Marshfield Care Center For Rehab And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Marshfield, Missouri.
- Location
- 800 South White Oak, Marshfield, Missouri 65706
- CMS Provider Number
- 265577
- Inspections on file
- 26
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Marshfield Care Center For Rehab And Healthcare during CMS and state inspections, most recent first.
The facility did not provide timely showers in accordance with resident preferences and care plans, resulting in several residents experiencing long gaps between showers and expressing dissatisfaction with their hygiene. Staff interviews revealed that showers were often missed due to staffing shortages and lack of a dedicated shower aide, and documentation of bathing and skin assessments was incomplete or missing.
Surveyors found the medication room cluttered with a large quantity of unused medications, including various prescription drugs awaiting destruction, due to the facility's failure to maintain a timely process for medication disposal. Multiple staff, including a CMT, LPN, ADON, and DON, acknowledged the ongoing disorganization and backlog, with the DON stating that the process and paperwork for destruction had not been completed for months.
A resident's code status was not clearly documented or accessible in required locations, leading to a delay when staff could not quickly determine the appropriate emergency response during a medical event. Staff interviews revealed that code status information was inconsistent and not updated due to a vacancy in the Social Services Director position, resulting in confusion and delayed initiation of CPR.
A resident with multiple medical conditions suffered a fall resulting in a fracture, but staff failed to notify the family and physician promptly, did not complete or document a full assessment or neurological checks, and did not initiate required fall monitoring. The facility also lacked policies and procedures for fall documentation and notification.
The facility failed to ensure that ordered medications were available and administered as prescribed, resulting in three residents missing multiple doses of essential medications. Staff did not consistently notify physicians when medications were unavailable, and there was confusion among staff regarding the use of the emergency medication kit and the process for obtaining medications for new admissions.
A resident with multiple risk factors for skin breakdown experienced deterioration and infection of pressure ulcers due to staff failing to provide wound care as ordered, incomplete and untimely wound assessments, and lack of care plan updates. Wound treatments were frequently undocumented or missed, and communication lapses among staff led to delayed recognition and management of new and worsening wounds, ultimately resulting in hospitalization for wound infection and abscess.
Staff failed to perform proper hand hygiene and did not follow Enhanced Barrier Precautions during wound care for three residents, including those with MRSA and surgical wounds. Supplies were reused after being dropped on the floor, shared between residents without disinfection, and EBP signage and PPE carts were not consistently available. Staff interviews revealed a lack of training and awareness regarding EBP, and facility policies on infection control were not followed in practice.
Surveyors found that food was not consistently protected from contamination due to unclean kitchen and serving areas, including debris and dried substances on the steam table, plate warmer, and toaster, as well as expired condiments in the serve-out refrigerator. Staff interviews revealed cleaning responsibilities were shared but not always completed due to limited staffing, and there was no clear policy for kitchen cleaning.
A staff member witnessed another staff verbally abusing a resident with cognitive impairment and reported it to the charge nurse, but the incident was not documented or reported to administration or the State Survey Agency within the required two-hour timeframe. The online report was submitted the next morning, and there was no evidence of timely investigation or proper notifications as required by facility policy.
A facility failed to promptly and thoroughly investigate an allegation of verbal abuse after a nurse aide reported witnessing another aide use profane language toward a resident with cognitive impairment and physical debility. The investigation was delayed, lacked comprehensive staff interviews, and did not include timely documentation or proper notifications, contrary to facility policy.
The facility failed to maintain food safety by improperly stacking wet dishware, not separating dented cans, and not ensuring staff wore appropriate hair restraints. Observations showed wet cups stacked together, dented cans stored with others, and a dietary aide with hair exposed while handling food, contrary to facility policies and FDA Food Codes.
The facility failed to provide written notification to residents and/or their representatives for hospital transfers, as required by policy. Three residents were transferred without documented notification, despite multiple instances of hospital transfers due to health issues. Interviews with staff revealed a lack of awareness and practice regarding the provision of transfer forms.
