Maple Grove Wellness & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Fenton, Missouri.
- Location
- 560 Corisande Hill Rd, Fenton, Missouri 63026
- CMS Provider Number
- 265395
- Inspections on file
- 15
- Latest survey
- August 29, 2025
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Maple Grove Wellness & Rehabilitation during CMS and state inspections, most recent first.
A nurse failed to verify a resident's identity and administered another resident's morphine sulfate and lorazepam, resulting in the resident experiencing adverse symptoms and requiring Narcan and hospital transfer. The nurse did not follow the facility's medication administration policy, including the required identity checks and communication with the resident.
Nineteen residents did not receive prescribed medications or treatments when an LPN refused to cover a hallway after another nurse left early, and the DON was unable to secure agency coverage in time. Residents with conditions such as diabetes, hypothyroidism, and heart disease missed critical care, and staff attempts to notify the DON during the shift were unsuccessful.
Facility staff did not notify the physician of a resident's urine culture and sensitivity results, which showed E. coli resistant to the prescribed antibiotic Bactrim DS. The resident, with multiple chronic conditions, was treated for cellulitis, but the required communication of lab results to the physician did not occur, as the Infection Preventionist failed to follow protocol.
The facility failed to provide the required minimum of two showers per week for five residents, leading to complaints and observations of poor hygiene. Residents with various medical conditions requiring assistance for bathing reported infrequent showers and unkempt appearances. The facility's policy was not followed, and the administrator acknowledged the expectation for regular showers.
The facility failed to repair essential kitchen equipment and ensure proper food storage in residents' personal refrigerators. Observations revealed malfunctioning kitchen appliances and expired, improperly stored food items. Interviews indicated a lack of clear responsibility and process for maintaining the refrigerators, leading to potential health risks for residents.
The facility failed to develop a Quality Assurance and Performance Improvement Plan (QAPI). Despite having policies outlining the QAPI process, the facility did not have a QAPI plan in place. The Administrator admitted they are starting fresh with QAPI and could not find any past documentation, with no Performance Improvement Projects (PIPs) in place.
The facility failed to ensure the QAPI committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. Key personnel did not attend the QAPI meeting, and no Performance Improvement Projects (PIPs) were in place. The Administrator admitted to starting fresh with QAPI and lacking past documentation, indicating a failure to address systemic quality deficiencies.
The facility failed to hold quarterly QAPI meetings with the required members, as mandated by their policy. A review showed no evidence of key members attending a recent meeting, and the Administrator admitted to not finding documentation of past meetings or having any PIPs in place. The facility census was 92 residents.
The facility failed to notify residents and/or their representatives in writing of transfers or discharges to a hospital, including the reasons for the transfer, and did not notify the Office of the State Long-Term Care Ombudsman. This deficiency was identified for 10 residents out of a sample of 19, with the facility's census being 92.
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, affecting all residents. Nursing schedules from February to April 2024 showed 11 days without RN coverage. The Administrator acknowledged the expectation for RN coverage, and the facility lacked an RN coverage policy.
The facility failed to notify residents of the availability and location of the most recent survey results. Multiple residents were unaware of a binder containing survey results, and the Administrator admitted the results had been misplaced following an administration change. A new survey binder was eventually created and placed on the front table.
The facility failed to consistently document the code status for two residents, leading to discrepancies in their medical records. Interviews with staff revealed confusion about the methods for determining code status, resulting in conflicting information being recorded.
The facility failed to provide a safe, clean, comfortable, and homelike environment. Observations revealed debris on a resident's oxygen concentrator, unpainted drywall patches, stained privacy curtains, and missing closet drawers. The Administrator and Director of Operations acknowledged these issues, indicating a deficiency in maintaining the expected standards.
The facility failed to provide adequate discharge documentation for a resident transferred to another facility, including a discharge summary and recapitulation of the resident's stay. Interviews with staff revealed a misunderstanding of the discharge policy, leading to the omission of required documentation.
