Livingston Manor Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chillicothe, Missouri.
- Location
- 939 East Birch, Chillicothe, Missouri 64601
- CMS Provider Number
- 265621
- Inspections on file
- 24
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Livingston Manor Care Center during CMS and state inspections, most recent first.
Surveyors found unsanitary conditions in the kitchen and food storage areas, including food debris, dirty surfaces, uncovered and undated food items, and improper storage practices. Staff interviews confirmed that food should be dated and stored properly, and the kitchen kept clean, but these standards were not consistently followed.
The facility did not ensure that posted menus matched the meals served, nor did it provide or communicate menu choices to residents with severe cognitive impairment. Staff failed to ask residents or families about meal preferences, and there was confusion among staff about responsibilities for menu updates and communication, resulting in residents not receiving meals as planned or having access to alternate options.
A resident with a history of behavioral issues struck another resident in the head during a dining room altercation. Despite care plan interventions and the facility's abuse policy requiring increased supervision after such incidents, staff did not implement closer monitoring for the resident who initiated the abuse until several days later, resulting in a failure to protect residents from physical abuse.
Staff failed to follow infection control protocols during wound care for two residents, including not performing hand hygiene with glove changes, not consistently wearing protective gowns when required, and handling personal items and treatment supplies with contaminated gloves. PPE was not readily available near resident rooms, and Enhanced Barrier Precautions were not properly implemented or ordered by a physician. The care plans did not address EBP, and staff interviews revealed gaps in knowledge and training regarding these precautions.
The facility failed to maintain professional standards in food safety and sanitation, including improper handwashing, incomplete food temperature checks, and inadequate food storage practices. Staff were observed using unsanitary handwashing techniques, and food temperature logs were incomplete, with some items not checked before serving. Additionally, personal items were improperly stored near food, and dishwashing practices were not consistently followed.
The facility failed to maintain resident dignity and privacy by applying clothing protectors without consent, standing while assisting residents with meals, and conducting medical procedures in the dining room. Residents were left exposed without privacy curtains, and blood sugar checks and insulin administration were done publicly, contrary to facility policy.
The facility failed to address and resolve grievances raised by residents during council meetings, as shown by the lack of documentation and follow-up on issues such as meal preferences, staff introductions, and cleanliness. Residents reported irregular and non-private meetings without reviews of their rights, and staff admitted to not providing feedback on concerns. The Administrator acknowledged the need for feedback, highlighting a gap between policy and practice.
The facility failed to provide residents access to their personal funds after business hours and on weekends, as confirmed by interviews with residents and staff. The facility's policy states that residents should manage their funds, but access is limited to office hours only.
The facility failed to manage residents' personal funds properly, resulting in negative balances for several discharged residents. The Business Office Manager was unaware of the reasons for these negative balances and did not know the source of funds when petty cash was negative. Interviews revealed confusion about fund refunds and a lack of proper financial oversight.
The facility did not periodically inform residents of their rights, as required. The policy on resident rights lacked guidance on communication timing, and four residents reported not receiving education on their rights. Meeting minutes from March to May 2024 showed no review of resident rights, and the Activity Director confirmed not discussing them during meetings.
A resident with severe cognitive impairment had conflicting resuscitation orders in their medical records, with the care plan indicating Do Not Resuscitate (DNR) status while the physician order sheet showed both DNR and full code entries. The facility failed to ensure clarity and consistency in the resident's advance directives, as required by their policy.
The facility failed to provide the correct Medicare forms to residents, using outdated and incorrect forms for three residents. This oversight involved the use of expired ABN forms and incorrect SNF ABN forms, contrary to the facility's policy requiring current CMS-approved forms. The Administrator admitted to the error during an interview.
The facility failed to maintain a clean and comfortable environment for its 29 residents, with issues such as uncomfortable temperatures, dust accumulation, and strong odors. Observations revealed broken infrastructure, including chipped tiles and missing blinds. Staff interviews highlighted challenges in obtaining necessary supplies and maintaining cleanliness. Resident council minutes showed ongoing complaints about dust and odors, with no documented resolutions, contributing to the facility's deficiencies.
The facility failed to ensure residents were informed about their grievance rights and did not provide accessible grievance forms. Residents were unaware of how to file grievances, lacked access to forms, and did not know the grievance officer. Staff interviews revealed inconsistencies in form accessibility, with forms located in areas inaccessible to residents, requiring staff assistance. The Administrator admitted forms were not posted or accessible, and there was no means for anonymous reporting.
The facility failed to implement its Abuse and Neglect policy by not completing required background checks and screenings for staff before they began working with residents. This affected multiple staff members, including LPNs and CNAs, as checks like the Family Care Registry and Employee Disqualification List were either delayed or not conducted. Interviews revealed that the Business Office Manager lacked access to necessary systems to perform these checks, and the Corporate Administrator acknowledged the oversight.
The facility failed to conduct comprehensive assessments for two residents, resulting in incomplete MDS documentation regarding their preferences for routine and activities. Both residents had severe cognitive impairments, and there was no evidence of interviews with family or staff to determine their preferences. The care plans included various interventions, but these were not effectively implemented, and the residents had minimal engagement in activities. The facility lacked a policy on comprehensive assessments and had not held care meetings since administrative changes.
The facility failed to complete Level 1 PASARR screenings for two residents before admission, as required by Medicaid rules. One resident had an incomplete Level 1 screening despite a diagnosis of unspecified psychosis and use of antipsychotic medication. Another resident, with severe cognitive impairment and multiple psychotropic medications, lacked a Level 1 PASARR in their medical record. The responsibility for PASARR completion was with the understaffed Social Services department.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in addressing medical and psychosocial needs. A resident's care plan omitted oxygen use despite a physician's order, another lacked an advance directive despite being a full code, and a third did not address side rail use despite cognitive impairment. Staff interviews revealed care plan meetings had not occurred due to administrative changes, and the facility lacked a social services or MDS coordinator.
