been a long time since their last visit. Similarly, Resident #34, who is diabetic, had not seen a podiatrist for over a year despite having an order for a podiatry evaluation. The resident expressed a need to see a podiatrist due to their diabetic condition. Interviews with facility staff revealed systemic issues in obtaining podiatry services. CNA W stated that CNAs were not allowed to clip toenails for diabetic residents, and a list for the podiatrist had been started six weeks prior without a visit occurring. LPN R mentioned difficulties due to thick toenails and staffing issues, while the social services director and the Director of Nursing acknowledged problems with securing a foot care provider, noting that a new podiatrist had been contracted but had not yet seen the residents.
Failure to Provide Restorative Services
Penalty
Summary
The facility failed to provide restorative services to three residents, resulting in a deficiency in maintaining or improving their range of motion and mobility. Resident #28 had limitations in neck and shoulder range of motion and required assistance with activities of daily living (ADLs). Despite a referral for restorative nursing to maintain upper body strength and standing tolerance, there was no evidence of restorative services being provided. Observations showed the resident was unable to assist with upper body movements and required maximum assistance for transfers. Resident #41, with diagnoses including chronic kidney disease and diabetes mellitus, had a restorative plan for upper and lower extremity strengthening. However, the resident did not receive any restorative nursing minutes, and there was no evidence of services being provided. The resident expressed a desire for restorative nursing but noted the facility lacked the staff to provide it. Resident #68, diagnosed with cerebrovascular disease and vascular dementia, was discharged from skilled therapy with a plan for a restorative program. Despite this, the resident's care plan did not include restorative nursing, and there was no documentation of such services. Observations indicated the resident required substantial assistance for mobility and transfers. Interviews with staff revealed the facility's restorative aide had been terminated, and no replacement had been hired, leading to the discontinuation of the restorative nursing program.
Deficiencies in Bed Rail Assessment and Consent
Penalty
Summary
The facility failed to properly assess and document the use of bed rails for several residents, leading to deficiencies in safety and informed consent. For Resident #15, the facility did not complete a bed rail entrapment assessment or obtain consent before installing bed rails. The resident expressed a preference for the left bed rail to be raised instead of the right, which was not addressed by the facility. The resident's care plan did not include any mention of bed rails, despite the resident using them for safety and comfort. Resident #39 also experienced a lack of proper assessment and documentation regarding bed rail use. The resident used a 1/8 bed rail for bed mobility, but there was no record of a bed rail assessment, entrapment assessment, or informed consent in the medical record. The resident's care plan mentioned the use of a U-bar for bed mobility but did not address the necessary assessments or consent. Similarly, Resident #44's medical record lacked side rail assessments, physician orders, and documentation of interventions attempted before bed rail installation. The resident had severe cognitive impairment and required assistance with mobility, yet the care plan did not address bed rail use or entrapment risk. Interviews with facility staff revealed confusion about responsibilities for bed rail assessments and consent, with the MDS Coordinator and nursing department cited as responsible parties.
Failure to Ensure Timely Certification of Nurse Aides
Penalty
Summary
The facility failed to ensure that two nurse aides, referred to as NA NN and NA OO, completed a nurse aide training program within four months of their employment. NA NN was employed as a nurse aide starting on November 13, 2023, and NA OO on October 3, 2023. At the time of review, neither had been certified as a nurse aide according to the state NA registry, despite being employed for over six and seven months, respectively. The Director of Nursing acknowledged the lack of a specific policy regarding nurse aide certification, stating that the facility followed regulatory guidance. Interviews with various staff members revealed a lack of clarity and responsibility regarding the tracking and completion of nurse aide training. The Social Service Director mentioned that she no longer kept track of CNA or NA training, and the RN Training Coordinator/MDS Coordinator stated she only assisted with NA training at another facility. The Business Office Manager confirmed the hire dates and provided training records, but there was no evidence of certification completion within the required timeframe. This lack of coordination and oversight led to the deficiency in ensuring timely certification of nurse aides.