The facility failed to inform residents and/or their legal representatives in writing of the bed hold policy at the time of transfer to the hospital for ten residents. Despite the facility's policy requiring written notification, the Social Services Director admitted that this was not done, and the Administrator and Director of Operations expected staff to provide this information, highlighting a discrepancy between policy and practice.
The facility failed to complete significant change MDS assessments within the required 14-day timeframe for two residents following their discharge from hospice services. The Administrator, Director of Operations, and MDS Coordinator acknowledged the oversight, which did not comply with the RAI Manual requirements.
The facility failed to document accurate MDS assessments for five residents, leading to discrepancies in their medical records. Errors included incorrect indications of insulin use, inaccurate diagnoses, and omissions of several medical conditions. Interviews with staff confirmed these inaccuracies, highlighting a failure to adhere to the facility's MDS completion and submission guidelines.
The facility failed to update and revise care plans for two residents, omitting critical interventions such as PICC line management. This deficiency was acknowledged by the Administrator and Director of Operations, who stated that care plans should reflect the current condition of the residents.
The facility failed to follow physician's orders for two residents and did not obtain a treatment order for one resident. One resident had inconsistent administration times for levothyroxine and was observed wearing prevalon boots without an order. Another resident also had inconsistent levothyroxine administration times, leading to abnormal TSH levels.
The facility failed to follow professional standards for PICC line care for two residents. One resident's PICC line dressing was not changed weekly, and the infusion was not disconnected or flushed promptly. Another resident's PICC line dressing was not changed weekly, and the line was accidentally pulled out during a dressing change, requiring replacement. The facility did not adhere to physician orders and professional standards for PICC line care.
The facility failed to screen four residents for Tuberculosis (TB) as per their policy. Medical records showed lapses in compliance, with missing documentation for annual TB tests and screenings. The facility's census was 92, indicating potential broader non-compliance issues.
The facility failed to provide a dining room large enough to accommodate all residents, leading to overcrowding and discomfort. Observations showed insufficient seating, and residents reported having to take food back to their rooms or wait for a seat. The Director of Operations acknowledged the issue but did not provide a satisfactory solution.
The facility failed to maintain a safe environment by allowing items to be stored on overbed light fixtures in multiple rooms. Observations included stuffed animals and crafts placed on the lights, posing a potential fire hazard. The facility did not have a specific policy for overbed lighting safety, although the admission packet prohibited such practices.
The facility failed to provide at least twelve hours of annual in-service education for two CNAs, with one CNA receiving only one hour and another receiving four hours of training. The Administrator confirmed the expectation of twelve hours of training per year, and the facility lacked an in-service training policy.
The facility staff failed to post the required daily nurse staffing information in a prominent location readily accessible to residents and visitors. Observations showed the information was not visible near nurse's stations or the main lobby. A CNA confirmed it was posted in the nurse's office, making it inaccessible to residents or visitors. The Administrator expected the information to be posted in a prominent location.
Failure to Prevent Significant Medication Error Due to Improper Resident Identification
Penalty
Summary
A significant medication error occurred when a nurse administered another resident's prescribed medications—morphine sulfate and lorazepam oral concentrate—to a cognitively intact resident with multiple chronic conditions, including diabetes, chronic kidney disease, heart failure, COPD, chronic respiratory failure, and chronic pancreatitis. The nurse failed to verify the resident's identity, did not explain the medications being administered, and did not confirm the resident's name prior to administration. The nurse was running behind on the medication pass and, in haste, called out the intended recipient's name, to which the wrong resident responded, and then administered the medications without further verification. Shortly after receiving the incorrect medications, the resident experienced nausea and a rapid decline in condition, including changes in vital signs and mentation. The resident reported that the nurse did not communicate or identify herself, nor did she provide any information about the medications being given. The error was discovered when the resident questioned what had been administered and another nurse intervened to monitor the resident's condition. The facility's medication administration policy required verification of resident identity and adherence to the seven rights of medication administration, including the right resident, right medication, and right dose. The nurse involved admitted to not following these protocols due to being in a hurry. The incident resulted in the resident requiring administration of Narcan and transfer to the hospital for further evaluation.