The facility failed to follow professional standards by not obtaining necessary physician's orders for blood sugar checks and side rails, and by incorrectly setting a low air loss mattress for a resident. Additionally, documentation for medications and treatments was incomplete, indicating lapses in care.
The facility failed to provide adequate personal hygiene care for several residents, including a resident who was not shaved as per preference, another who did not receive oral care or have their face and hands washed, and a third who received improper perineal care. Observations and staff interviews confirmed these deficiencies, highlighting a lack of adherence to the facility's care policies.
The facility failed to provide meaningful daily activities for residents, impacting their physical, mental, and psychosocial well-being. Several residents, including those with severe cognitive impairments, were minimally engaged in activities over several months. The Activity Director lacked formal training and faced budget constraints, while staff had no dementia-specific training, leading to inadequate activity provision.
The facility failed to lock wheelchair brakes during transfers for three residents, all of whom were dependent on staff for mobility and required mechanical lifts. Observations showed that CNAs did not lock the brakes while using the Invacare hydraulic lift 9805P, and the facility's policy did not specify this requirement. Interviews revealed a lack of training and awareness among staff, as confirmed by the DON.
The facility failed to provide proper respiratory care for residents requiring oxygen therapy. One resident had an incorrect oxygen setting and an empty humidified water bottle, while another had undated oxygen tubing. Staff interviews revealed confusion about responsibilities for changing tubing and filling humidified bottles, contrary to facility policy.
The facility failed to assess and manage the use of bed rails for two residents, leading to potential safety risks. One resident was not assessed for entrapment risk, and no physician's order was obtained for side rails. Another resident, with severe cognitive impairment, was not assessed for alternatives to side rails. Staff interviews revealed improper procedures and documentation regarding bed rail use.
The facility did not comply with the requirement to have an RN on duty for eight consecutive hours per day, seven days a week. Staffing records showed multiple instances of non-compliance across several months. The Administrator and DON acknowledged the requirement and the lapses in coverage.
A facility reported a 32% medication error rate, affecting four residents. Errors included improper administration of nasal spray, failure to provide Seroquel Rub for psychosis, and incorrect insulin pen use. Medications were crushed against guidelines, and insulin pens were not primed or cleaned properly.
The facility failed to ensure proper insulin administration, resulting in significant medication errors for two residents. An LPN did not prime insulin pens before administering insulin, contrary to facility policy. The LPN acknowledged the oversight, and the DON confirmed the correct procedure was not followed.
The facility failed to ensure proper labeling and storage of medications, with a resident's Flonase nasal spray lacking a pharmacy label and medications left at the bedside of two residents. Additionally, medication drawers were found unclean, and staff were unaware of cleaning responsibilities.
The facility failed to ensure the Dietary Manager (DM) had the necessary certification and skills to manage food and nutrition services. Despite being in the role since April 2021, the DM was still enrolled in a certification program, which would not be completed until November 2024. Interviews confirmed that the DM should have been certified, indicating non-compliance with staffing requirements.
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of TB screening for newly hired staff and the absence of hand sanitizer on the memory care unit. Employee files showed no TB tests were completed for six sampled staff members, contrary to facility policy. Additionally, hand sanitizer dispensers were empty due to supply issues, with staff confirming the absence of hand sanitizer since March. The Director of Nursing was unaware of the shortage, indicating a communication gap in infection control management.
The facility failed to ensure that the call light system was accessible for residents, with observations showing call lights out of reach or improperly placed. This affected residents with severe cognitive impairments and dependencies on staff for personal care. Despite maintenance checks, some rooms lacked functioning call light strings, and staff interviews revealed inconsistent practices in ensuring accessibility.
A facility failed to complete a discharge summary for a resident at the time of their planned discharge. The resident, who had intact cognitive skills and was independent in several activities of daily living, was diagnosed with seizure disorder, anxiety, depression, high blood pressure, and PTSD. Despite the facility's policy requiring a comprehensive discharge summary, the resident's medical record lacked this documentation, as confirmed by the Administrator.
The facility employs an Activity Director who lacks the necessary qualifications and certifications to oversee the activity program. Despite being in the role since 2017, the director has not completed an approved training program and has no specific training in dementia activities. Interviews with facility administrators revealed a lack of knowledge about the certification requirements for this position.
A resident with severe cognitive impairment and a stage 3 pressure ulcer did not receive ordered pressure ulcer care, including the use of pressure off-loading boots and weekly skin assessments. Observations showed the resident without boots in bed, and staff interviews revealed non-compliance with care orders. The facility lacked a specific pressure ulcer policy, contributing to the deficiency.
A facility failed to provide proper catheter care, leading to potential risk of UTIs for a resident. Staff did not clean the catheter tubing or drainage spout, placed the graduate on the floor, and did not secure the catheter tubing with a leg strap. The CNA used incorrect techniques during peri care, including using the same area of a wash cloth for different skin areas and using paper towels. Interviews revealed staff were not following proper procedures.
Failure to Maintain Sanitary Food Storage and Kitchen Conditions
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen and food storage areas to maintain sanitary conditions and proper food storage practices. Specifically, food debris was found under the three-compartment sink, and dirt and debris were present under the prep table. A metal storage rack above the prep table was covered in dirt and dust, and an uncovered cake was placed directly beneath this dirty rack. The refrigerator handles were sticky, a black substance was noted along the dish room floor drain, and a dust-covered fan was blowing across a tray with open glasses containing ice. Additionally, the trash can by the prep table lacked a lid, and a window near the prep table was dirty. In the dry storage area, a box of canned baked beans was stored directly on the floor. In the freezer, several opened packages of food items, including sausage patties, chicken patties, and French toast sticks, were undated and not properly sealed. Interviews with staff, including a dietary staff member, the Dietary Manager, the Registered Dietitian, and the Administrator, confirmed that food should be dated, stored in closed containers, and the kitchen should be kept clean and sanitary. Staff acknowledged that maintaining cleanliness is a shared responsibility, but sometimes tasks are overlooked. The facility's own policy requires the dining services manager to ensure cleaning and sanitation, with all staff trained on cleaning frequency and a posted cleaning schedule, but these standards were not met as evidenced by the observed unsanitary conditions and improper food storage.