Deficiency in CNA In-Service Education Hours
Penalty
Summary
The facility failed to ensure that each Certified Nurse Assistant (CNA) received the required 12 hours of in-service education per year, as mandated by their individual performance review. This deficiency was identified through interviews and record reviews, which revealed that two CNAs, who had been employed for over a year, did not have any documented evidence of education hours or competencies in the past year. The facility's assessment outlined specific areas where staff education and competencies were to be demonstrated, including activities of daily living, mobility, fall prevention, and other critical care areas. However, the records for CNA C and CNA PP showed only new hire training with no subsequent competencies or education hours documented. Interviews with various staff members, including the Director of Nursing, Social Service Director, and RN Training Coordinator, highlighted a lack of clarity and responsibility regarding the tracking and implementation of CNA training and competencies. The Social Service Director stated that she no longer tracked CNA training, while the RN Training Coordinator claimed not to conduct any CNA education or competencies. The Interim Director of Nursing mentioned attempts to implement a computer software training system, which had not been accomplished, and acknowledged the absence of a training schedule. This lack of coordination and documentation led to the deficiency in meeting the required in-service education hours for CNAs.
Failure to Review and Follow Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the monthly pharmacy drug regimen recommendations were reviewed or followed up on for three residents. The facility's policy required a consultant pharmacist to perform a comprehensive review of each resident's medication regimen and clinical record at least monthly, with findings and recommendations reported to the director of nursing, attending physician, medical director, and administrator. However, for Resident #8, there was no documentation of the pharmacy consultant's reports with recommendations, nor any evidence that the facility addressed these recommendations with the resident's physician, despite multiple entries in the progress notes indicating the need to 'see report.' Similarly, for Resident #13, the pharmacy consultant's reports were not documented in the resident's medical record, and there was no evidence that the facility addressed the recommendations with the resident's physician. The resident had a complex medical history, including bipolar disorder, conversion disorder with seizures, and major depressive disorder, and was on multiple medications. Despite the pharmacy consultant's notes indicating the need to 'see report,' there was no follow-up or documentation of the recommendations being addressed. For Resident #20, the facility also failed to document and address the pharmacy consultant's recommendations. The resident had a history of chronic pain syndrome, major depressive disorder, and generalized anxiety disorder, among other conditions. The pharmacy consultant recommended a gradual dose reduction for Alprazolam, but there was no response from the resident's physician, and the facility did not follow up on this recommendation. The director of nursing was unaware that the pharmacy recommendations had to be printed from the pharmacy website and did not have access to the reports until the survey date, resulting in missing documentation and unaddressed recommendations.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of psychotropic medications for several residents. Specifically, the facility did not limit PRN (as needed) psychotropic medication orders to 14 days unless a physician documented the necessity for an extension. This was observed in the cases of three residents who had ongoing PRN orders without appropriate stop dates or physician justification for continuation beyond the 14-day limit. Additionally, there was a lack of documentation indicating that these medications were administered, suggesting a failure in monitoring and managing the medication orders effectively. Furthermore, the facility did not attempt or document gradual dose reductions (GDR) for residents on psychotropic medications, nor did they provide clinical justification for maintaining current dosages. This was evident in the cases of several residents who were prescribed medications such as Trintellix, Rexulti, Zoloft, Lexapro, Wellbutrin XL, and alprazolam. The medical records lacked evidence of GDR attempts or contraindications, indicating a failure to adhere to guidelines that require regular evaluation and adjustment of psychotropic medication dosages. The facility's policy on antipsychotic medication use did not specifically address the requirements for GDRs or 14-day stop dates, contributing to the deficiencies observed. Interviews with the Director of Nursing (DON) revealed a lack of awareness and access to pharmacy consultant reports, which are crucial for identifying and addressing medication management issues. The absence of these reports and the failure to act on pharmacy recommendations further highlight the facility's shortcomings in ensuring safe and appropriate use of psychotropic medications.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and at a safe and appetizing temperature. Multiple residents reported that their meals were often served cold, with some describing the food as terrible, overcooked, or soggy. Observations confirmed these complaints, with test trays showing food temperatures well below acceptable levels. For instance, green beans were served at 114 degrees Fahrenheit, hashbrowns at 96 degrees, and fried potatoes at 90.3 degrees, all of which are below the standard for hot food service. Additionally, the food was described as bland or overly salty, further indicating a lack of attention to flavor and seasoning. The dietary staff, including the Dietary Manager and Registered Dietician, were interviewed and expressed expectations that meals should be served hot and prepared in a way that conserves nutritive value, flavor, and appearance. However, the process of serving meals, particularly to residents eating in their rooms, took an extended period, resulting in food cooling significantly before being consumed. Despite the staff's stated expectations, there was a clear disconnect between these expectations and the actual service provided, as evidenced by the residents' complaints and the observed food temperatures.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship program, which is a critical component of its infection prevention and control program. The program's policy outlined responsibilities for the infection preventionist (IP) or designee, including auditing clinical assessment documentation at the time of antibiotic prescription, ensuring completeness of antibiotic prescribing documentation, and monitoring antibiotic initiation. Additionally, the policy required tracking of C. difficile and antibiotic-resistant infections, as well as maintaining a monthly infection/antibiotic control log and line listing. However, during the survey, it was found that these protocols were not being followed. The interim Director of Nursing (DON), who had been serving as the infection prevention and control professional (IPCP) due to staffing turnover, admitted to not having conducted any antibiotic surveillance logs or tracking of antibiotic use since taking over the role. This inaction led to a lack of monitoring and documentation of antibiotic use in the facility. Medical record reviews revealed that several residents were treated with antibiotics, but there was no evidence of the required oversight and documentation as per the facility's policy. The interim DON acknowledged the failure to implement the antibiotic stewardship program due to time constraints and staffing issues.