Failure to Administer Medications and Treatments Due to Staffing Refusal
Penalty
Summary
The facility failed to follow physician's orders for 19 residents on the 100 hall, resulting in missed administration of critical medications and treatments. The review of medical records and medication administration records revealed that residents with diagnoses such as Type II Diabetes Mellitus, Hypothyroidism, Coronary Heart Disease, pneumonia, COPD, and Muscular Dystrophy did not receive prescribed medications, including various types of insulin, Levothyroxine, antibiotics, pain medication, and inhalation treatments. Blood sugar checks and other ordered care were also not performed as required by the residents' care plans and physician orders. The deficiency occurred during the night shift when only one nurse, an LPN, remained after the scheduled nurse for the 200 hallway left early. The LPN assigned to the 100 hallway refused to provide care or administer medications to the residents on that hall, stating discomfort with covering both hallways due to limited experience at the facility. The Director of Nursing (DON) was informed of the staffing issue and attempted to secure an agency nurse, who was expected to arrive by 11:00 P.M., but did not arrive until the morning. The DON left the facility after giving the keys to the LPN, who refused to accept responsibility for the 100 hallway. Throughout the night, no medications or treatments were administered to any residents on the 100 hallway. Staff, including a CNA, attempted to contact the DON to report the ongoing issue, but did not receive a response until after the shift. The following morning, the LPN confirmed to the DON that no care had been provided to the 100 hallway residents, and subsequently resigned. The facility did not provide a policy on medication administration when requested.
Failure to Notify Physician of Antibiotic-Resistant UTI Lab Results
Penalty
Summary
Facility staff failed to ensure proper antibiotic stewardship for a resident when they did not notify the resident's physician of the results from a urine culture and sensitivity (C&S) test. The resident, who had a history of diabetes, chronic kidney disease stage 2, COPD, hypertension, and adult failure to thrive, complained of burning during urination and had a urine sample collected. The physician was contacted for other symptoms and prescribed Bactrim DS for cellulitis, but there was no documentation that the physician was informed of the urine C&S results, which later showed Escherichia coli resistant to Bactrim DS. The facility's policy required staff to communicate pertinent clinical information, including lab results, to physicians to promote appropriate diagnosis and antibiotic prescribing. However, the Infection Preventionist, who was responsible for reviewing lab results and notifying the physician, did not follow this protocol. The Director of Nursing confirmed that the physician was not made aware of the urine C&S results, and the physician stated that a different antibiotic would have been prescribed if notified. There was no documentation that the alternate physician reviewed the lab results during a subsequent visit.
Failure to Provide Adequate Showering for Residents
Penalty
Summary
The facility failed to provide a minimum of two showers per week for five out of six sampled residents, potentially affecting all residents in the facility with a census of 92. The facility's policy stated that residents should be offered a shower at least once weekly and as requested, but this was not adhered to. The Resident Council Meeting Minutes also indicated ongoing complaints about the lack of showers. Resident #1, with diagnoses including supra ventricular tachycardia, respiratory failure, and depression, was observed with body odor and unkempt hair. The resident reported receiving showers only once or twice a month, despite needing assistance from staff. Resident #2, with severe cognitive impairment and multiple health issues, also reported not receiving the required showers, leading to greasy hair and dirty sheets. Both residents expressed dissatisfaction with the frequency of showers and the lack of staff assistance. Similarly, Residents #4, #5, and #6, all with various medical conditions requiring assistance for bathing, reported receiving showers far less frequently than the expected twice a week. Observations confirmed their unkempt appearance and body odor. Interviews with these residents revealed that they often requested showers but were either ignored or given excuses by the staff. The facility administrator acknowledged the expectation for showers to be given at least twice a week and for refusals to be documented.