Failure to Post and Follow Accurate Menus for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that posted menus were accurate, prepared in advance, and followed for residents, specifically affecting three residents with severe cognitive impairment and self-care deficits related to Alzheimer's disease or dementia. Observations revealed that the posted lunch menu listed breaded pork chop, au gratin potatoes, zucchini and tomatoes, cornbread, and frosted poke cake, but residents were instead served ham, cauliflower, and Jello with fruit. No alternate menu options were posted, and the menu board did not reflect what was actually served. Interviews with staff and a family member indicated that residents did not receive menus, were not asked about their meal preferences, and that staff were unclear about who was responsible for communicating with families regarding food choices. The Dietary Manager acknowledged that the wrong menu was posted and that the dietary department was responsible for updating menus daily, including posting alternates. The Activities Director stated that she did not ask residents in the memory care unit about their meal preferences, and believed kitchen staff were responsible for this task. These actions and inactions resulted in the facility not meeting its own policies for menu planning and resident participation.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident hit them in the head. The incident occurred in the dining room when one resident, who had a history of verbal and physical behaviors and was care planned for altercations, approached another resident and took their milk. After a brief interaction where the first resident awoke and bumped the other's arm, the second resident poured milk on the first and then struck them in the head before staff could intervene. The dietary staff separated the residents and notified nursing staff, who assessed both residents and found no injuries. The resident who was struck had multiple diagnoses, including palliative care, lung cancer, dementia, chronic kidney disease, COPD, cellulitis, major depressive disorder, and anemia. This resident was assessed as having moderately impaired cognition but was able to communicate and had not displayed behavioral issues. The resident who initiated the altercation had diagnoses of dementia, psychosis, anemia, pain, malnutrition, heart disease, and osteoarthritis, with severely impaired cognition and a history of behavioral issues, including altercations with other residents. Their care plan included interventions to monitor and separate them from others during meals. Despite the incident, the facility did not implement increased monitoring or closer supervision for the resident who initiated the abuse until six days later, when they were moved to a secured memory care unit. The facility's abuse policy required increased supervision and protective measures for residents involved in such incidents, but these were not put in place immediately following the event.
Failure to Maintain Infection Control Precautions During Wound Care
Penalty
Summary
Facility staff failed to maintain standard infection control precautions during wound care for two residents. Observations revealed that staff did not perform hand hygiene with glove changes, did not consistently wear personal protective gowns when required, and handled items such as glasses and treatment carts with contaminated gloves. In both cases, staff entered resident rooms and began wound care procedures without washing their hands, and did not change gloves or perform hand hygiene after touching their faces or other potentially contaminated surfaces. Additionally, staff did not always have the necessary PPE available near or outside the resident rooms, and signage indicating Enhanced Barrier Precautions (EBP) was absent. For one resident with multiple wounds and a history of heart failure, UTI, stroke, and anxiety, staff did not address wounds in the care plan or obtain a physician's order for EBP, despite the presence of wounds requiring such precautions. During wound care, staff failed to change gloves and perform hand hygiene at appropriate intervals, touched their faces and glasses with gloved hands, and handled treatment supplies with contaminated gloves. The resident's wounds were treated without adherence to EBP protocols, and staff interviews confirmed a lack of knowledge and training regarding EBP. For another resident with a stage 4 pressure ulcer and multiple stage 2 ulcers, staff similarly did not obtain a physician's order for EBP or include EBP in the care plan. During wound care, staff did not wear protective gowns as required, failed to perform hand hygiene before and after glove changes, and handled personal items and treatment supplies with contaminated gloves. Both staff members left the resident's room without performing hand hygiene. The Director of Nursing confirmed that these actions were not in line with facility expectations or policies.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as evidenced by multiple observations and interviews. Staff members, including the Dietary Manager and Dietary Aide B, were observed using improper handwashing techniques, such as using the same paper towel to turn off the faucet and dry their hands. This practice was acknowledged as unsanitary by both the staff and the facility's administration. Additionally, the facility's policy on handwashing and glove use was not consistently followed, contributing to the deficiency. The facility also failed to properly monitor and record food temperatures, which is crucial for preventing foodborne illnesses. Observations revealed that not all food items were temperature checked before being served to residents, and the food temperature logs were incomplete. For instance, hamburger patties and tomato soup were served without temperature checks, contrary to the facility's policy. Interviews with the Dietary Manager and staff confirmed that all foods should be temperature checked, but this was not consistently practiced. Furthermore, the facility did not maintain proper food storage and sanitation practices. Observations showed that food items were not dated when opened, and personal items were stored near food, which is against the facility's policy. Temperature logs for refrigerators and freezers were also incomplete, indicating a lack of regular monitoring. The facility's dishwashing practices were also deficient, as the dishwasher was not tested twice daily as required, and logs were not consistently completed. These lapses in food safety and sanitation practices contributed to the overall deficiency identified by the surveyors.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents in several instances. Staff members applied clothing protectors to residents in the dining rooms without asking for their consent, and they stood while assisting residents with eating, which is against the facility's policy. Additionally, a resident was left exposed to the hallway while wearing only a brief and T-shirt, with no privacy curtain pulled, despite being dependent on staff for personal hygiene and dressing due to severe cognitive impairment and cerebral palsy. The facility also failed to maintain privacy and dignity during medical procedures. Blood sugar levels were checked, and insulin was administered to residents in the dining room in the presence of other residents. This practice was observed with two residents, one of whom had a blood sugar level of 292 and received insulin in the dining room. The facility's policy requires such procedures to be conducted in private settings, such as the residents' rooms, to ensure dignity and privacy. Interviews with staff members, including CNAs and the Director of Nursing, revealed a lack of adherence to the facility's policies regarding resident dignity and privacy. Staff members acknowledged that they should sit while assisting residents with meals and should ask residents if they want clothing protectors. The Director of Nursing confirmed that staff are expected to pull privacy curtains when residents are exposed and to conduct medical procedures in private settings.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to promptly address and resolve grievances voiced by residents during resident council meetings, as evidenced by the lack of documentation and follow-up on issues raised. The facility's policy on resident rights and grievance handling, dated 1/1/24, mandates that residents should be supported in exercising their rights, including voicing grievances without fear of reprisal, and that the facility should respond to grievances. However, the review of resident council meeting notes from March, April, and May 2024 revealed that issues such as meal preferences, staff introductions, noise levels, cleanliness, and transportation were raised by residents but were not documented as resolved or followed up on. The notes also failed to indicate whether the resolutions were satisfactory to the residents or how they were informed about their rights or the process for reporting abuse and neglect. Interviews with residents and staff further highlighted the facility's shortcomings in addressing grievances. Residents reported that council meetings were irregular, lacked privacy, and did not include reviews of resident rights. They also expressed that they were not informed of any responses to their recommendations. The Activities Director, who facilitated the meetings, admitted to not having recent education sessions on grievance procedures and not receiving feedback from the administration on resident concerns. The Administrator acknowledged that residents should receive feedback on their grievances, indicating a gap between policy and practice in the facility's grievance handling process.