The facility failed to provide written notification of its bed-hold policy to residents or their representatives upon hospital transfer. Three residents were transferred without receiving the required documentation, despite the facility's policy. Interviews revealed staff were unaware of the requirement, indicating a systemic issue in policy adherence.
The facility failed to maintain a sanitary environment in the kitchen and dining areas, with dead bugs found in light fixtures. Observations showed bugs in multiple lights, and interviews revealed a lack of communication and awareness among staff regarding maintenance responsibilities. The facility lacked a policy for light fixture maintenance, contributing to the oversight.
A resident with bradycardia and Parkinson's disease was administered diltiazem despite physician orders to hold the medication if systolic blood pressure was below 110 mmHg. The medication was given on multiple occasions when the resident's blood pressure was below this threshold, as documented by a CMT. Interviews with staff, including the LPN, DON, and Administrator, confirmed the failure to adhere to the prescribed parameters, highlighting a deficiency in medication monitoring.
A resident with diabetes received insulin without the pen being primed, as required by the manufacturer's instructions. An LPN administered the insulin without priming, believing it was unnecessary, despite the resident's high blood sugar level. Interviews revealed inconsistent practices among staff, with the DON confirming that priming is part of the training provided. Facility policies did not address priming insulin pens.
A facility failed to maintain an effective pest control program, resulting in a gnat infestation in a room shared by two residents. One resident, with no cognitive impairment, reported that the other, with severe cognitive impairment, left food and cups in the room, attracting gnats. Staff were aware of the issue but did not effectively address it, and the Administrator was unaware of the problem until it was pointed out. Despite some efforts, the facility's actions were insufficient to prevent the ongoing presence of gnats.
Failure to Provide Timely Showers and Support Resident Choice
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not providing timely bathing for four out of seven sampled residents. Facility policy required that residents receive showers in accordance with their preferences, care plans, and scheduled protocols, with staff responsible for assisting with bathing, performing skin assessments, and documenting these activities. However, documentation and interviews revealed that several residents did not receive showers as scheduled, with significant gaps between showers and incomplete records for October and November. Residents expressed dissatisfaction, noting that they felt unclean and that their preferences for at least weekly or biweekly showers were not honored. One resident with Alzheimer's disease and COPD required substantial assistance with ADLs and was care planned for weekly showers, but records showed only two showers in October and one in November, with a 16-day gap between some showers. Another resident, cognitively intact but needing assistance due to radiculopathy and dementia, was scheduled for weekly showers but experienced a 21-day gap between documented showers. A third resident, also cognitively intact and with a below-the-knee amputation, was care planned for twice-weekly showers but received only two showers in over a month. A fourth resident, recently admitted and with acute and chronic respiratory failure, reported going eleven days before being offered a shower, despite a preference for frequent showers and no care plan or nursing notes documenting bathing. Staff interviews confirmed that showers were often missed due to staffing shortages and lack of a dedicated shower aide. The shower schedule was posted daily, but aides reported difficulty completing showers when short-staffed, and documentation was inconsistent. Leadership acknowledged the issue, noting that the number of completed shower sheets was lower than expected and that improvements were needed. Residents' preferences for bathing were not consistently honored, and documentation of showers and skin assessments was incomplete or missing.
