Medicalodges Nevada
Inspection history, citations, penalties and survey trends for this long-term care facility in Nevada, Missouri.
- Location
- 1210 West Ashland, Nevada, Missouri 64772
- CMS Provider Number
- 265493
- Inspections on file
- 20
- Latest survey
- August 6, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Medicalodges Nevada during CMS and state inspections, most recent first.
A resident did not receive a nourishing, palatable, and well-balanced diet that met daily nutritional and special dietary needs, resulting in a deficiency related to dietary services.
Staff failed to follow infection control policies and CDC guidance by wearing N95 masks incorrectly after two staff tested positive for Covid-19. Multiple staff, including a Restorative Aide, Nursing Assistant, Hospitality Aide, LPN, and the Administrator, were observed with the bottom strap of their N95 masks hanging below the chin, preventing a proper seal. Despite having received training, staff did not consistently don N95 masks as required by facility policy and CDC recommendations.
A facility failed to report abuse and neglect within the required timeframe. A CNA was accused of verbally and physically abusing three residents, including telling a resident with cerebral palsy to "shut up" and roughly pushing a resident with severe cognitive impairment in a wheelchair. The incidents were not reported to management or the state agency until two days later, violating the facility's policy and state regulations.
The facility failed to employ a qualified dietary manager, as the hired DM lacked the necessary certification and documentation of training. Despite having experience in the food industry, the DM's certification was expired, and they had not completed an online dietary certification program. The facility also lacked a written policy on certification requirements for the dietary manager position.
The facility failed to implement enhanced barrier precautions and proper hand hygiene during wound care for residents with MDROs and chronic wounds. Staff were not adequately trained on EBP, leading to improper use of PPE. Observations showed that an LPN did not change gloves or perform hand hygiene between stages of wound care, violating infection control protocols. Interviews confirmed that hand hygiene should be performed before and after resident care, but practices did not align with these expectations.
The facility did not designate a qualified infection preventionist (IP) for its infection prevention control program. The interim DON was enrolled in an IPC certification program but had not completed it, and no other staff were certified. The facility lacked a policy for the IP position and required certification.
The facility failed to maintain resident dignity and privacy by not providing dignity bags for catheter bags, not knocking before entering a resident's room, and standing over residents during meal assistance. Three residents had their catheter bags visibly exposed, and staff entered a resident's room without knocking during catheter care. Additionally, staff stood over residents while assisting with meals, rather than sitting next to them and interacting respectfully.
The facility failed to have a qualified activities program director, leading to inconsistent activity scheduling and resident boredom. Observations showed residents engaging in activities without staff leadership, and interviews confirmed the absence of a full-time director. The facility is seeking to hire a new director while department heads and volunteers temporarily lead activities.
The facility failed to complete ordered labs and x-rays for two residents, leading to potential delays in care. A resident with severe cognitive impairment did not have labs completed, resulting in a hospital visit. Another resident's hip x-rays were not done despite being ordered. Additionally, a resident did not receive restorative therapy due to staffing issues, leading to a decline in their ability to bear weight.
The facility failed to properly assess and document the use of side rails for residents, leading to deficiencies in care. Staff used side rails for residents assessed as inappropriate for their use, and failed to document risk reviews, obtain informed consent, or secure physician orders. Observations revealed improper use of grab bars without necessary documentation or assessments, highlighting a lack of compliance with regulatory requirements.
The facility failed to ensure that three nurse aides completed their CNA training within four months of hire. NA H, NA J, and NA A lacked documentation of training completion due to various issues, including technical problems and pending test results. The DON and Administrator acknowledged the deficiency, noting the absence of a facility policy on nurse aide certification.
The facility failed to provide suitable snack alternatives for diabetic residents outside of scheduled meal times. Observations showed that available snacks were mostly sugary, with limited protein options. Staff interviews confirmed that only a few sandwiches were provided, and the rest were sugary snacks. A diabetic resident expressed concern over the lack of non-sugary snacks, and the RD emphasized the need for appropriate options like fruit or protein snacks.
A long-term care facility failed to maintain a functional call light system, leading to delayed responses for residents needing assistance. One resident with moderate cognitive impairment experienced a nonfunctional call light, resulting in a fall and injury. Another resident with a hip fracture faced distress due to unanswered call lights. The facility lacked sufficient pagers, and the call light monitor was non-operational, contributing to the deficiency.