Lack of Access to Personal Funds After Hours
Penalty
Summary
The facility failed to ensure that residents had access to their personal funds after business hours and on weekends, which is a violation of resident rights. The facility's policy on resident rights, revised in December 2016, states that residents should be able to manage their personal funds or have the facility manage them. However, during a group interview, four residents reported that they did not have access to their funds during these times. The Business Office Manager confirmed that residents could only access their money when someone was in the office, and there was no access on weekends. The Administrator and Corporate Administrator acknowledged that residents currently do not have access to their funds after hours and that efforts are made to notify the business office in advance if funds are needed outside of business hours.
Deficiency in Managing Residents' Personal Funds
Penalty
Summary
The facility failed to properly manage and account for residents' personal funds, leading to negative balances in the facility's operating account for several discharged residents. The monthly petty cash reconciliation logs showed negative balances, indicating a lack of proper fund management. Specifically, four residents were affected, with negative balances ranging from -10.00 to -11,020.90 in the facility's operating account. The Business Office Manager, who was new to the position, was unaware of the reasons behind these negative balances and did not know the source of funds when the petty cash balance was negative. Additionally, the manager was uncertain about the timeframe for returning funds to residents or their guardians after discharge. Interviews with the Business Office Manager, an Accounting Firm Consultant, and the Regional Administrator revealed further issues. The Business Office Manager had not updated the Interim Aging report after issuing a check to a deceased resident, and there was confusion about whether funds had been refunded to a resident who moved to another facility. The Regional Administrator confirmed that there should be no negative accounting balances and that funds should be returned within 30 days of discharge. These deficiencies highlight a lack of proper financial management and oversight in handling residents' personal funds.
Failure to Inform Residents of Their Rights
Penalty
Summary
The facility failed to ensure that residents were informed of their rights periodically during their stay, both orally and in writing. The facility's policy on resident rights, revised in December 2016, outlined the rights of residents but did not specify when these rights should be communicated. During a group interview, four residents confirmed they had not received education about their rights. Additionally, a review of resident council meeting minutes from March to May 2024 showed no documentation that resident rights were reviewed. The Activity Director, who facilitated these meetings, admitted to not covering resident rights during the sessions.
Failure to Clarify Advance Directives
Penalty
Summary
The facility failed to clarify the status of advance directives for a resident, leading to a discrepancy in the resident's medical records. The resident, who was severely cognitively impaired and dependent on staff for daily activities, had conflicting orders regarding resuscitation status. The care plan indicated the resident was a Do Not Resuscitate (DNR), while the physician order sheet had conflicting entries, one indicating a DNR status and another indicating a full code status. The facility's policy requires that advance directives be prominently displayed in the medical record and that any changes be communicated to the care team. However, the inconsistency in the resident's resuscitation status was not addressed until the survey, indicating a lapse in following the established procedures for managing advance directives. This oversight could potentially lead to confusion among staff regarding the resident's treatment preferences.
Incorrect Use of Medicare Forms in Facility
Penalty
Summary
The facility failed to provide the correct Skilled Nursing Facility (SNF) Advance Beneficiary Notices (ABN) to residents, which are essential for informing them about potential financial responsibilities for services not covered by Medicare. Specifically, the facility used incorrect forms for three out of twelve sampled residents. Resident #27 and Resident #28 were both given an outdated ABN form CMS-R-131 instead of the required SNF ABN form CMS-10055. Additionally, Resident #83 was provided with a Notice of Medicare Non-Coverage form that lacked a CMS number and an incorrect SNF ABN form. The facility's policy mandates the use of the current CMS-approved forms to ensure residents are properly informed about their Medicare coverage and potential liabilities. The Business Office Manager (BOM) is responsible for issuing these notices and maintaining a log of them. However, the review revealed that the facility did not adhere to these policies, resulting in the use of expired and incorrect forms. During an interview, the Administrator acknowledged the mistake of not using the correct forms.