Failure to Timely Destroy and Account for Unused Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the proper storage, destruction, and accountability of medications. During an observation of the medication room, surveyors found the counter space cluttered with a large quantity of unused medications, including medication cards, bottles, bags, and individual doses for 22 residents. Additional medications were found stored in a white bucket above the medication refrigerator. The medications included a variety of prescription drugs such as muscle relaxants, antibiotics, blood pressure medications, and insulin, all of which were no longer in use and awaiting destruction. The facility's policy required unused, contaminated, or expired prescription drugs to be disposed of in accordance with state laws and regulations, and for the destruction process to be witnessed and documented appropriately. Interviews with staff confirmed the ongoing issue. A Certified Medication Tech stated that the medication room was a mess and contained non-narcotic medications that were no longer in use, and that nursing managers were responsible for destroying expired medications. An LPN and the ADON both acknowledged that the medication room was disorganized and full of medications pending destruction, with the ADON noting that it had been several months since the room was clean and orderly. The MDS Coordinator described the room as a disaster that had been in that state for at least a couple of months. The DON admitted that the medication room was currently a mess, with a significant backlog of non-narcotic medications needing destruction, and that the process and paperwork required to address the issue had not been completed due to time constraints. The Interim Administrator also confirmed that the medication room should be kept clean and organized, and that all medications not in use should be destroyed in a timely manner. The facility's failure to maintain a process for the timely destruction of unused medications resulted in a cluttered and disorganized medication room, contrary to facility policy and regulatory requirements.
Failure to Document and Communicate Resident Code Status
Penalty
Summary
The facility failed to maintain a clear and accessible procedure for documenting and communicating a resident's code status and advance directives, as required by its own policy. For one resident, the code status was not documented in the designated sections of the medical record, including the face sheet, physician orders, and the code status book. During a medical emergency, staff were unable to quickly locate the resident's code status, resulting in a delay in initiating CPR. The resident's admission baseline care plan indicated full code status, but this information was not consistently reflected or easily accessible in other required documentation locations. Multiple staff interviews confirmed that code status information should be available in the resident's chart, on the door, and in the code status book at the nurses' station, with all sources matching. However, staff reported that the Social Services Director (SSD), who was responsible for updating and auditing code status information, had not been in the position for some time, leading to discrepancies and outdated records. The newly hired SSD was in the process of auditing and updating code statuses, but at the time of the incident, the information was not current or consistent across all required locations. During the emergency, the LPN was unable to find the resident's code status after searching the physician orders, face sheet, and code status book, resulting in a delay of approximately five minutes before CPR was initiated. Other staff corroborated the difficulty in locating the code status and the expectation that this information should be readily available and consistent. The lack of clear documentation and communication of the resident's code status directly contributed to the delay in providing appropriate emergency care.
Failure to Notify and Monitor After Resident Fall Resulting in Fracture
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards of practice for a resident who experienced a fall resulting in a fracture. The staff did not notify the resident's family or physician in a timely manner following the fall with possible injury. Documentation of the initial assessment and ongoing fall monitoring, including neurological checks, was not completed as required. The facility also lacked a policy and procedure related to falls, fall documentation, and fall notifications. The resident involved had diagnoses including Alzheimer's disease, muscle weakness, high blood pressure, and respiratory failure, and required supervision and a walker for mobility. After the fall, the resident was found on the floor complaining of pain in the left hip and was assisted back to bed by staff. The LPN on duty did not document a full assessment, including baseline neurological checks, and did not notify the physician or the resident's family at the time of the incident. Vital signs were reportedly obtained but not documented, and the nurse did not initiate required fall monitoring or incident reporting procedures. Subsequent shifts identified the resident's continued pain and loss of independence with mobility, leading to an x-ray that revealed a probable fracture. Only then were the physician and family notified, and the resident was transferred to the hospital. Interviews with staff and leadership confirmed that the expected process for falls was not followed, including assessment, documentation, notification, and monitoring. The deficiency was further compounded by the absence of a facility policy on falls and related documentation.
