Milan Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Milan, Missouri.
- Location
- 52435 Infirmary Road, Milan, Missouri 63556
- CMS Provider Number
- 265238
- Inspections on file
- 24
- Latest survey
- October 30, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Milan Health Care Center during CMS and state inspections, most recent first.
Two residents, one with cognitive impairment and another with a history of mental health conditions, were subjected to non-consensual sexual contact by another resident with moderately impaired cognition. The incidents involved inappropriate touching and exposure, with both victims displaying distress and fear following the events. Staff and care plans did not adequately address or monitor the perpetrator's behaviors, nor did they provide sufficient supervision to prevent these incidents.
The facility did not provide a full-time DON who was not also serving as a charge nurse when the census was over 60, as required by policy. Staffing records and staff interviews confirmed that on several days, there was no DON coverage due to staff shortages and the interim administrator's absence.
The facility did not maintain adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
A resident with a history of mental illness and behavioral symptoms was physically assaulted by another resident with dementia and mood disturbances, despite care plans and behavior monitoring intended to prevent such incidents. The aggressor had previously exhibited hostile behavior and targeted the victim, but staff interventions were not effective in preventing the altercation in the smoking area.
The facility failed to provide a full-time DON who did not serve as a charge nurse, despite having a census over 60 residents. The DON frequently worked as a charge nurse, violating facility policy and federal regulations. Additionally, the facility did not maintain eight consecutive hours of RN staffing on at least two occasions. Interviews revealed staffing challenges, with the DON unable to fulfill administrative duties due to working as a charge nurse.
The facility failed to maintain clean and intact ceilings in food-related areas, risking contamination. Moisture damage, flaking paint, and dust buildup were observed. Additionally, the ice machine lacked a proper air gap, posing a contamination risk. Staff were unaware of these issues, indicating lapses in oversight.
The facility failed to complete required Significant Change in Status Assessments (SCSA) for four residents after significant changes in their conditions, including cognitive decline, new diagnoses, changes in ADLs, and hospice enrollment. The MDS Coordinator was not informed of these changes due to a lack of communication, leading to non-compliance with federal regulations.
The facility failed to accurately code the MDS for four residents, resulting in discrepancies in their assessments. Inaccuracies included cognitive status, preferences, and functional limitations, with residents marked as rarely/never understood despite being alert and oriented. The MDS/Care Plan Coordinator noted past coding issues and a lack of formal training, while the Activity Director reported challenges due to frequent coordinator changes and technical issues. The Administrator expected accurate MDS completion but noted staff were not consistently conducting resident interviews.
The facility failed to update care plans for several residents, leading to deficiencies in care. One resident experienced a decline in cognitive and physical abilities, including a new pressure ulcer and colostomy, without care plan updates. Another resident's care plan lacked documentation for a PICC line used for IV antibiotics. A third resident's care plan did not reflect changes in communication and ADL needs, while a fourth resident's care plan inaccurately documented oxygen therapy and ADL independence.
The facility failed to provide adequate ADL care and hygiene for several residents, as evidenced by inconsistent shower schedules and improper perineal care. Residents were not receiving regular showers, and staff did not perform complete perineal care during incontinence episodes. Documentation was incomplete, and staffing shortages contributed to these deficiencies. The Director of Nursing and Administrator acknowledged the issues but had no plan in place to address them.
The facility failed to provide adequate nursing staff, resulting in missed showers and restorative care for residents. Observations showed residents with poor hygiene and worsening contractures due to insufficient care. Staffing levels were consistently below required numbers, with the DON and department heads covering nursing roles. The facility had previously used agency staff but was not allowed to do so at the time.
The facility failed to ensure meals were served at safe and appetizing temperatures, as required by policy. Observations and interviews revealed that several residents received meals that were not hot enough, with food temperatures not consistently checked during service. The Dietary Manager admitted that the cook did not always monitor temperatures, leading to meals being served outside the acceptable range.
The facility failed to ensure proper hand hygiene and glove use, leading to deficiencies in infection control. Staff did not wash hands between glove changes or sanitize soiled surfaces properly. Respiratory equipment was improperly stored, and medication administration lacked adherence to hygiene protocols. These actions indicate systemic issues with infection control policies.