Facility Fails to Maintain Kitchen Equipment and Ensure Proper Food Storage
Penalty
Summary
The facility failed to repair essential kitchen equipment, including the convection oven, stove top burners, flat top grill, and oven. Observations revealed significant issues such as a wooden block holding up the stove, rust covering the inside of the oven, missing knobs, and debris buildup. Interviews with the Dietary Manager and cooks confirmed that the malfunctioning equipment slowed down meal preparation and made it challenging to cook meals efficiently. Despite informing the administration, the necessary repairs or replacements were not made, affecting the dietary staff's ability to perform their duties effectively. The facility also failed to ensure that food stored in residents' personal refrigerators was maintained at safe temperatures and that expired foods were discarded. Observations of several residents' refrigerators showed expired and improperly stored food items, including undated leftovers and uncovered containers. Interviews with residents indicated that no one regularly checked their refrigerators for expired food, temperature, or cleanliness. The Dietary Manager, housekeeping staff, and Director of Nursing provided conflicting information about who was responsible for these tasks, revealing a lack of a clear process or schedule for maintaining the refrigerators. The Administrator and Director of Operations acknowledged that housekeeping was supposed to check the temperatures, discard expired foods, and clean the refrigerators daily. However, the observations and interviews indicated that this was not being done consistently, leading to potential health risks for the residents. The facility's failure to maintain kitchen equipment and ensure proper food storage practices demonstrated significant deficiencies in their operations, potentially affecting all residents.
Failure to Develop a QAPI Plan
Penalty
Summary
The facility failed to develop a Quality Assurance and Performance Improvement Plan (QAPI). The facility's policy, revised in February 2020, outlines the responsibilities of the QAPI committee, including overseeing the implementation of the QAPI plan, identifying and correcting quality deficiencies, and monitoring the effectiveness of corrective actions. However, the facility did not have a QAPI plan in place, despite having policies that describe the QAPI process. During an interview, the Administrator admitted that they are starting fresh with QAPI and could not find any past documentation. The facility has no Performance Improvement Projects (PIPs) in place and plans to have weekly QAPI meetings. The absence of a QAPI plan was confirmed through both interviews and record reviews, indicating a significant gap in the facility's quality assurance and performance improvement efforts.
Failure to Implement QAPI Plan
Penalty
Summary
The facility failed to ensure the Quality Assurance Performance Improvement (QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. The facility's policy required an ongoing, facility-wide, data-driven QAPI program focused on indicators of care outcomes and quality of life for residents. However, the review of the QAPI committee notes showed no evidence of key personnel such as the Medical Director, Director of Nursing, or Infection Preventionist attending the meeting. Additionally, there were no Performance Improvement Projects (PIPs) in place, which are essential for addressing and correcting quality deficiencies. During an interview, the Administrator admitted that they were starting fresh with QAPI and could not find any past documentation of QAPI activities. Despite having a recent meeting, the facility had no PIPs in place and planned to have weekly QAPI meetings moving forward. This lack of documentation and absence of PIPs indicated a failure to systematically analyze underlying causes of systemic quality deficiencies and implement corrective actions, as required by their QAPI policy. This deficiency had the potential to affect all residents in the facility, which had a census of 92 at the time of the survey.