Failure to Inspect Bed Rails for Entrapment Risks
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails to identify potential entrapment risks for residents using these assistive devices. This deficiency was identified during a review of 24 sampled residents, including three specific residents who used bed rails or assist bars. The facility's policy on bed rail use, which includes guidelines from the FDA on potential zones of entrapment, was not adhered to, as there was no documentation of regular inspections being conducted. Resident #15, who is at risk for falls due to poor balance and impulsivity, had a care plan that did not document regular inspections of their bed frame, mattress, and bed rails. Observations showed inconsistencies in the positioning of the bed rails, and the resident expressed a preference for the left rail to be raised, which was not accommodated. Similarly, Resident #39, who requires substantial assistance for mobility, had a 1/8 bed rail in use, but there was no evidence of inspections for entrapment risks. Resident #44, with severe cognitive impairment and a high fall risk, also had a 1/8 bed rail in use without documented inspections. Interviews with facility staff revealed a lack of clarity regarding responsibilities for measuring entrapment zones. The Maintenance Supervisor was unaware of his responsibility to measure these zones, and the Director of Nursing acknowledged that staff had not been conducting monthly measurements as required. This lack of communication and adherence to policy contributed to the facility's failure to ensure the safety of residents using bed rails.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to provide care that enhanced resident dignity for two residents. One resident, who was cognitively intact and required assistance with personal hygiene and dressing, reported feeling like a burden due to the nursing staff's comments when the facility was short-staffed. The resident mentioned that staff would respond to call lights with remarks such as 'What do you want now?' and 'Let's get this done. I have several things to do,' which made the resident feel uncomfortable and burdensome. Another resident, also cognitively intact, reported that the Social Service Director (SSD) did not treat residents with dignity and respect. The resident described being scolded by the SSD in front of others, which was humiliating and embarrassing. The resident also observed the SSD scolding and talking down to other residents, which was intimidating. Despite reporting this behavior to a previous Director of Nursing, the current Director of Nursing was unaware of any concerns with the SSD.
Failure to Notify Resident of Trust Fund Balance Exceeding Medicaid Limit
Penalty
Summary
The facility failed to notify a resident and/or their representative when the resident's trust account balance reached $200 less than the Supplemental Security Income (SSI) resource limit, which is a requirement for residents receiving Medicaid benefits. This deficiency was identified for one resident in a sample of 24, with the facility census being 67. The resident in question had a family member designated as the responsible party and Durable Power of Attorney for financial and health care decisions. The resident's trust fund account balance exceeded the Medicaid resource limit of $5,726.00, reaching $5,887.24 on April 30, 2024, and $5,748.24 on May 20, 2024. However, there was no evidence that the facility provided notice to the resident or their legal representative about the account balance exceeding or approaching the Medicaid eligibility limit. Interviews with the Business Office Manager (BOM) and the regional resident fund manager revealed a lack of awareness and communication regarding the resident's trust fund balance. The BOM admitted to not realizing the resident's balance exceeded the limit and had not sent a notice to the resident's Durable Power of Attorney. The regional resident fund manager indicated reliance on the facility's bookkeeper to monitor the trust fund balances and mentioned that the responsibility also lay with the family to monitor the balance. This oversight in monitoring and notifying the appropriate parties led to the deficiency identified in the report.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation of an abuse allegation as per its policy. A resident reported that a CNA slapped them in the face during care, which was not adequately investigated. The facility's policy requires immediate investigation, including interviews with involved staff and residents, but this was not fully executed. The incident involved a resident who alleged that a CNA slapped them, causing them to fall and sustain a skin tear. The resident reported the incident to the police through the administrator. The facility's documentation lacked interviews or statements from key staff members who were on duty during the incident, and there were no interviews with other residents who received care from the alleged staff member. Interviews with staff revealed gaps in the investigation process. The DON and Administrator acknowledged that interviews with other residents and staff were not conducted, and no educational measures on abuse were initiated. The facility's failure to follow its abuse investigation protocol resulted in an incomplete investigation of the reported incident.