Failure to Provide Timely Medications and Notify Physicians of Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring that ordered medications were available for administration and by failing to notify physicians when medications were unavailable. This resulted in three residents not receiving their prescribed medications as ordered. The facility's own policy required medications to be administered as ordered by the physician and in accordance with professional standards, but this was not followed in these cases. One resident with multiple chronic conditions, including multiple sclerosis, hypothyroidism, and restless legs syndrome, did not receive several medications for multiple days after admission. Documentation showed that doses of pantoprazole, venlafaxine, mirabegron, and ropinirole were not administered due to the drugs not being available. There was no documentation that the physician was notified of these missed doses. The resident reported not refusing any medications and expressed that missing these medications for several days would negatively affect their well-being. Another resident with a history of pulmonary embolism, hypertension, and congestive heart failure also did not receive several ordered medications, including antihypertensives, supplements, and an antifungal, due to unavailability. Again, there was no documentation of physician notification regarding the missed doses. A third resident, who had chronic pain following a leg amputation, did not receive pregabalin for several days because the prescription was not renewed in time and the medication was not available, despite some doses being present in the emergency kit. Staff interviews revealed confusion about the process for obtaining and administering medications from the emergency kit and inconsistent practices regarding physician notification when medications were unavailable.
Failure to Provide and Document Pressure Ulcer Care per Physician Orders
Penalty
Summary
The facility failed to provide pressure ulcer care in accordance with professional standards and its own policies, resulting in the deterioration and infection of wounds for a resident. Staff did not consistently provide wound care as ordered by the physician, with multiple instances where wound treatments were not documented as completed on the Treatment Administration Record (TAR) for both the right heel and right gluteal fold wounds. There was also a lack of documentation explaining missed treatments, and the care plan was not updated to reflect the resident's actual skin breakdown and current wound treatments. The resident involved had significant risk factors, including a history of stroke with left-sided weakness, diabetes with circulatory complications, incontinence, and was admitted with a pressure ulcer. Despite these risks, staff failed to conduct timely and complete wound assessments, did not update the care plan to address new or worsening wounds, and did not ensure that wound care orders from the external wound care provider were entered and followed. The wound care provider's notes indicated periods of wound improvement and deterioration, with changes in wound size, drainage, and the presence of nonviable tissue, but these changes were not consistently addressed by facility staff. Interviews with facility staff, including CNAs, LPNs, the MDS Coordinator, the ADON, and the Administrator, revealed a lack of awareness and communication regarding the resident's wounds, inconsistent documentation practices, and failure to notify the wound care provider of new or worsening wounds. The resident ultimately developed an abscess with purulent drainage requiring hospital transfer and surgical intervention. Throughout the period reviewed, the facility did not maintain accurate and timely wound care records, did not follow physician orders, and did not update the care plan as required.
Failure to Implement Effective Infection Control and Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple staff not performing proper hand hygiene and not following Enhanced Barrier Precautions (EBP) during wound care for three residents. Observations revealed that staff, including LPNs and the MDS Coordinator, did not perform hand hygiene before or after glove changes, after contact with potentially contaminated surfaces, or between different wound care tasks. Supplies such as wound cleanser bottles and dressings were placed on potentially contaminated surfaces without barriers, dropped on the floor and reused, and shared between residents, including those with MRSA, without proper disinfection or dedicated use. For one resident with a history of stroke, diabetes, and MRSA in a buttock wound, staff failed to perform hand hygiene at multiple points during wound care, reused supplies that had fallen on the floor, and returned unused supplies from the resident's room to the general treatment cart. Similar lapses were observed with two other residents, one with diffuse large