Facility Fails to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment, affecting all 29 residents. Observations revealed several deficiencies, including uncomfortable temperatures, with the south dining room recorded at 67 degrees, prompting residents to wear blankets and coats. The facility also had issues with cleanliness, as cobwebs were found in the chapel room, dust caked on bathroom fan coils, and strong odors of feces in certain hallways. Additionally, the facility struggled with maintaining its infrastructure, with chipped and broken tiles, missing blinds, and unsanded and unpainted drywall patches. Interviews with staff highlighted systemic issues contributing to these deficiencies. The Housekeeping Supervisor and Aides reported difficulties in obtaining hand sanitizer refills that fit the dispensers, and the Maintenance Supervisor acknowledged responsibility for cleaning fans and vents but noted a lack of replacement blinds and infrequent cleaning of wall heating units. The Administrator expressed expectations for a clean and homelike environment, including the replacement of broken tiles and blinds, repainting of missing paint spots, and ensuring the facility was free of odors. Resident council minutes further corroborated the ongoing issues, with residents repeatedly raising concerns about dust, unclean windows, and odors in various areas of the facility. Despite these complaints, resolutions were not documented in subsequent council minutes, indicating a lack of effective response to resident feedback. The combination of these factors contributed to the facility's failure to uphold a safe and comfortable environment for its residents.
Deficiency in Grievance Process Accessibility
Penalty
Summary
The facility failed to ensure that residents were aware of their right to file grievances, both in writing and anonymously, and did not provide the necessary contact information for the grievance official. The facility's policy outlined that grievances could be voiced verbally or in writing to staff members or grievance officials, and that information on how to file a grievance should be available to residents. However, during interviews, residents expressed that they were unaware of how to complete a grievance, did not have access to grievance forms, and did not know who the grievance officer was. Observations confirmed that grievance forms were not readily available to residents or their families. Interviews with staff revealed inconsistencies in the location and accessibility of grievance forms. An LPN mentioned that grievance forms were located in the employee break room, which residents could not access. The Administrator stated that forms were at the nurses' station but required residents or families to request them from staff. A CNA was unaware of the current grievance officer and how residents could submit anonymous grievances. Another CNA confirmed that forms were at the nurses' station but required staff assistance to access. The Administrator acknowledged that forms were not posted or accessible to residents or their families, and there was no means for anonymous reporting.
Failure to Implement Abuse and Neglect Policy
Penalty
Summary
The facility staff failed to implement their Abuse and Neglect policy by not completing necessary background checks and screenings for employees before they began working with residents. This deficiency affected eight out of ten sampled staff members, including LPNs, CNAs, housekeeping aides, and dietary aides. The facility's policy required background, reference, and credential checks to be completed on potential employees, but these were not conducted in a timely manner. For instance, the Family Care Registry checks for several employees were completed after their hire dates, and the Employee Disqualification List (EDL) and Certified Nurse Aide Registry were not checked for some staff. Interviews with the Business Office Manager and Corporate Administrator revealed that the background checks were not completed as required before staff started working. The Business Office Manager, who started in March, did not have access to run EDL checks or complete Family Care Registry checks. The Corporate Administrator confirmed that background checks should be completed upon hire and before staff begin working at the facility. This lack of adherence to the facility's policy on abuse and neglect prevention led to the deficiency noted in the report.
Failure to Conduct Comprehensive Assessments for Resident Preferences
Penalty
Summary
The facility failed to ensure accurate comprehensive assessments were completed on the Minimum Data Set (MDS) for two residents. For Resident #3, the MDS did not include preferences for customary routine and activities, and there was no evidence that interviews were conducted with the resident, family, or staff to determine these preferences. The resident had severe cognitive impairment and was involved in very few activities, despite having a care plan that included various interventions such as one-on-one visits and participation in activities like aromatherapy and listening to music. The daily activity sheets showed minimal engagement, with the resident participating in only three activities over a period of several months. Similarly, Resident #14's MDS lacked information on preferences for routine and activities, and no interviews were conducted with family or staff to gather this information. The resident had severe cognitive impairment and a history of anxiety, depression, and disinterest in activities. The care plan indicated that the resident would participate in activities of choice at least once a week, but there was no documentation to support consistent engagement in activities. The care plan also included interventions such as one-on-one visits and assisting the resident to the activity room, but these were not effectively implemented. The facility did not provide a policy on comprehensive assessments, and the Activity Director, who had been in the role since 2017 without any certifications, acknowledged the lack of care meetings since administrative changes. The Administrator expected interviews with family, significant others, or staff during comprehensive assessments, but this was not carried out. The absence of an MDS Coordinator further contributed to the deficiency in conducting thorough and accurate assessments.
Failure to Complete PASARR Screenings Prior to Admission
Penalty
Summary
The facility failed to ensure that staff completed a Level 1 PASARR screening for mental disorders or intellectual disabilities prior to admission for two residents. The facility's policy requires coordination with the PASARR program to screen all applicants for serious mental disorders or intellectual disabilities in accordance with Medicaid rules. A Level 1 screening should be completed before admission, and if positive, a Level II evaluation is required. However, for Resident #26, the Level 1 screening was not signed and did not indicate the required level of care, despite the resident having a diagnosis of unspecified psychosis and being on antipsychotic medication. Resident #14's records showed severely impaired cognition and dependence on staff for various activities of daily living. The resident was on multiple psychotropic medications and had diagnoses including dementia, anxiety disorder, and schizophrenia. Despite these conditions, there was no Level 1 PASARR located in the resident's medical record. The resident had been admitted from another long-term care facility, and a Level 1 PASARR was completed by the previous facility, but it did not trigger a Level II evaluation. Interviews with facility staff revealed that the responsibility for completing PASARRs lay with the Social Services department, which was currently understaffed, with the Administrator temporarily filling in. The facility's failure to complete the necessary PASARR screenings prior to admission for these residents represents a deficiency in adhering to regulatory requirements for pre-admission screening and resident review.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. For Resident #81, the care plan did not include the use of oxygen, despite a physician's order for oxygen therapy to maintain adequate oxygen saturation levels. This oversight was noted during an observation and confirmed through interviews with the Director of Nursing and a Licensed Practical Nurse, who acknowledged that care plans should address the use of oxygen. Resident #25's care plan was found lacking as it did not include an advance directive, even though the resident was documented as a full code in the physician's orders and electronic medical record. This gap in the care plan was highlighted during an interview with a Certified Nurse Aide, who indicated that code status information was typically accessed through stickers on doors or electronic records. For Resident #29, the care plan did not address the use of side rails or assist bars, despite the presence of a u-shaped rail on the resident's bed. The resident's admission MDS indicated severe cognitive impairment and a need for assistance with personal care, yet the care plan did not reflect these needs. Interviews with staff revealed that care plan meetings had not been conducted since administrative changes, and the facility lacked a social services or MDS coordinator, contributing to the deficiencies in care planning.