Inaccurate MDS Coding and Assessment
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, as required by the Resident Assessment Instrument (RAI) manual. The MDS assessments did not accurately reflect the resident's status, particularly in terms of falls and mobility. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and spinal issues, experienced several falls that were not properly documented in the MDS. The assessments failed to include both injury and non-injury falls, and there were discrepancies in the resident's mobility status, as the resident was observed to always be in a wheelchair, contrary to the MDS documentation. The acting MDS coordinator, who was only present at the facility part-time, admitted to completing the MDS assessments without full knowledge of the residents. She relied on staff input and was not present during interdisciplinary team meetings, which contributed to the inaccuracies in the assessments. The Director of Nursing acknowledged that the MDS assessments were expected to be completed according to the RAI manual but was unsure of their accuracy due to the part-time status of the MDS coordinator. The facility's failure to ensure accurate MDS coding highlights a lack of comprehensive assessment and coordination among staff. The resident's frequent falls and the discrepancies in their documented mobility and fall history indicate a significant oversight in the assessment process. This deficiency underscores the importance of having knowledgeable and consistent staff involved in the MDS assessment process to ensure accurate and up-to-date resident information.
Failure to Document and Manage PASARR for Resident with Mental Health Changes
Penalty
Summary
The facility failed to properly document and manage the Pre-admission Screening and Resident Review (PASARR) process for a resident who exhibited significant mental health changes. The resident, who had a history of major depressive disorder and was later diagnosed with schizophrenia, was admitted without a completed Level I PASARR. The facility also failed to file for a Level II PASARR when the resident's conditions changed, including the addition of schizophrenia to their diagnoses. The resident experienced suicidal thoughts and ideations, which led to hospitalization. Despite these significant changes in the resident's mental health status, the facility did not notify the appropriate state-designated authority for a PASARR evaluation and determination. The resident's medical record lacked updates to the care plan or Minimum Data Set (MDS) regarding the suicidal thoughts and ideations, and there was no documentation of outpatient psychiatric services being arranged. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion and management of PASARRs. The Business Office Manager believed the PASARR was complete, while the Social Services Designee was unaware of her responsibility in ensuring PASARRs were completed. The Director of Nursing acknowledged the resident's refusal of additional services upon admission but was uncertain if further support was offered after the resident's mental health deteriorated.
Deficiencies in Catheter and Incontinence Care
Penalty
Summary
The facility failed to provide proper care for a resident with an indwelling urinary catheter, leading to potential contamination and infection risk. The resident, who had a history of urinary tract infections (UTIs), was observed with the catheter drainage bag and tubing touching the floor, contrary to the facility's policy. Despite being educated on the importance of keeping the bed raised to prevent the catheter from touching the floor, the resident often refused to comply, and staff did not implement additional interventions to address this issue. Observations showed the urine in the catheter bag was brown and cloudy, with sediment present, indicating possible contamination. Another deficiency was noted in the care of a resident with urinary incontinence. The resident, who required substantial assistance due to limited mobility and cognitive impairment, was not provided with proper perineal care. A Certified Nurse Aide (CNA) failed to wash hands between assisting two residents, one of whom was incontinent of feces, and used the same area of a cloth multiple times while cleaning the second resident's perineal area. This practice did not adhere to infection control protocols, increasing the risk of spreading bacteria that cause infections. Interviews with staff, including the Director of Nursing (DON), confirmed that catheter bags should not be on the floor and that proper hand hygiene and perineal care techniques were expected. However, the staff did not consistently follow these protocols, contributing to the deficiencies observed. The facility's failure to ensure adherence to infection control practices for catheter and incontinence care resulted in increased risk of UTIs for the residents involved.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