B-cell lymphoma and surgical wounds, and another with MRSA infection and heart failure. In all cases, EBP signage was missing, PPE carts were not consistently available, and staff did not consistently use gowns and gloves as required for high-contact care activities. Interviews with staff and leadership revealed a lack of training and awareness regarding EBP, with several staff members unable to define EBP or describe when and how to implement it. Staff also reported inconsistent practices regarding the use and disposal of wound care supplies, hand hygiene, and PPE. Facility policies required hand hygiene and the use of PPE, but these were not followed in practice, and there was no evidence of staff education or competency assessment on EBP.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, resulting in multiple instances where food was not protected from possible contamination. Observations throughout the day revealed that the chrome surfaces surrounding the water wells of the steam table, the plate warmer, and the lower shelf of the steam table were consistently covered with debris, dried food particles, and dried liquid substances. The trash can lid was also found splattered with dried substances, and a tub of butter was left on the back counter with a spatula covered in butter resting on top. The toaster on the back counter was observed to be covered in crumbs, with the inside containing a layer of crumbs and dried substances on the chrome edging. These unsanitary conditions persisted throughout multiple observations at different times of the day, indicating a lack of thorough cleaning and maintenance of non-food contact surfaces in the kitchen and serving areas. Interviews with staff, including dietary aides, cooks, the Dietary Manager (DM), the Administrator, and the Director of Nursing (DON), confirmed that the responsibility for cleaning the dining room tables, steam table, plate warmer, microwave, toaster, and serving area countertops after each meal was shared among the kitchen staff. However, staff reported difficulty in completing all required cleaning tasks between meals due to limited staffing, with only two kitchen staff working each shift. The facility did not have a policy regarding cleaning the kitchen and/or serving station, and the daily deep cleaning schedule outlined specific tasks for certain days but did not ensure consistent cleanliness after each meal service. Additionally, the facility failed to ensure that condiments kept in the serve-out refrigerator were not expired. Observations showed several condiments in squeeze bottles, such as mustard, mayonnaise, salad dressing, and barbecue sauce, were hand-labeled with use-by dates. Interviews revealed that some kitchen staff were new and not yet in the habit of checking use-by dates on condiments and other food items. Staff were expected to label bottles to be used within seven days and discard contents after that date, but this practice was not consistently followed, leading to the presence of expired condiments in the refrigerator.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse by a staff member toward a resident was reported immediately to facility management and to the State Survey Agency within the required two-hour timeframe. According to the facility's policy, all allegations of abuse, including verbal abuse, must be reported to the administrator and the State Survey Agency no later than two hours after the incident. In this case, a nurse aide witnessed another aide verbally abusing a resident by using profane language and reported the incident to the charge nurse between 10:15 P.M. and 10:20 P.M. However, there was no documentation by the charge nurse regarding the allegation, and no immediate notification was made to the administration or the State Survey Agency as required. The resident involved had a history of age-related physical debility, mild cognitive impairment, and generalized anxiety disorder, and required assistance with daily activities. The resident's care plan indicated communication problems and cognitive loss, necessitating respectful and clear communication from staff. Despite these vulnerabilities, the facility's documentation showed a lack of timely and appropriate response to the reported abuse, with no evidence of staff interviews (other than the accused aide), no summary statement, and no documentation of notifications to the administration, physician, or the resident's family. The online report to the State Survey Agency was not made until the following morning, well beyond the required two-hour window. Interviews with various staff members confirmed their understanding that all abuse allegations should be reported immediately and to the State within two hours. The administrator and DON acknowledged that the incident constituted verbal abuse and should have been reported promptly, and that the charge nurse failed to ensure timely notification and initiation of an investigation.