The facility failed to conduct a criminal background check and a Nurse Aide Registry check for a new employee, Housekeeping S, before they had contact with residents. The facility's policy requires these checks to be completed and documented before employment, but the personnel file lacked this documentation. Interviews confirmed the oversight, with the Business Office Manager acknowledging the absence of required checks and the Administrator noting the lack of a specific written policy.
A facility failed to complete the required PASARR screening for a resident with mental disorders and intellectual disabilities. The resident, admitted with conditions such as bipolar disorder and mild intellectual disabilities, did not have a PASARR screening completed prior to or upon admission, nor after changes in condition. The facility did not notify the state agency or re-complete the screening when the resident's stay extended beyond the 30-day respite period. Interviews revealed that staff were unable to locate a completed level 2 PASARR form and were unsure of the requirements.
A resident at risk for pressure ulcers developed a new ulcer on their toe, which was not documented or treated promptly by the LTC facility. Despite the podiatrist's orders, the facility delayed implementing wound care, leading to infection and deterioration. Interviews revealed communication and coordination issues among staff, contributing to the deficiency.
A non-weight bearing resident with severe cognitive impairment was improperly transferred using a gait belt instead of a mechanical lift, as required by their care plan. Observations showed staff lifting the resident with legs hanging in the air, contrary to the need for a mechanical lift due to the resident's inability to bear weight. Interviews revealed inconsistencies in staff understanding of the resident's transfer needs, with the Kardex and care plan not accurately reflecting the current requirements.
A facility failed to follow up on a pharmacist's recommendation to titrate a resident's dementia medication, despite physician approval. The resident, with multiple diagnoses including dementia, was not titrated as recommended. Interviews revealed a lack of a clear process for handling pharmacy recommendations, with confusion among staff about responsibilities for entering and reviewing orders.
The facility did not follow approved pureed diet menus for two residents, substituting non-equivalent items like cottage cheese and yogurt for vegetables. Staff interviews revealed a lack of adherence to prescribed menus and diet cards, with the Dietary Manager admitting to not knowing how to puree certain items. The facility also lacked a policy on pureed diets, leading to inconsistencies in meal preparation.
Failure to Provide Adequate and Appropriate Diet
Penalty
Summary
The facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs. This deficiency was identified based on observations and findings that residents did not consistently receive meals that were adequate in nutrition, taste, or tailored to their specific dietary requirements.
Failure to Ensure Proper Use of N95 Masks During Covid-19 Outbreak
Penalty
Summary
Staff at the facility failed to implement and maintain an effective infection prevention and control program as required by both facility policy and CDC guidance. Despite two staff members testing positive for Covid-19, multiple staff—including a Restorative Aide, Nursing Assistant, Hospitality Aide, LPN, and the Administrator—were observed wearing N95 masks incorrectly, with the bottom strap hanging below the chin rather than secured at the nape of the neck. This improper use of N95 masks prevented a proper seal, which is necessary for effective respiratory protection. Staff interviews confirmed that, although they had received training on proper PPE use, they were not consistently following the correct donning procedures for N95 masks. Facility policies and CDC guidance reviewed in the report clearly outlined the correct method for donning N95 respirators, including the placement of both straps and the importance of achieving a tight seal. Observations and interviews revealed that staff were aware of the requirement to wear N95 masks after exposure to Covid-19 positive individuals, but failed to adhere to these protocols in practice. The deficiency was identified through direct observation, staff interviews, and review of training and policy documents, with no mention of corrective actions or follow-up at the time of the report.
Failure to Timely Report Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and neglect within the required two-hour timeframe to the State Survey Agency. The incident involved a certified nurse aide (CNA) who was accused of verbal and physical abuse towards three residents. The abuse occurred between 3:00 A.M. and 5:00 A.M. on 12/15/24, but the facility's management was not informed until 12/17/24. The delay in reporting the incident to the Department of Health and Senior Services (DHSS) was a violation of the facility's policy and state regulations. Resident #1, who has cerebral palsy and is dependent on others for activities of daily living, was reportedly told to "shut up" by CNA F after yelling for help. Resident #2, who has severe cognitive impairment and uses a wheelchair, was roughly pushed by CNA F, causing the resident's legs to bend back under the wheelchair. Resident #3 experienced rough handling when CNA F yanked the resident's brief down, causing the resident to scream. These actions were witnessed by CNA E, who did not report them immediately to the charge nurse or management. Interviews with staff revealed that they were aware of the requirement to report abuse and neglect within two hours, yet the incident was not reported in a timely manner. CNA E eventually reported the incidents to the Administrator two days later, prompting an investigation. The failure to report the abuse immediately and the rough handling of residents constituted a deficiency in the facility's adherence to its abuse, neglect, and exploitation policy.