The facility failed to accommodate the needs of two residents requiring power wheelchairs for independence. One resident, a paraplegic, was denied a power wheelchair despite having a physician's order and Medicaid approval, leaving them dependent on staff. Another resident with multiple sclerosis faced threats of having their motorized chair taken away, despite no documented safety concerns. The administrator's personal preference against motorized chairs led to these denials, contradicting the facility's policy on assistive devices.
The facility failed to provide adequate restorative nursing services to two residents, resulting in a deficiency in maintaining or improving their range of motion and mobility. Resident #30, who is paraplegic, and Resident #55, who has severe cognitive impairment, both required passive range of motion exercises. However, the facility's records showed inconsistent documentation and a lack of comprehensive restorative plans. Interviews revealed that staffing shortages led to the restorative aide being frequently pulled to work as a CNA, contributing to the lack of consistent care.
A facility failed to prevent residents from accessing fire-starting materials, resulting in two fire incidents in a shared room. Staff detected a fire in the bathroom trash can, which a resident extinguished, but later a second fire occurred in a box on one resident's side. The residents had significant medical and behavioral histories, including schizophrenia and COPD, and were listed as unsupervised smokers despite care plans indicating the need for supervision. Staff interviews revealed lapses in monitoring and enforcement of the smoking contraband policy.
The facility failed to report an alleged sexual abuse incident involving two residents to the state agency. A nurse aide found a resident in another's room, leading to concerns of sexual activity. Despite staff reporting the incident to an LPN and the ADON, it was not reported to the state agency as required. The residents involved had diagnoses of dementia and Alzheimer's disease.
The facility failed to investigate an alleged sexual abuse incident between two residents. Despite staff concerns, the LPN and ADON dismissed the situation as exaggerated and did not conduct necessary interviews with other residents or staff. The Director of Nursing and Administrator were unaware of the incident's seriousness, resulting in a deficiency in addressing the alleged abuse.
A resident with impaired cognition and mobility needs was not safely secured in a transport van, leading to an accident. The resident slid out of the wheelchair due to unsecured front wheels and an improperly positioned seatbelt. The incident resulted in minor injuries and a hospital evaluation, revealing no acute injuries but existing degenerative spondylosis.
The facility failed to protect two residents from sexual abuse by not assessing their capacity to consent to sexual activity. Both residents had cognitive impairments and legal guardians, with one having a history of hypersexual behavior. Staff observed inappropriate behaviors but did not implement specific interventions until after the residents were found naked in bed together.
The facility failed to thoroughly investigate an allegation of sexual abuse between two residents, neglecting to interview other residents and all staff present. Both residents had histories of cognitive impairment and inappropriate behavior. The DON was aware of escalating behavior but did not implement specific interventions.
Failure to Protect Residents from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect two residents from sexual abuse by another resident, resulting in two separate incidents involving non-consensual sexual contact. In the first incident, a resident with a history of bipolar disorder, anxiety, and major depressive disorder, who was cognitively intact, reported that another resident with moderately impaired cognition grabbed their breast without consent while they were outside in the courtyard. The victim expressed fear of being alone and of further encounters with the perpetrator. The incident was witnessed by another resident, and the victim was visibly distressed when recounting the event. Approximately four hours after the first incident was reported, staff discovered another resident, who had dementia and impaired cognition, in the perpetrator's room. This resident was found sitting on the bed with their shirt pulled up, exposing their breasts, and their pants were on inside out. The resident was distraught and tearful, refused to return to their room, and instead stayed in the common area overnight. Staff interviews and documentation confirmed that this resident required moderate to maximal assistance with activities of daily living and had no prior behaviors of wandering or entering other residents' rooms. The facility's records and staff interviews revealed that the perpetrator had previously made inappropriate sexual comments and advances toward other residents, including discussing sexually explicit material and making repeated requests for relationships despite being told no. The care plans for the involved residents did not address these behaviors or provide adequate interventions to prevent such incidents. Staff were not monitoring the perpetrator closely enough after the initial report of abuse, and there was a lack of supervision for the cognitively impaired resident who was later found in the perpetrator's room. These failures led to both residents being subjected to non-consensual sexual contact.