Failure to Maintain Quarterly QAPI Meetings with Required Members
Penalty
Summary
The facility failed to maintain quarterly Quality Assurance and Performance Improvement (QAPI) committee meetings with the required members. The facility's policy, revised in March 2020, mandates that the QAPI committee includes the Administrator, Director of Nursing Services, Medical Director, Infection Preventionist, and representatives from various departments. However, a review of an Inservice Log dated 04/26/24 showed no evidence of the Medical Director, Director of Nursing, or Infection Preventionist attending the meeting. Additionally, the Administrator admitted to not finding documentation of past QAPI meetings and confirmed that no Performance Improvement Projects (PIPs) were in place. During interviews, the Administrator and Director of Operations acknowledged the expectation for the facility to hold QAPI meetings at least quarterly with the required members present. Despite the recent meeting, the lack of documentation and absence of key members indicate non-compliance with the facility's QAPI policy. The facility census at the time was 92 residents.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of transfers or discharges to a hospital, including the reasons for the transfer, and did not notify the Office of the State Long-Term Care Ombudsman. This deficiency was identified for 10 residents out of a sample of 19, with the facility's census being 92. The facility's policy required that a Transfer to Another Facility form be filled out, explaining the reason for the transfer and the bed hold policy, and that this information be communicated to the resident or their representative. However, this procedure was not followed for the sampled residents, as there was no documentation of written notification to the residents or their representatives, nor was there any notification to the Ombudsman at the time of transfer to the hospital. The Social Services Director confirmed that they do not issue written transfer/discharge notices for hospital transfers, and the Administrator and Director of Operations stated that they would expect staff to notify the resident or their representative in writing and send a copy to the Ombudsman. Resident #2 was transferred to the hospital multiple times without written notification to the resident or their representative, and without notifying the Ombudsman. Similar deficiencies were found for Resident #4, who was transferred to the hospital on multiple occasions without the required notifications. Resident #11's medical record also showed a lack of documentation for written notification to the resident or their representative and the Ombudsman during a hospital transfer. Resident #14 experienced multiple hospital transfers without the necessary written notifications, and the same issue was found for Resident #52, who was transferred to the hospital three times without proper documentation. Other residents, including Resident #56, Resident #64, Resident #67, Resident #85, and Resident #444, also experienced hospital transfers without the required written notifications to themselves or their representatives and without notifying the Ombudsman. The facility's failure to follow its own policy and regulatory requirements for notifying residents, their representatives, and the Ombudsman in writing during hospital transfers was a consistent issue across multiple cases, as confirmed by interviews with the Social Services Director and the facility's administration.
Failure to Provide RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, as required. This deficiency had the potential to affect all residents, with a facility census of 92. The nursing schedules from February 1, 2024, through April 30, 2024, revealed that there were 11 days without any RN scheduled. Specific dates without RN coverage included February 17, March 2, 3, 16, 17, 30, 31, and April 13, 14, 27, 28. During an interview on May 7, 2024, the Administrator acknowledged the expectation for RN coverage for at least eight hours a day, seven days a week. Additionally, the facility did not provide an RN coverage policy.
Failure to Notify Residents of Survey Results
Penalty
Summary
The facility failed to notify residents of the availability and location of the most recent survey results in an accessible location. This deficiency was identified during a resident council meeting where multiple residents collectively stated they were unaware of a binder containing survey results or its placement. The facility's census was 92 at the time. The Administrator admitted during an interview that the survey results had been misplaced following an administration change. A new survey binder was eventually created and placed on the front table, but this was after the deficiency was noted.
Inconsistent Documentation of Code Status
Penalty
Summary
The facility failed to consistently document the code status for two residents, leading to discrepancies in their medical records. For one resident, the medical record showed conflicting information with both full code and Do Not Resuscitate (DNR) statuses documented. The resident had a care plan that listed both statuses with corresponding interventions and goals. Interviews with the resident and staff revealed confusion about the resident's current code status, with the resident indicating a change from hospice to full code, which was not consistently reflected in the documentation. For another resident, the medical record also showed conflicting information with both full code and DNR statuses documented. The care plan listed a DNR status, but staff interviews revealed inconsistencies in how code statuses were communicated and documented. Certified Nurse Assistants (CNAs) and the Director of Nursing (DON) provided different methods for determining code status, including lists at the nurse's station and symbols on resident doors, leading to further confusion. The Administrator and Director of Operations confirmed that the code status should be consistently reflected throughout the resident's chart, which was not the case for these residents.
Failure to Maintain a Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents. Observations of a resident's room on multiple occasions revealed that the oxygen concentrator had debris on the filter and the left side of the concentrator. Additionally, there were twenty drywall patches on the walls and corners of the room that were not painted over. Another room was observed to have stained privacy curtains with a brown substance, and a different room had missing bottom drawers from the closet and bent trim. These observations indicate a lack of adherence to the facility's general cleaning procedure, which requires reporting dirty curtains, burnt-out light bulbs, and missing items to the housekeeping supervisor for maintenance repairs. During an interview, the Administrator and Director of Operations acknowledged that they would expect curtains to be clean and free from dirt, debris, and stains, oxygen concentrators to be cleaned weekly, and closets and drawers to be in working condition. They also stated that they would expect the walls of resident rooms to be free from drywall patches after maintenance has had a reasonable amount of time to paint over them. The failure to meet these expectations was evident in the observed conditions of the resident rooms, indicating a deficiency in maintaining a safe, clean, comfortable, and homelike environment for the residents.