Deficiencies in Professional Standards and Documentation
Penalty
Summary
The facility failed to adhere to professional standards of care in several instances, impacting multiple residents. For Resident #16, the staff did not obtain a physician's order for the use of a low air loss mattress, nor did they set the mattress according to the resident's weight, which was significantly lower than the setting used. Interviews with staff revealed a lack of clarity regarding who was responsible for adjusting the mattress settings, and the Director of Nursing confirmed that the settings were incorrect and should have been documented in the treatment administration record. For Residents #12 and #24, the facility did not secure physician's orders for blood sugar monitoring, despite both residents being prescribed insulin for diabetes management. Interviews with nursing staff, including LPNs and the Director of Nursing, confirmed that there should have been orders specifying the frequency of blood sugar checks. This oversight indicates a failure to follow the facility's policy for medication and treatment orders, which requires such orders to be documented and consistent with safe and effective practices. Additionally, Resident #29 had a side rail on their bed without a physician's order, contrary to facility policy. Interviews with CNAs and the Director of Nursing revealed that the side rail was present because it was already attached to the bed, not due to a clinical need. Furthermore, documentation for Resident #24 was incomplete, with several entries missing in the Medication Administration Record and Treatment Administration Record, which the Director of Nursing and Administrator acknowledged as indicating that treatments or medications were not administered.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in personal hygiene care. Resident #24, who had severe cognitive impairment and was dependent on staff for personal hygiene, was not shaved as per his/her preference, despite expressing a desire to be shaved daily. Observations confirmed that the resident had noticeable hair growth, indicating a lack of grooming care. Interviews with staff revealed that shaving was only offered on shower days or upon resident request, which was not consistently adhered to. Resident #12, who had a left above-knee amputation and required extensive assistance with personal hygiene, did not receive oral care or have his/her face and hands washed during morning care. Despite being dependent on staff for these tasks, the care provided was incomplete, as confirmed by observations and staff interviews. The staff acknowledged the oversight and stated that oral care and washing should have been offered as part of the morning routine. Resident #16, who was severely cognitively impaired and dependent on staff for all ADLs, did not receive proper perineal care. During incontinent care, staff used the same area of a washcloth to clean different areas of the skin, which is against the facility's policy. This improper technique was observed during care and confirmed by staff interviews. Additionally, oral care was not provided to the resident, despite being dependent on staff for such care. The Director of Nursing confirmed that the expected standard of care was not met in these instances.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of meaningful activities on a daily basis to meet the interests and the physical, mental, and psychosocial well-being of several residents. Observations, interviews, and record reviews revealed that five out of twelve sampled residents were not engaged in activities that catered to their needs and preferences. The facility's policy outlined a comprehensive approach to activities, but the implementation was lacking, as evidenced by the minimal engagement of residents in activities over a period of several months. Resident #3, who was severely impaired and dependent on a wheelchair, was engaged in activities on only three out of 147 days. The care plan indicated daily one-on-one interactions and participation in activities like aromatherapy and listening to music, but these were not consistently documented or observed. Similarly, Resident #14, with severely impaired cognition and wandering behavior, was engaged in activities on only five days. Despite a care plan that included one-on-one visits and participation in activities like coloring and music, the resident was often observed pacing or sitting without engagement. Other residents, such as Resident #22, #24, and #25, also showed minimal participation in activities, with records indicating engagement on only a few days out of many. Interviews with staff, including the Activity Director, revealed a lack of resources, training, and support for conducting activities, particularly for residents with dementia. The Activity Director had no formal training or certification and faced budget constraints, which further hindered the ability to provide meaningful activities. Additionally, there was no dementia-specific training for staff, and activities were not planned for weekends or holidays, contributing to the deficiency in meeting residents' needs.
Failure to Lock Wheelchair Brakes During Transfers
Penalty
Summary
The facility failed to ensure proper safety measures during resident transfers, specifically by not locking wheelchair brakes, which is a critical step in preventing accidents. This deficiency was observed in the cases of three residents who were dependent on staff for mobility and required mechanical lifts for transfers. The facility's policy on using mechanical lifting devices did not explicitly state the need to lock wheelchair brakes during transfers, contributing to the oversight. Observations revealed that staff members, including CNAs, did not lock the wheelchair brakes while transferring residents using the Invacare hydraulic lift 9805P. Resident #16, who has severe cognitive impairment and is dependent on staff for all activities of daily living, was transferred without the wheelchair brakes being locked. Similarly, Resident #24, with severe cognitive impairment and multiple diagnoses, was transferred from a wheelchair to a bed without the brakes being locked. Resident #3, who is dependent on a wheelchair and staff for mobility and personal care, was also transferred without the brakes being locked. Interviews with staff indicated a lack of training and awareness regarding the necessity of locking wheelchair brakes during transfers, as confirmed by the Director of Nursing.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide proper respiratory care for residents requiring oxygen therapy, as evidenced by several deficiencies observed during the survey. For one resident, the oxygen concentrator was set incorrectly at three liters instead of the prescribed two liters, and the humidified water bottle was found empty. Additionally, the oxygen tubing was on the floor and lacked a date, contrary to the facility's policy that requires tubing to be dated and changed weekly. This resident had severe cognitive impairment and was dependent on staff for various activities of daily living, with diagnoses including non-traumatic spinal cord dysfunction and cerebral palsy. Another resident, who had congestive heart failure, was observed with oxygen set at three liters, and the oxygen tubing was not dated. Interviews with staff revealed a lack of clarity regarding responsibilities for changing oxygen tubing and filling the humidified water bottle. Both CNAs and LPNs acknowledged that the oxygen tubing should not be on the floor and should be dated when changed, and that the humidified water bottle should contain sterile water. The facility's policy mandates these practices to ensure safe and appropriate respiratory care.