Failure to Provide Full-Time DON Coverage When Census Exceeded 60
Penalty
Summary
The facility failed to provide a full-time Director of Nursing (DON) who did not serve as a charge nurse when the facility census exceeded 60 residents, with the census documented at 86 and 87 on the affected dates. Review of staffing sheets revealed that there was no DON coverage on multiple dates in June 2025. Interviews with the DON and administrator confirmed that the DON had been reassigned to charge nurse duties due to staffing shortages, and the interim administrator, who was acting as DON, was absent from the facility for several days, resulting in no DON coverage during those times. The facility's own policy required a full-time DON, and this requirement was not met on the specified dates.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that the required staffing levels and licensed nurse coverage were not consistently maintained as mandated.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident involved a resident with a history of encephalopathy, bipolar II disorder, schizoaffective disorder, and anxiety disorder, who was at risk for aggression and behavioral symptoms, including wandering and verbal aggression. The care plan for this resident included interventions to avoid confrontation and to intervene as necessary to protect the safety of others. Despite these measures, the resident was physically assaulted by another resident who struck them multiple times in the face. The resident who committed the assault had diagnoses of generalized anxiety disorder, major depressive disorder, and dementia, and was noted to have impaired thought processes and mood disturbances with agitation. Prior to the incident, this resident had exhibited aggressive and hostile behaviors, including yelling, using profanity, and threatening others. Behavior monitoring and increased assessment were implemented, but staff were unable to redirect the resident effectively during behavioral crises. On the day of the incident, the resident admitted to hitting the other resident after a confrontation in the smoking area. Interviews with staff and other residents revealed that the aggressor had a history of targeting the victim and had previously intervened in altercations involving the victim and other residents. Staff were aware of the behavioral issues and previous incidents but did not anticipate the physical altercation. The facility's abuse and neglect policy required identification and intervention for residents at risk of abuse or with behaviors that could lead to conflict, but these measures were insufficient to prevent the incident.
Staffing Deficiencies and DON Role Mismanagement
Penalty
Summary
The facility failed to provide a full-time Director of Nursing (DON) who did not serve as a charge nurse, despite having a census over 60 residents. The facility's policy required a full-time DON and stipulated that the DON could only serve as a charge nurse when the facility's average daily occupancy was 60 or fewer residents. However, the facility's staffing sheets revealed that the DON frequently worked as a charge nurse, even when the census was as high as 98. This was a clear violation of the facility's policy and federal regulations. Additionally, the facility did not maintain eight consecutive hours of Registered Nurse (RN) staffing daily on at least two occasions. On January 11 and 12, 2025, the staffing sheets showed no RN coverage for eight consecutive hours, which is a requirement for the facility. The facility's assessment indicated that federal regulations required 3.48 hours per resident day of direct care, with 0.55 hours from RNs, but the facility failed to meet this requirement on those days. Interviews with the DON and the administrator revealed that the facility had been struggling with staffing issues. The DON reported working almost every day as a charge nurse and being unable to fulfill her administrative duties. The facility had previously relied on agency staff to fill charge nurse roles, but this practice stopped on January 1, 2025. The administrator confirmed that the DON worked the floor most of February and was only able to perform her DON role for two days that month. The Regional Director of Operations acknowledged the staffing challenges and mentioned the possibility of bringing agency staff back to the facility.