Failure to Provide Adequate Discharge Documentation
Penalty
Summary
The facility failed to provide adequate discharge documentation for a resident transferred to another facility. Specifically, the facility did not include a discharge summary or recapitulation of the resident's stay, which is required to ensure a safe and effective transition of care. The facility's policy mandates that a discharge summary and post-discharge plan be developed, including a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge. However, the medical record for the resident in question showed no such documentation upon their transfer to another facility. Interviews with facility staff revealed a misunderstanding or misapplication of the discharge policy. The Social Services Director indicated that discharge summaries are not typically filled out for residents transferred to another facility, and the Administrator confirmed this practice. The Director of Operations also stated that discharge summaries are only completed when a resident is discharged to go home, not when transferring to another nursing home. This practice is inconsistent with the facility's written policies and resulted in the failure to provide necessary discharge documentation for the resident.
Failure to Inform Residents of Bed Hold Policy
Penalty
Summary
The facility failed to inform residents and/or their legal representatives in writing of the bed hold policy at the time of transfer to the hospital for ten residents out of 19 sampled residents. The facility's policy required that the bed hold policy be explained and documented in writing upon obtaining a discharge order for hospital transfer. However, the medical records for the ten residents showed no documentation that the bed hold policy was communicated in writing during their transfers. This included multiple instances of hospital transfers and readmissions for each resident, with no written notification provided as required by the facility's policy. During interviews, the Social Services Director admitted that they do not issue a written copy of the bed hold policy to residents or their representatives when residents are sent to the hospital, as it was included in the initial admission package. The Administrator and Director of Operations stated that they expect staff to inform the resident or resident representative in writing of the bed hold policy upon hospitalization, indicating a discrepancy between the facility's policy and actual practice. This failure to provide written notification of the bed hold policy at the time of transfer was identified as a deficiency by the surveyors.
Failure to Complete Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for two residents following their discharge from hospice services. For Resident #6, the medical record showed a quarterly MDS assessment indicating hospice services on 01/28/23 and a discharge from hospice services on an unspecified date. However, the facility did not complete a significant change MDS within 14 days after the discharge. Similarly, for Resident #67, the medical record showed a significant change MDS indicating the resident no longer received hospice services and a discharge date from hospice services, but the facility again failed to complete a significant change MDS within the required 14-day timeframe. During interviews, the Administrator, Director of Operations, and MDS Coordinator all acknowledged that the MDS should be updated and completed within the required timeframes as per the Resident Assessment Instrument (RAI) Manual. The MDS Coordinator specifically noted that a significant change MDS should be completed with each hospice admission and discharge to accurately reflect the resident's current condition. The failure to adhere to these requirements resulted in the deficiency noted in the report.
Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to document accurate Minimum Data Set (MDS) assessments for five residents, leading to discrepancies in their medical records. Resident #2's quarterly MDS assessment incorrectly indicated the use of insulin, despite no such order being present in the medical record. Resident #6's annual MDS assessment inaccurately marked Parkinson's disease and omitted diagnoses of GERD, macular degeneration, and glaucoma. Additionally, the quarterly MDS assessment for Resident #6 incorrectly indicated a life expectancy of less than six months following discharge from hospice services. Resident #9's quarterly MDS assessment incorrectly included a diagnosis of PTSD, which was not present in the medical record. Resident #64's quarterly MDS assessment failed to mark several diagnoses, including cardiac dysrhythmias, GERD, dementia, and anxiety. Resident #69's annual MDS assessment omitted diagnoses of heart failure, pneumonia, and Vitamin B-12 deficiency anemia. Interviews with facility staff, including the Social Services Director, Administrator, Director of Operations, and MDS Coordinator, confirmed the inaccuracies in the MDS assessments. The MDS Coordinator acknowledged that all active diagnoses should be reflected in Section I of the MDS and that non-insulin diabetes medication should not be coded as insulin. The facility's policy on MDS completion and submission timeframes, revised in October 2023, mandates that assessments be completed and submitted based on the current requirements published in the Resident Assessment Instrument (RAI) Manual. The deficiencies indicate a failure to adhere to these guidelines, resulting in inaccurate documentation of residents' conditions.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans with specific interventions to meet the individual needs of two residents. Resident #67, who was admitted with chronic kidney disease, cellulitis, GERD, insomnia, and heart failure, had orders for meropenem, normal saline flush, and PICC dressing changes. However, the care plan revised on 05/02/24 did not address the PICC line, which is a critical component of the resident's treatment plan. This omission indicates a lack of thorough analysis and updating of the care plan based on the resident's current medical needs and interventions as required by the facility's policy. Similarly, Resident #444, admitted with bacteremia, Type 2 diabetes, congestive heart failure, acute osteomyelitis, and a non-pressure chronic ulcer, had orders for daptomycin and PICC dressing changes. The care plan revised on 04/22/24 also failed to address the PICC line. During an interview, the Administrator and Director of Operations acknowledged that care plans should reflect the current condition of the resident and should be updated by facility staff when the responsible Registered Nurse is unavailable. This failure to update care plans as per the facility's policy resulted in deficiencies in the care provided to these residents.
Failure to Follow Physician's Orders and Obtain Treatment Orders
Penalty
Summary
The facility failed to follow physician's orders for two residents and did not obtain a treatment order for one resident. Resident #11 had an order for levothyroxine to be taken every morning on an empty stomach, but the medication administration times ranged from 7:46 A.M. to 12:45 P.M., with the medication being administered late on 20 out of 64 days. Additionally, Resident #11 was observed wearing prevalon boots on multiple occasions without a treatment order for them. The Assistant Director of Nursing acknowledged the lack of an order for the boots and mentioned that staff sometimes remove them because they get hot and itchy. Resident #56 also had an order for levothyroxine to be taken every morning, but the medication administration times ranged from 7:01 A.M. to 12:34 P.M., with the medication being administered late on 30 out of 64 days. The resident's thyroid stimulating hormone (TSH) levels were abnormally high, indicating improper administration of the medication. Interviews with the Director of Nursing, a Licensed Practical Nurse, and a Certified Medication Technician confirmed that levothyroxine should be given on an empty stomach or at bedtime, and the resident's TSH labs supported that the medication was not being administered correctly.
Failure to Follow PICC Line Care Protocols
Penalty
Summary
The facility failed to ensure staff provided necessary care and services in accordance with professional standards of practice for two residents. For Resident #67, the staff did not follow policies and procedures regarding PICC line care and administration of IV antibiotics. The resident's PICC line dressing, dated 04/20/24, was not changed weekly as required, and the infusion was not disconnected or flushed promptly after completion. The Director of Nursing and an LPN were unaware of the resident's PICC line, indicating a lack of communication and oversight in the facility's care processes. For Resident #444, the staff also failed to adhere to PICC line care protocols. The resident's PICC line dressing, dated 04/24/24, was not changed weekly, and there was blood around the catheter site. An LPN experienced difficulty flushing the line, which was found to be pulled out approximately three centimeters and appeared kinked. The night nurse had accidentally pulled the line partway out during a dressing change, and the PICC line company had to be contacted to replace the line. The Director of Nursing confirmed that the staff should not attempt to reinsert a displaced PICC catheter. Interviews with the residents and staff revealed that the facility did not follow physician orders and professional standards for PICC line care. The Administrator and Director of Operations acknowledged that a registered nurse should complete PICC line dressing changes and that the line should be flushed and cared for according to physician orders. They also stated that infusions should be disconnected promptly after completion and that staff should not attempt to reinsert a displaced PICC catheter.