Deficiency in Employing Qualified Dietary Manager
Penalty
Summary
The facility staff failed to employ a qualified dietary manager for food and nutrition services, as required by regulations. The dietary manager (DM) was hired without documentation of the necessary training, experience, or qualifications to meet the certification requirements for the position. Although the DM had six years of cooking experience and ten years as a food industry manager, their certification was from another state and had expired at the time of hiring. The DM had started an online dietary certification program but had not completed it. The facility did not provide a written policy regarding the certification requirements for the dietary manager, nor did they have documentation of the DM's current certification or sufficient training.
Inadequate Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to maintain a complete infection prevention and control program by not implementing the policy regarding enhanced barrier precautions (EBP) for residents infected with multidrug-resistant organisms (MDRO) or those with chronic wounds and indwelling medical devices. Staff were not adequately trained on EBP, leading to improper use of personal protective equipment (PPE) during high-contact resident care activities. Interviews with staff, including a Certified Medication Technician, a Registered Nurse, and the Director of Nursing, revealed a lack of awareness and understanding of the need for gowns during catheter and wound care unless there was a confirmed infection. The facility also failed to ensure proper hand hygiene practices during wound care for two residents. Observations showed that a Licensed Practical Nurse (LPN) did not change gloves or perform hand hygiene between different stages of wound care for a resident with a pressure ulcer. The LPN handled contaminated items and then proceeded to apply wound treatment without washing hands or changing gloves, which is against the facility's hand hygiene policy. Similarly, another LPN did not perform hand hygiene between glove changes while treating a resident's toe wound, further demonstrating non-compliance with infection control protocols. Interviews with staff, including a Certified Medication Technician, a Registered Nurse, and the Director of Nursing, confirmed that hand hygiene should be performed before and after resident care, between glove changes, and when transitioning from dirty to clean tasks. However, the observed practices did not align with these expectations, indicating a systemic issue in adhering to infection control policies. The facility's failure to provide a policy or procedures regarding wound care further contributed to the deficiency.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist (IP) with specialized training in infection prevention and control (IPC) for its infection prevention control program. The facility, with a census of 45, did not have a policy related to the IP position or the required certification. The interim Director of Nursing (DON), who had been in the position for about two months, was enrolled in the State's online IPC program but had not completed the certification. The facility offered other staff nurses the opportunity to enroll in the course, but none had completed it. The previous interim DON, who worked only as needed, was also not certified in the IPC program. The Administrator expected the current interim DON to complete the certification process, as no other staff members were certified.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents by not providing dignity bags for catheter bags for three residents. These residents, who were cognitively intact and dependent on staff for toileting, were observed with their catheter bags visibly exposed in common areas and from the hallway. Despite the residents' preferences for privacy, the staff did not ensure the catheter bags were covered, and the facility lacked a care plan addressing the use of dignity bags. Interviews with staff, including nurse aides and the Director of Nursing, confirmed that catheter bags should be covered at all times, especially in common areas. Additionally, the facility did not respect the privacy of a resident when staff entered the resident's room without knocking. This resident, who had moderate cognitive impairment and used a wheelchair, was receiving catheter care when multiple staff members entered the room without announcing themselves. This lack of privacy was acknowledged by various staff members, including the Administrator, who stated that residents have the right to privacy and that staff should knock before entering. The facility also failed to provide dignified meal assistance to three residents. Staff were observed standing over residents while assisting them with meals, rather than sitting next to them and interacting at their pace. Interviews with staff, including a CNA and the DON, indicated that staff should sit next to residents during meal assistance to ensure a respectful and interactive experience. The facility did not have a policy pertaining to meal assistance, which contributed to this deficiency.
Lack of Designated Activities Program Director
Penalty
Summary
The facility failed to ensure that a qualified individual was designated as the activities program director, which is a requirement for maintaining an effective activities program. The facility, with a census of 45, did not have a policy pertaining to the activity program or the requirements for the program director. A review of the facility's staff listing and staffing schedules for May and June 2024 showed no individual listed or scheduled as an activities program director. Observations revealed that residents were engaging in activities such as Bingo and exercise without the presence of a designated staff member to lead these activities. Instead, a CNA/Staffing Coordinator was observed leading activities when available, indicating a lack of a full-time activity director. Interviews with staff and family members highlighted the absence of a designated activities program director. The Director of Nursing and the Administrator confirmed that the former activities director had changed positions, and the facility was in the process of hiring a new director. In the interim, department heads and volunteers were attempting to lead activities based on a previously set calendar, but there was no consistency in providing one-on-one activities for residents who did not attend group activities. A family member of a resident expressed concerns about the lack of one-on-one interaction and the residents' boredom, which was corroborated by the DON, who noted recent complaints from residents about being bored.