Ceiling Maintenance and Ice Machine Drain Deficiencies
Penalty
Summary
The facility failed to maintain the cleanliness and condition of ceilings in critical areas such as the dishwasher room, dry food storage room, and above food preparation and serving areas, which could potentially lead to food contamination. Observations revealed moisture damage and dark stains on the ceiling in the dry food storage room, cracked and flaking paint in the dishwasher room, and dust and debris buildup around ceiling vents above the steam table. The Dietary Manager was unaware of these issues, and the Maintenance Director acknowledged the problem but indicated that the maintenance department was responsible for repairs and cleaning, which were not being conducted as frequently as needed. Additionally, the facility did not maintain a proper air gap for the ice machine drain in the dining room, which could lead to contamination. The ice machine's drain pipes extended below the flood rim level of the floor drain, lacking the necessary air gap. The Maintenance Supervisor was unaware of this deficiency, and the Administrator expected the ice machine to have an air gap and the kitchen ceilings to be clean and well-maintained, indicating a lapse in oversight and adherence to facility policies.
Failure to Complete Significant Change Assessments
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for four residents following significant changes in their conditions. The SCSA is a federally mandated assessment tool that must be completed within 14 days after a significant change in a resident's condition is identified. This failure was identified during a review of 24 sampled residents, where four residents experienced significant changes in their health status, including cognitive decline, new diagnoses, changes in activities of daily living (ADLs), and enrollment in hospice care, without the required SCSA being completed. Resident #18 experienced a decline in cognitive function, new diagnoses including pneumonia and a Stage III pressure ulcer, and a decline in ADLs, yet no SCSA was completed. Resident #36 had new delusions, a new diagnosis of bipolar disorder, increased incontinence, significant weight loss, and new IV access, but the facility did not complete an SCSA. Resident #59 had a new diagnosis of pneumonia, cognitive decline, increased pain, significant weight loss, and was placed on hospice care, but the SCSA was not completed within the required timeframe. Resident #79 was admitted to hospice care, but the facility failed to complete the SCSA within 14 days of the hospice start date. The MDS Coordinator, responsible for completing these assessments, was not informed of the hospice admission due to a lack of communication, as daily nursing meetings were not occurring. This lack of communication and oversight led to the failure to complete the necessary assessments, resulting in a deficiency in the facility's compliance with federal regulations.
Inaccurate MDS Coding Leads to Assessment Discrepancies
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for four residents, leading to discrepancies in their assessments. The MDS, a federally mandated assessment tool, was not completed in accordance with the Resident Assessment Instrument (RAI) manual. This resulted in inaccurate reflections of the residents' cognitive status, preferences, and functional limitations. For instance, Resident #30 was marked as rarely/never understood in some sections, despite being alert and oriented during an interview. Similarly, Resident #33, who had severe cognitive impairment, was marked as somewhat important for all preferences, although the resident was unable to consistently answer questions. Resident #36's MDS indicated cognitive intactness, but the resident had multiple diagnoses, including dementia and traumatic brain injury, which could affect cognitive function. The resident's preferences were marked as somewhat important, despite expressing differing interests during an interview. Resident #71's MDS showed inconsistencies in functional limitations and hospice status, with no documentation to support significant changes. The resident was observed with visible limitations in range of motion, contradicting the MDS entries. The facility's MDS/Care Plan Coordinator acknowledged issues with past MDS coding and noted a lack of formal MDS training. The Activity Director also reported challenges with MDS completion due to frequent changes in MDS coordinators and technical issues with data transfer. The Administrator expected accurate MDS completion but noted that staff were not consistently leaving their offices to conduct resident interviews, contributing to the inaccuracies.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans to reflect the current care needs of four residents, leading to deficiencies in their care. Resident #18 experienced a significant decline in cognitive and physical abilities, including the development of a Stage III pressure ulcer, a new urinary catheter, and a colostomy following hospitalization. Despite these changes, the resident's care plan was not updated to reflect the new conditions and care requirements, such as the need for mechanical transfer and increased assistance with activities of daily living (ADLs). Resident #25's care plan did not address the presence or care of a peripherally inserted central catheter (PICC) line, despite the resident receiving intravenous antibiotics for a wound through the PICC line. The resident's quarterly Minimum Data Set (MDS) indicated the use of intravenous access and medications, yet the care plan lacked documentation of these critical medical interventions. Resident #33's care plan was outdated and did not reflect changes in the resident's communication abilities, ADL assistance needs, and ambulatory status. Observations showed the resident with disheveled hair, unshaven, and wearing wet clothing, indicating inadequate personal hygiene care. Similarly, Resident #54's care plan was not updated to reflect changes in oxygen therapy requirements and the need for assistance with ADLs following hospitalization. The care plan inaccurately documented the resident's independence in ADLs and did not address the correct oxygen settings or the use of a BiPAP machine.