Failure to Screen Residents for Tuberculosis
Penalty
Summary
The facility failed to screen four residents for Tuberculosis (TB) as per their policy. The policy mandates that all residents be screened for TB infection and disease, with specific guidelines for new admissions, readmissions, and annual screenings. However, the medical records of four residents showed lapses in compliance. Resident #4 was admitted on an unspecified date and had an annual TB test on 02/20/24, but there was no read date or documentation of TB testing or screening. Resident #11, admitted on an unspecified date, had their last annual screening on 01/19/23, with no subsequent documentation. Similarly, Resident #69 and Resident #444, both admitted on unspecified dates, had their last annual screenings on 01/19/23, with no further documentation of TB testing or screening since then. The facility's failure to adhere to its TB screening policy was identified through observation, interview, and record review. The policy requires annual risk assessments and regular testing for residents with specific health conditions or risk factors. Despite these requirements, the facility did not document the necessary TB screenings for the four residents, indicating a significant lapse in infection prevention and control measures. The facility's census at the time was 92, highlighting the potential for broader non-compliance issues within the resident population.
Inadequate Dining Room Space
Penalty
Summary
The facility failed to provide a dining room large enough to accommodate the residents, affecting one resident out of 19 sampled residents and three residents outside the sample, with the potential to affect all residents. Observations showed that the main dining room had 11 round tables with room for four chairs at each table, totaling 44 seating places, and one table with five residents. Additionally, an unknown staff member was observed squeezing between tables and bumping two residents' chairs while they were eating. The assisted dining room had 21 seating places, making a total of 65 seating places in the two dining rooms, which was insufficient for the facility census of 92 residents. Interviews with residents revealed dissatisfaction with the dining room arrangements. One resident mentioned taking food back to their room because the dining room was overcrowded. Another resident stated that the dining room was too full, causing some residents to leave and come back when a seat was available. A third resident expressed frustration over the inability to choose where to sit and noted that residents in wheelchairs were required to sit on one side of the dining room. The Director of Operations acknowledged that residents could eat in either dining room and that staff should be able to pass trays without bumping into residents, but the observations and resident interviews indicated otherwise.
Failure to Maintain Safe Overbed Lighting
Penalty
Summary
The facility failed to provide a safe and functional environment for the residents by allowing items to be stored on top of overbed light fixtures in three rooms. This practice was observed on multiple occasions, with items such as stuffed animals and crafts being placed on the light fixtures. These observations were made on different dates and times, indicating a recurring issue. The facility census was 92, and the deficient practice had the potential to affect all residents and staff in the facility. The facility did not have a specific policy for overbed lighting safety, although the facility's admission packet did include a rule against storing personal items on the overhead light fixture due to safety hazards. During an interview, the Administrator and Director of Operations acknowledged that items should not be placed on the light fixtures due to the potential fire hazard. Specific observations included three stuffed animals on the light over the bed in one room, two heart-shaped crafts in another, and various other items in additional rooms. These observations were consistent over two days, highlighting a lack of adherence to safety protocols and the facility's own rules and regulations regarding the storage of personal items.
Inadequate In-Service Education for CNAs
Penalty
Summary
The facility failed to conduct at least twelve hours of nurse aide in-service education per year, affecting two out of two sampled Certified Nurse Assistants (CNA) D and E. CNA D, hired on 04/10/19, had only one hour of annual in-service training for the period from April 2023 through April 2024. Similarly, CNA E, hired on 03/11/19, had only four hours of annual in-service training for the same period. During an interview, the Administrator acknowledged that CNAs are expected to have at least twelve hours of in-service education per year. The facility did not provide an in-service training policy.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility staff failed to post the required daily nurse staffing information, which includes the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, in a prominent location readily accessible to residents and visitors. The facility census was 92. Observations from 04/29/24 through 05/03/24 showed that the required daily nurse staffing information was not found near any of the nurse's stations or the main lobby where it would be easily visible to residents and visitors. During an interview on 05/03/24, a Certified Nurse Aide (CNA) stated that the daily nurse staffing information was posted in the nurse's office behind the nurse's station, making it inaccessible to residents or visitors. The Administrator confirmed on 05/07/24 that she would expect the facility staffing to be posted in a prominent location that is readily accessible to residents and visitors.
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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