Failure to Assess and Manage Bed Rail Use
Penalty
Summary
The facility failed to properly assess and manage the use of bed rails for two residents, leading to potential safety risks. Resident #29 was not assessed for the risk of entrapment from bed rails before installation, and no physician's order was obtained for the use of side rails. Additionally, the facility did not measure entrapment zones for the installed side rails for this resident. The resident's care plan did not address the use of side rails or assist bars, and the monthly device schedule did not include the resident's room in zone measurements for side rail entrapment. Resident #14, who had severely impaired cognition and required substantial assistance with daily activities, was also not assessed for alternatives to side rails. Although a cane rail was ordered for bed mobility and repositioning, there was no side rail assessment completed, and the electronic medical record did not reflect any such assessment. The monthly device schedule showed inconsistent measurements of the bed rail zones over several months, indicating a lack of consistent monitoring and assessment. Interviews with facility staff revealed a lack of proper procedures and documentation regarding the installation and use of bed rails. Certified Nurse Aides and the Maintenance Supervisor indicated that side rails were installed without proper assessment or physician's orders, and the Administrator acknowledged that side rail assessments and measurements should be completed prior to installation. This lack of adherence to facility policy and regulatory requirements contributed to the deficiencies identified in the report.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure compliance with the requirement to have a Registered Nurse (RN) on duty for eight consecutive hours per day, seven days a week. This deficiency was identified through interviews and a review of staffing records. The facility's policy, reviewed on January 1, 2024, stated the intent to comply with RN staffing requirements, yet staffing sheets revealed multiple instances where no RN was scheduled for the required hours. Specifically, there was no RN coverage for eight consecutive hours on several dates in October 2023, March 2024, April 2024, and May 2024. During an interview on May 30, 2024, the Administrator and the Director of Nursing acknowledged the requirement for RN coverage and the lapses in meeting this requirement.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported error rate of 32% based on eight errors out of 25 opportunities. This affected four residents, including one who received crushed Senna and Thera-tabs M tablets through a PEG tube, contrary to guidelines that these medications should not be crushed. Additionally, the administration of Fluticasone Propionate nasal spray was incorrect, as the LPN did not follow the prescribed method, including failing to close one nostril and administering only one spray instead of two. Another resident did not receive Seroquel Rub as prescribed from March until late May due to a lack of supply, resulting in 64 missed doses. The medication was intended to be applied topically four times daily for unspecified psychosis. The staff was unaware of the duration the resident had been without the medication, indicating a lapse in medication management and communication within the facility. Furthermore, insulin administration errors were noted for two residents. The LPN failed to prime the insulin pens and did not clean the port with an alcohol wipe before attaching the needle, which is against the facility's policy. These errors in insulin administration were observed with both Novolog and Humalog insulin pens, highlighting a consistent issue with following proper procedures for insulin delivery.
Failure to Prime Insulin Pens Leads to Medication Errors
Penalty
Summary
The facility failed to ensure a safe and effective medication administration system, resulting in significant medication errors involving insulin administration for two residents. The facility's policy requires insulin pens to be primed before each use to prevent air from entering the insulin reservoir. However, observations revealed that an LPN did not follow this protocol. For one resident, the LPN removed the cap from a Novolog insulin pen, attached the needle without cleaning the port, and administered 14 units of insulin without priming the pen. Similarly, for another resident, the LPN administered Humalog insulin without priming the pen, following the same incorrect procedure. Interviews with the LPN and the Director of Nursing confirmed the failure to adhere to the facility's insulin administration policy. The LPN acknowledged the oversight in not cleaning the port and not priming the insulin pens before administration. The Director of Nursing reiterated that the staff should clean the insulin port with an alcohol wipe and prime the insulin pens with two units before administering insulin. These actions and inactions led to the deficiency in medication administration, affecting the residents' care.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as well as maintaining cleanliness in medication storage areas. During an observation, it was noted that a bottle of Flonase nasal spray belonging to a resident did not have a pharmacy label, and the resident's name handwritten on the bottle was mostly wiped off. Additionally, two medication drawers contained a sticky powdery substance, and the registered nurse on duty was unaware of who was responsible for cleaning the medication carts. Furthermore, medications were found left at the bedside of two residents, which is against the facility's policy. One resident, with severe cognitive impairment and multiple dependencies, had a medication cup with a clear liquid and crushed medication left on their bedside table. Another resident, also with severe cognitive impairment and various dependencies, had antifungal powder with miconazole nitrate 2% left on the sink in their room without a label, despite having no orders for such medication or for self-administration. Interviews with staff, including the LPN and DON, confirmed that medications should not be left at the bedside and should have proper pharmacy labeling.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the necessary competencies and skills to effectively manage the food and nutrition services. The job description for the DM position, dated 2020, required certification as a dietary manager, food service manager, or similar national certification, or an associate's or higher degree in food service management or hospitality. Additionally, two years of experience in food service management was required, with prior healthcare foodservice experience preferred. However, the DM, who had been in the position since April 2021, did not have the required dietary certification and was still enrolled in a 15-month program that would not be completed until November 2024. Interviews with the DM and facility administrators confirmed that the DM should have been certified, highlighting a gap in compliance with the facility's staffing requirements.