Deficiencies in ADL Care and Hygiene Practices
Penalty
Summary
The facility failed to provide adequate care and assistance for activities of daily living (ADLs) to six residents who were unable to perform these tasks independently. Observations and interviews revealed that residents were not receiving necessary personal hygiene care, including regular showers and proper perineal care. For instance, one resident was observed to have not received a shower for 21 days, despite being scheduled for two showers per week. Another resident was found with greasy hair and flaky skin, indicating a lack of regular bathing. Additionally, staff failed to perform complete perineal care during incontinence episodes, as evidenced by the use of only toilet paper instead of soap and water or appropriate peri-care products. The facility's documentation was inconsistent and incomplete, with several instances where there was no record of showers being offered or refused. Residents expressed dissatisfaction with the frequency and timing of showers, and some reported feeling frustrated due to the lack of control over their personal care schedules. Staff interviews confirmed that there were not enough personnel to meet the scheduled shower requirements, and department heads were not assisting with showers as expected. This lack of staffing and support contributed to the failure to provide adequate ADL care. Furthermore, the facility's policies on incontinence care and shower schedules were not consistently followed. Residents were found wearing double incontinence products, which is against facility policy, and were not being checked and changed every two hours as required. The Director of Nursing and the Administrator acknowledged these deficiencies, noting that recent staffing shortages had impacted the ability to provide the necessary care. Despite these acknowledgments, the facility did not have a plan in place to address these issues at the time of the report.
Inadequate Staffing Leads to Missed Care in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by the lack of routine showers and restorative nursing care for several residents. Observations and interviews revealed that residents were not receiving scheduled showers, leading to poor personal hygiene. For instance, one resident, who was dependent on staff for showers due to paraplegia, only received one shower in February and none in early March, despite being scheduled for two showers per week. Another resident with severe cognitive impairment received only two out of eight scheduled showers over a month-long period, with no documentation of refusals. Additionally, the facility did not provide adequate restorative nursing care to prevent the decline in residents' activities of daily living and worsening contractures. One resident with paraplegia and contractures was supposed to receive passive range of motion (PROM) exercises three times a week but reported receiving them sporadically, sometimes going weeks without any restorative care. The resident expressed concerns about worsening contractures and increased spasms due to the lack of consistent care. Another resident with severe cognitive impairment and functional limitations in range of motion was scheduled for daily PROM but had numerous gaps in the documentation, indicating missed sessions. The facility's staffing levels were consistently below the required numbers to meet residents' needs, as documented in the facility's staffing sheets. The Director of Nursing (DON) and other department heads often had to cover nursing roles due to staff shortages. The facility had previously used agency staff to fill gaps but was not allowed to do so at the time of the report. Interviews with the DON and other staff confirmed the ongoing staffing challenges, which directly impacted the facility's ability to provide necessary care to residents.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to adhere to its policy regarding the monitoring and serving of food at safe and appetizing temperatures, resulting in a deficiency. Observations and interviews revealed that residents frequently received meals that were not served at the appropriate temperatures. Several residents reported that their meals were often cold or not hot enough, whether they ate in the dining room or in their rooms. The facility's policy required staff to record food temperatures at the beginning and during the tray line service, and to reheat or chill food items if they did not meet acceptable serving temperatures. However, staff did not consistently check food temperatures during meal service, as evidenced by the test tray showing the tuna noodle casserole at 118.2 degrees Fahrenheit and the tossed salad at 77.0 degrees Fahrenheit, both outside the acceptable temperature range. The Dietary Manager acknowledged that the cook did not always check food temperatures midway through meal service, and the Administrator confirmed the expectation for hot foods to be served hot and cold foods to be served cold. Despite the initial cooking temperatures being within acceptable parameters, the failure to monitor and maintain these temperatures during service led to the deficiency. The facility census was 98, and the issue affected multiple residents, as indicated by their complaints about the temperature of their meals.