Failure to Timely and Thoroughly Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to document a timely and thorough investigation into an allegation of verbal abuse involving a resident. A nurse aide reported witnessing another aide enter a resident's room and use profane language, calling the resident derogatory names and instructing them to stop contacting their family. The reporting aide stated that the charge nurse was notified of the incident shortly after it occurred, but there was no immediate initiation of an investigation or documentation of the allegation in the resident's medical record. The resident involved had a history of age-related physical debility, mild cognitive impairment, and generalized anxiety disorder, and required assistance with daily activities. The resident's care plan noted communication problems and cognitive loss, emphasizing the need for respectful staff interactions. Despite these vulnerabilities, the facility's investigation documentation was limited to a single witness statement and unsigned questionnaires from seven residents about their feelings of safety, with no evidence of interviews with other staff or documentation of notifications to administration, the physician, or the resident's family. Interviews with facility staff confirmed that allegations of abuse should be reported immediately and investigated by administration. However, the investigation was delayed because the initial notification to administration was not confirmed, and the investigation did not include comprehensive staff interviews or timely documentation. The administrator and DON acknowledged that the process was not followed as required by facility policy, which mandates immediate reporting and thorough investigation of abuse allegations.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain food safety standards by improperly handling clean dishware, which could lead to contamination. Observations revealed that staff stacked wet plastic cups on top of each other, trapping water between them, contrary to the 2022 Food Code and the facility's own policy, which require air drying of dishes before storage. Interviews with dietary aides and the dietary manager confirmed that dishes should be air-dried and not stacked while wet, yet this practice was not followed. Additionally, the facility did not adequately separate dented cans from other canned goods, posing a risk of contamination. Observations showed dented cans of apples stored alongside other cans, despite the facility's policy to set aside and discard dented cans. Interviews with dietary aides and the dietary manager indicated that dented cans should be placed in a separate area and not used, but this procedure was not consistently implemented. Furthermore, the facility did not ensure that staff wore appropriate hair restraints while handling food. A dietary aide was observed wearing a ball cap with hair hanging below it, without a hair net, while preparing and serving food. The facility's policy and the 2013 Food Code require hair to be effectively restrained to prevent contamination. Interviews with staff and the administrator highlighted a misunderstanding about the requirement for hair nets when wearing a ball cap, leading to non-compliance with the hair restraint policy.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding transfers or discharges to the hospital, as required by their policy. This deficiency was identified for three residents out of a sample of 18, with a facility census of 51. The facility's policy, revised in December 2016, mandates that details of a transfer or discharge be documented in the medical record and communicated to the receiving healthcare provider, and that appropriate notice be provided to the resident and/or legal representative. For Resident #3, multiple instances were noted where the resident was transferred to the hospital due to issues with a feeding tube, but there was no documentation of written notification provided to the resident or their representative. Similarly, Resident #4 was transferred to the hospital on two occasions due to health concerns, but again, there was no documentation of written notification. Resident #30 was also transferred to the hospital without documented written notification to the resident or their representative. Interviews with facility staff, including an LPN, the Social Service Director, the Director of Nursing, the Administrator, and the Director of Operations, revealed a lack of awareness and practice regarding the provision of transfer forms to residents and/or their representatives. The staff did not make copies of the transfer forms, and there was no system in place to ensure that residents or their representatives received the necessary documentation during transfers to the hospital.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives upon transfer to a hospital, as required by their own policy. This deficiency was identified for three residents who were transferred to the hospital for various medical reasons. The facility's policy mandates that residents or their representatives be informed in writing about the bed-hold policy prior to any transfers or therapeutic leaves, but this was not documented for the residents in question. Resident #3, who had diagnoses including acute kidney failure and schizophrenia, was transferred multiple times to the hospital due to issues with a feeding tube and other medical concerns. Despite these transfers, there was no documentation indicating that the resident or their representative received written information about the bed-hold policy. Similarly, Resident #4, who had mild cognitive impairment, was transferred to the hospital twice due to severe stomach pain and other symptoms, but again, there was no documentation of the bed-hold policy being provided. Resident #30, with conditions such as COPD and diabetes, was also transferred to the hospital without receiving the required bed-hold policy documentation. Interviews with facility staff, including the LPN, Social Service Director (SSD), Director of Nursing (DON), and Administrator, revealed a lack of awareness and training regarding the requirement to provide the bed-hold policy upon resident transfer. The SSD admitted to not sending the bed-hold policy to residents or their representatives and was unaware of this requirement until reviewing the policy. The DON and Administrator confirmed that the policy was not being sent as required, indicating a systemic issue in the facility's adherence to its own policies.