Failure to Complete Ordered Labs, X-rays, and Restorative Therapy
Penalty
Summary
The facility failed to provide care per standard practice by not completing ordered labs and x-rays for two residents, leading to potential delays in care. Resident #26, who had severe cognitive impairment and multiple diagnoses including dementia and hypertension, was ordered a urinalysis, complete blood count, and complete metabolic panel on 06/08/24 after exhibiting lethargy and low blood pressure. However, these labs were not entered or completed, and the resident was later sent to the hospital on 06/12/24 with a new order for antibiotics for a urinary tract infection. Interviews with staff revealed a lack of clarity on why the orders were not completed, and there was no policy or procedure in place for following physician orders for laboratory or diagnostic imaging. Resident #29, who was cognitively intact but dependent on staff for activities of daily living, was ordered bilateral hip x-rays on 05/24/24 due to hip pain. The order was not entered, and no x-ray results were found in the resident's medical record. Staff interviews indicated that the x-ray order was not completed, and the Director of Nursing noted that the mobile order company could have come out the same day the order was sent. The Administrator was unsure why the x-rays were not completed as ordered. Additionally, the facility failed to provide restorative therapy for Resident #33, who had multiple diagnoses including Parkinsonism and dementia with Lewy bodies. The resident was discharged from skilled physical therapy with recommendations for restorative nursing three to five times per week. However, the restorative nurse aide was often pulled to work the floor, resulting in no restorative therapy being done. Interviews with staff and the resident's family member confirmed the lack of consistent restorative therapy, and the resident experienced a decline in their ability to bear weight.
Deficiencies in Side Rail Use and Documentation
Penalty
Summary
The facility failed to ensure proper assessment and documentation before the use of side rails for residents, leading to deficiencies in care. Specifically, staff used side rails for two residents who had been assessed as not appropriate for side rail use. Additionally, the facility did not document a risk versus benefit review, obtain informed consent, care plan side rail use, obtain physician orders for the use of side rails, or complete measurements to reduce the risk of entrapment for two other residents. These actions were observed and documented during a survey, highlighting a lack of compliance with regulatory requirements. Resident #39, who was severely cognitively impaired and dependent on staff for activities of daily living, was observed with a grab bar in the upright position on multiple occasions. Despite this, the resident's care plan did not include any mention of grab bar use, and a clinical health review had previously determined that side rails, grab, or transfer bars would not be utilized. Similarly, Resident #40, who was cognitively intact but required assistance for mobility, was observed with a grab bar installed by the therapy department without any documented consent or assessment. Further deficiencies were noted with Resident #10 and Resident #29, both of whom had side rails in use without proper documentation or physician orders. Resident #10, who had left-sided hemiparesis and used an electric wheelchair, had no documented consent or risk assessment for side rail use. Resident #29, who had a history of falls and used a wheelchair, also lacked documentation of consent, risk assessment, or physician orders for side rail use. Interviews with staff revealed a lack of awareness and understanding of the procedures required for the installation and use of grab bars, contributing to the facility's failure to comply with regulatory standards.
Failure to Ensure Timely CNA Training Completion
Penalty
Summary
The facility failed to ensure that three nurse aides (NAs) completed a certified nurse aide (CNA) training program within four months of their employment. NA H, hired on September 7, 2023, had no documentation of completing the training program and was unsure about the start date of the online classes, although they were nearly completed. NA J, hired on September 11, 2023, also lacked documentation of training completion, with a Licensed Practical Nurse (LPN) indicating that NA J had taken the test recently, but results were pending. NA A, hired on October 19, 2023, had not completed the training due to technical issues with the online classes, which required a reset. The Director of Nursing (DON), who had been in the position for about two months, acknowledged that nurse aide training should be completed within four months of hire. The facility did not have a policy regarding nurse aide certification or training, relying instead on state guidelines. The Administrator confirmed that staff were hired as NAs and worked onsite, with the expectation of certification within four months. However, the facility was aware that they were not meeting this requirement for the staff in question.