Infection Control Deficiencies in TB Screening and Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of tuberculosis (TB) screening for newly hired employees. A review of employee files for six out of ten sampled staff members, including nurse aides and registered nurses, revealed that none had completed the required Mantoux test screening for TB prior to their hire dates. The facility's policy mandates that all healthcare workers be tested for TB upon hire and annually thereafter, with new employees not allowed to work until the test results are known. However, the Business Office Manager and Administrator acknowledged the oversight, indicating a lack of adherence to the policy. Additionally, the facility failed to provide alcohol-based hand rub (ABHR) on the memory care unit, as observed during multiple inspections. Hand sanitizer dispensers in various rooms and the North dining room were found empty, and staff interviews confirmed the absence of hand sanitizer on the unit since March. The facility's hand hygiene policy requires proper hand hygiene procedures to prevent infection spread, with ABHR being the preferred method in most clinical situations. Despite this, the facility experienced issues with receiving the correct hand sanitizer refills for their dispensers, leading to a prolonged period without adequate hand hygiene resources. Interviews with staff, including CNAs and the Housekeeping Supervisor, highlighted the ongoing challenges in maintaining hand sanitizer availability. The facility's supplier had discontinued the refills that fit the existing dispensers, resulting in a mismatch between the dispensers and the refills received. This issue persisted despite attempts to install new dispensers and redistribute existing ones from closed areas. The Director of Nursing was unaware of the hand sanitizer shortage, indicating a communication gap within the facility's management regarding infection control resources.
Inaccessible Call Light System in LTC Facility
Penalty
Summary
The facility failed to ensure that the call light system was accessible for residents in their rooms, leading to deficiencies in care. Observations revealed that call lights were out of reach for several residents, including those with severe cognitive impairments and dependencies on staff for personal care. For instance, one resident's call light was found on the floor, while another's was draped over a light fixture, making it inaccessible. These issues were observed across multiple rooms, affecting residents who required substantial assistance due to conditions such as dementia, anxiety disorders, and physical impairments. The facility's policy mandates that call lights be within reach of residents to allow them to call for assistance. However, the report highlights that in several instances, call lights were either not attached to the wall units or were placed in positions that residents could not access. This was particularly concerning for residents with severe cognitive impairments and those who were dependent on staff for mobility and personal hygiene. Interviews with staff confirmed that some residents did not understand the concept of using call lights, and there were instances where call light strings were missing or broken. The deficiency was further compounded by the facility's failure to address these issues promptly. Although maintenance staff had recently checked and installed call lights, there were still rooms without functioning call light strings. Staff interviews indicated a lack of consistent practice in ensuring call lights were within reach, with some staff acknowledging that call lights should not be draped over furniture or left on the floor. The facility's administrator also confirmed that call lights should be accessible to residents at all times.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for one of the residents, identified as Resident #30, at the time of their planned discharge. The facility's policy, revised in December 2016, mandates that a discharge summary and post-discharge plan be developed to assist residents in adjusting to their new living environment. This summary should include a comprehensive recapitulation of the resident's stay, their medical history, current diagnoses, functional status, and medication therapy, among other details. However, upon review, it was found that Resident #30, who was admitted on May 8, 2023, and discharged on April 3, 2024, did not have a discharge summary in their medical record. Resident #30's quarterly Minimum Data Set (MDS) indicated that they had intact cognitive skills and were independent in several activities of daily living, such as eating and toilet use, but required assistance with oral hygiene and personal hygiene. The resident had diagnoses including seizure disorder, anxiety, depression, high blood pressure, and PTSD. Despite these details, the facility did not provide a care plan for the resident, and the absence of a discharge summary was confirmed during an interview with the Administrator, who acknowledged that there should have been a recapitulation of the resident's stay in their medical record.
Unqualified Activity Director Employed
Penalty
Summary
The facility failed to employ a qualified activity professional to oversee its activity program. The current Activity Director, who has been in the position since 2017, has not completed an approved activity professional training program. The director received only one day of training before assuming the role and has attended some general training sessions with other staff but lacks specific certifications in activity programming and dementia care. Interviews with the Corporate Administrator and the Administrator revealed a lack of awareness regarding the certification requirements for the Activity Director role. Additionally, the facility did not provide a policy outlining the training and requirements for activity professionals.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident with severe cognitive impairment and a stage 3 pressure ulcer on the left heel. The resident, who was dependent on a wheelchair and always incontinent, was at risk for pressure ulcers and had unhealed pressure ulcers. Despite having physician orders to float the resident's heels in bed using pressure off-loading boots and to conduct weekly skin assessments, these orders were not consistently followed. Observations showed that the resident did not have the pressure-reducing boots on while in bed on multiple occasions, and there were missing entries for the required skin assessments and wound dressing checks. Interviews with facility staff, including an LPN and a CNA, revealed that there were issues with staff compliance in applying the resident's heel protectors as ordered. The Director of Nursing confirmed the expectation that the resident's orders for offloading heels should be followed. The facility also lacked a specific policy on pressure ulcers, which may have contributed to the inconsistency in care. The failure to adhere to the prescribed treatment and assessment protocols led to a deficiency in the care provided to the resident.
Improper Catheter Care and Peri Care Practices
Penalty
Summary
The facility failed to provide proper catheter care to prevent urinary tract infections for a resident. The staff did not clean the catheter tubing or the drainage spout and placed the graduate directly on the floor, which is against the facility's policy. The resident, who was always continent of urine and incontinent of bowel, did not have a leg strap to secure the catheter tubing, and the care plan did not address the use of a urinary catheter. During an observation, a CNA placed the graduate on the floor, emptied the drainage bag without cleaning the spout, and did not secure the catheter tubing with a leg strap. The CNA also failed to clean the urinary catheter tubing and did not separate and clean all skin folds during peri care. The CNA used a wash cloth incorrectly by using the same area to clean different parts of the skin and used a paper towel for peri care, which is not appropriate. Interviews with the CNA, another NA, and the DON revealed that the staff were not following proper procedures for catheter care and peri care. The CNA admitted to not using alcohol pads to clean the spout and not securing the catheter tubing. The DON confirmed that staff should not use the same area of a wash cloth for different areas of the skin, should not use paper towels for peri care, and should ensure the catheter tubing is anchored and cleaned.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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