Sanitation Deficiency in Kitchen and Dining Areas
Penalty
Summary
The facility staff failed to maintain a sanitary and comfortable environment in the kitchen and dining areas, as evidenced by the presence of dead bugs in the light fixtures. Observations conducted on two separate occasions revealed several dead bugs in lights located just before entering the kitchen, above the refrigerator and freezer, and at the entrance of the kitchen. The facility did not have a policy regarding the maintenance of light fixtures, which contributed to the oversight. Interviews with various staff members, including dietary aides, the dietary manager, the maintenance director, and the administrator, highlighted a lack of communication and awareness regarding the issue. Dietary aides indicated that maintenance was responsible for cleaning the lights, but they were unsure of the frequency of cleaning. The dietary manager and maintenance director both stated that maintenance was responsible for the lights, with a monthly checklist in place, but neither was aware of the dead bugs. The administrator confirmed that maintenance was responsible and that kitchen staff should report issues in a requisition book, indicating a breakdown in the reporting and maintenance process.
Failure to Monitor Medication Parameters for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs due to inadequate monitoring of diltiazem administration. The resident, who had diagnoses including cognitive communication deficit, bradycardia, and Parkinson's disease, was prescribed diltiazem with specific parameters to hold the medication if the systolic blood pressure was below 110 mmHg. Despite this, the medication was administered on multiple occasions when the resident's blood pressure was below the prescribed threshold, as documented by a Certified Medication Technician (CMT). This failure to adhere to the physician's orders was confirmed through interviews with the Licensed Practical Nurse (LPN), the CMT, the Director of Nursing (DON), and the Administrator, all of whom acknowledged the importance of following the medication parameters. The resident's care plan highlighted the risk of adverse reactions due to the variety of medications being administered, and the need for staff to administer medications as ordered. However, the staff did not comply with the order to hold diltiazem when the resident's blood pressure was below the specified level, potentially risking further hypotension. The DON and Administrator both expressed that they expected staff to follow physician orders and acknowledged that the medication should not have been administered when the resident's blood pressure was out of parameters.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility staff failed to ensure that all residents were free from significant medication errors when a Licensed Practical Nurse (LPN) did not prime an insulin pen before administering insulin to a resident. The resident, who was cognitively intact, had a medical history that included chronic obstructive pulmonary disease, high blood pressure, peripheral vascular disease, and diabetes. The resident's physician had ordered Novolog insulin to be administered subcutaneously with meals, and the resident's blood sugar level was recorded at 305 mg/dL before the insulin was administered. However, the LPN did not follow the manufacturer's instructions to prime the insulin pen, which involves selecting two units, tapping the cartridge to collect air bubbles, and ensuring a drop of insulin appears at the needle tip before administration. Interviews with facility staff revealed inconsistencies in the understanding and practice of priming insulin pens. The LPN involved in the incident believed that the pens were pre-dosed and pre-primed, and therefore did not require priming. In contrast, another LPN stated that they always prime insulin pens before use, and the Director of Nursing (DON) confirmed that staff are trained to prime insulin pens with two units of insulin before each use. The DON also stated that this training is provided upon hire and annually. The facility's policies on insulin administration and medication administration did not address the need to prime insulin pens, despite the manufacturer's instructions indicating its necessity.
Ineffective Pest Control Program Leads to Gnat Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of multiple gnats in a room shared by two residents. One resident, who had no cognitive impairment, reported that the other resident, who had severe cognitive impairment, left food and cups in the room, attracting gnats. Observations over several days confirmed the presence of gnats around food items and cups in the room, with staff acknowledging the issue but not effectively addressing it. Interviews with various staff members, including a CNA, housekeeper, CMT, RN, and the Maintenance Director, revealed that the presence of gnats was known, particularly in the room of the resident with severe cognitive impairment. Staff reported attempts to manage the situation by picking up food and cups, and a pest control company was mentioned as spraying the facility. However, the Maintenance Director was not aware of the issue until recently and had only taken limited actions, such as installing plug-in devices in some rooms. The Administrator was unaware of the gnat problem in the specific room until it was brought to her attention during an observation. She stated that staff should report such issues to maintenance or administrative staff. Despite some efforts to address the problem, such as cleaning specific rooms and using pest control measures, the facility's actions were insufficient to prevent the ongoing presence of gnats in the residents' room.
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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