Inadequate Snack Options for Diabetic Residents
Penalty
Summary
The facility failed to provide suitable and nourishing snack alternatives for diabetic residents outside of scheduled meal services. Observations revealed that the snacks available at the nurses' station after 7:00 P.M. were primarily sugary or salty, with no protein options available. The dietary staff placed a limited number of sandwiches on the tray, which were quickly consumed, leaving no suitable options for diabetic residents later in the evening. The evening and night shift staff did not have access to the kitchen or additional food items after 7:00 P.M., and there was no refrigerator available for storing protein-rich snacks. Interviews with staff and residents highlighted the inadequacy of the snack options provided. A diabetic resident expressed concern over the lack of non-sugary snacks available in the evening. The Dietary Manager confirmed that only a few sandwiches were provided for diabetic residents, and the rest of the snacks were sugary. The Registered Dietician emphasized the importance of offering appropriate snacks, such as fruit or protein options, to diabetic residents. The Administrator acknowledged that the kitchen staff prepared snacks before leaving at 7:00 P.M., but the available options were insufficient for the needs of diabetic residents throughout the night.
Deficient Call Light System in LTC Facility
Penalty
Summary
The facility failed to maintain a properly functioning call light system, resulting in significant delays in response times for residents needing assistance. Resident #41, who has moderate cognitive impairment and is independent in personal care, experienced a nonfunctional call light system. Despite pressing the call light, staff did not respond for over twenty minutes, and the call light did not alert staff pagers. This led to the resident having to crawl to a roommate's side to use their call light for assistance. The maintenance director and administrator were unaware of the non-functioning call light, and the maintenance checks were reportedly conducted monthly. Resident #200, with a history of a right hip fracture and chronic atrial fibrillation, also faced issues with the call light system. The resident reported pressing the call light multiple times without receiving a response, leading to distress and the risk of incontinence. The facility's call light history showed multiple instances where the call light was activated but not responded to, with the alerts automatically resetting without staff intervention. Interviews with staff revealed a lack of awareness and understanding of the call light system's functionality and the expectation for timely responses. The facility's call light system was further compromised by a shortage of pagers, with some staff not having access to them. Observations showed that some staff did not have pagers, and the call light monitor at the nurse's station was not operational due to recent remodeling. The administrator acknowledged the shortage of pagers and the need for a system that escalates alerts to supervisory levels if not answered promptly. Despite the expectation that all staff should respond to call lights, the lack of functioning equipment and communication hindered their ability to do so effectively.
Failure to Conduct Required Background Checks for New Employee
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not conducting a criminal background check (CBC) and a Nurse Aide (NA) Registry check for a new employee, Housekeeping S, before they had contact with residents. The facility's policy mandates that all new employees be investigated for any history of abuse, neglect, or exploitation prior to employment. Additionally, non-licensed employees are required to undergo a CBC, and the results should be maintained in their personnel file. However, a review of Housekeeping S's personnel file revealed that there was no documentation of a CBC request or a NA Registry check, despite the employee being hired and having contact with residents. Interviews with the Business Office Manager (BOM) and the interim Director of Nursing (DON) confirmed that the facility uses an electronic system with a checklist to ensure all necessary background checks are completed before hiring. The BOM acknowledged the absence of CBC and NA Registry documentation for Housekeeping S and stated that these checks should be completed and documented before an employee begins orientation. The Administrator also confirmed that the facility lacked a specific written policy for CBC and NA Registry checks, relying instead on regulations, and emphasized that the BOM should ensure all checklist steps are completed and documented prior to hiring.
Failure to Complete PASARR Screening for Resident
Penalty
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASARR) for a resident with mental disorders and intellectual disabilities. The resident, who was admitted with diagnoses including bipolar disorder, major depressive disorder, mild intellectual disabilities, and impulse disorder, did not have a completed PASARR screening prior to or upon admission, nor after changes in condition. The resident's care plan indicated mood and behavior problems, and the resident was at risk for aggression. Despite these issues, the facility did not notify the state agency or re-complete the PASARR screening when the resident's stay extended beyond the 30-day respite period. Additionally, the facility did not conduct a new PASARR screening after the resident experienced changes in condition, including a new diagnosis in 2020 and a psychiatric hospital stay in 2022. Interviews with the Social Services Director and the Administrator revealed that they were unable to locate a completed level 2 PASARR form for the resident and were unsure of the requirements for completing the form. This lack of documentation and understanding of the PASARR process contributed to the deficiency in ensuring the resident received appropriate care and services.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent new ulcers from developing for a resident, leading to a deficiency. The resident, who was at risk for developing pressure ulcers, was admitted with diagnoses including diabetes and required pressure-reducing devices for bed and chair. Despite these precautions, a new ulcer developed on the resident's left second toe, which was not documented or treated in a timely manner. The nursing assistant reported the issue to the charge nurse, but the conversation and the condition of the resident's toe were not documented in the progress notes. The podiatrist identified the ulcer as a pressure wound and provided specific treatment orders, which were not added to the resident's Physician Order Sheet or care plan. The facility staff delayed implementing the podiatrist's orders, and the resident's wound care was not initiated until several days later. The wound showed signs of infection and deterioration, with the resident experiencing pain and the wound not improving until a referral to a wound care clinic was made. The facility's failure to document, track, and implement timely wound care orders contributed to the worsening of the resident's condition. Interviews with facility staff revealed a lack of communication and coordination in managing the resident's wound care. The LPN responsible for wound care did not promptly enter new orders into the system, and there was confusion among staff regarding the current treatment plan. The Director of Nursing and the Administrator were unaware of the delay in treatment initiation, highlighting systemic issues in the facility's wound care management process.
Improper Transfer of Non-Weight Bearing Resident
Penalty
Summary
The facility failed to ensure an environment as free of accident hazards as possible when staff transferred a non-weight bearing resident using a gait belt instead of a mechanical lift. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was observed being transferred by CNAs and nursing staff using a gait belt, despite the resident's care plan indicating the need for a mechanical lift due to the inability to bear weight and other health considerations. The resident's care plan and clinical health review indicated total dependence on staff for transfers and the requirement of a mechanical lift due to the resident's inability to consistently bear weight, history of falls, and fragile skin. However, observations showed that staff used a gait belt to lift the resident from a wheelchair to a bed, with the resident's legs hanging in the air and not bearing any weight. Interviews with staff revealed inconsistencies in the understanding and implementation of the resident's transfer needs, with some staff believing the resident was a one-to-two-person pivot transfer, while others acknowledged the need for a mechanical lift. The facility did not provide a policy regarding transferring residents, gait belt use, or mechanical lift use, contributing to the deficiency. Interviews with the Director of Nursing and the Administrator highlighted a lack of clarity and communication regarding the resident's transfer status, with the Kardex and care plan not accurately reflecting the resident's current needs. This lack of proper documentation and adherence to the resident's care plan led to unsafe transfer practices, putting the resident at risk of harm.
Failure to Implement Pharmacist Recommendations for Medication Titration
Penalty
Summary
The facility failed to implement a process to ensure that pharmacist recommendations were followed up and implemented when approved by a physician. This deficiency was identified when the facility did not adjust a resident's medication as recommended by the pharmacist and agreed to by the physician. The resident, who had diagnoses including left-sided hemiplegia, dementia, diabetes, and heart failure, was receiving Namenda for dementia. The pharmacist recommended a titration of the medication, which was agreed upon by the physician, but no titration attempts were documented in the resident's physician order sheet. Interviews with facility staff revealed a lack of a clear process for following up on pharmacy recommendations. The Registered Nurse mentioned that orders received via fax should be entered in a timely manner, but there was confusion about who was responsible for entering these orders. The Director of Nursing indicated that it was the responsibility of a specific LPN to ensure orders were taken off, but was unsure why the titration was not completed. The Administrator stated that new orders should be entered into the computer system and reviewed within 24 hours, but acknowledged issues with staff not following through with orders. There was no established process for ensuring pharmacy recommendations were followed up on, leading to the oversight in the resident's medication management.
Failure to Follow Approved Pureed Diet Menus
Penalty
Summary
The facility failed to adhere to approved menus to meet the nutritional needs of residents requiring pureed diets. Specifically, two residents who required pureed meals were not provided with the approved menu items. Instead, the dietary staff substituted non-equivalent items, such as cottage cheese and yogurt, for vegetables. The Dietary Manager admitted to not knowing how to puree certain menu items, leading to inappropriate substitutions. The Registered Dietician confirmed that substitutions should be like-kind and nutrient equivalent, which was not the case in this situation. Interviews with various staff members, including the Dietary Manager, Dietary Aide, Registered Dietician, Director of Nursing, and the Administrator, revealed a lack of adherence to the prescribed menu and diet cards. The staff acknowledged that the substitutions made were not equivalent and did not meet the residents' dietary needs. The facility also lacked a policy regarding pureed diets, contributing to the inconsistency in meal preparation and delivery.
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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