Infection Control Deficiencies in Hand Hygiene and Equipment Handling
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove use among nursing staff, leading to multiple deficiencies in infection prevention and control. Observations revealed that staff did not wash their hands after direct resident contact and between glove changes. For instance, a nurse assistant was observed handling soiled incontinence briefs and cleaning feces from surfaces without changing gloves or washing hands. This practice was repeated across different residents, with staff failing to perform hand hygiene before and after glove use, and touching clean surfaces with soiled gloves. Additionally, the facility did not ensure that soiled surfaces were sanitized appropriately. A nurse assistant was observed using perineal wipes to clean feces from surfaces, unaware of the need to use a disinfectant. This lack of proper sanitation was compounded by the improper handling of respiratory care supplies. A resident's BiPAP and nebulizer equipment were found unbagged and improperly stored, with the BiPAP mask even touching the floor, which was not addressed by the staff. Furthermore, the facility failed to adhere to infection control protocols during medication administration. A registered nurse was observed administering insulin without performing hand hygiene between glove changes and after handling the glucometer. Similarly, a certified medication technician administered eye drops without wearing gloves. These actions indicate a systemic issue with adherence to infection control policies, as confirmed by interviews with staff who acknowledged the lapses in hand hygiene and glove use.
Facility Fails to Accommodate Residents' Need for Power Wheelchairs
Penalty
Summary
The facility failed to accommodate the needs and preferences of residents requiring power wheelchairs for independence, as evidenced by the experiences of two residents. Resident #30, who is paraplegic and cognitively intact, was denied assistance in obtaining a power wheelchair despite having a physician's order and Medicaid approval. The facility administrator forbade power chairs, citing safety concerns, and suggested the resident move to another facility. This decision left Resident #30 feeling hopeless, discriminated against, and dependent on staff for mobility, as the resident was confined to a geri chair that required staff assistance for movement. Resident #11, who uses a motorized chair due to multiple sclerosis and is cognitively intact, faced threats from the administrator to have their chair taken away. The resident's medical records showed no documented safety concerns or incidents of running into others, contrary to the administrator's claims. The resident's driving assessment indicated they could drive with some difficulty, but no specific pass or fail criteria were noted. The lack of mirrors and speed adjustments recommended in the assessment were not addressed, and the resident expressed concerns about losing independence and becoming more depressed without the chair. The facility's policy on the use of assistive devices emphasizes the importance of providing necessary equipment to maintain or improve residents' function and dignity. However, the administrator's actions contradicted this policy by preventing residents from using power wheelchairs, which are essential for their independence. The therapy director confirmed that the residents were eligible for power chairs and that therapy could assist in ensuring safe use, but the administrator's personal preference against motorized chairs led to the denial of these necessary accommodations.
Inadequate Restorative Nursing Services for Residents
Penalty
Summary
The facility failed to provide adequate restorative nursing services to two residents, resulting in a deficiency in maintaining or improving their range of motion and mobility. The facility did not adhere to its policy of developing comprehensive restorative plans that include specific interventions, measurable goals, and documentation of the services provided. This failure was observed in the cases of two residents, both of whom had significant physical impairments requiring restorative care. Resident #30, who is paraplegic and uses a gerichair for mobility, was supposed to receive passive range of motion (PROM) exercises as part of their care plan. However, the facility's records showed inconsistent documentation of these exercises, with no clear indication of the frequency, duration, or specific goals of the interventions. The resident reported experiencing increased spasms and worsening contractures, indicating a lack of consistent restorative care. The facility's documentation did not reflect any refusals of care by the resident, suggesting that the services were simply not provided as required. Similarly, Resident #55, who has severe cognitive impairment and functional limitations due to a stroke, was also supposed to receive daily PROM exercises. The facility's records showed numerous gaps in the documentation of these exercises, with no evidence of refusals by the resident. The facility failed to maintain a restorative plan of care that included specific interventions and goals, and there was no documentation of regular evaluations by the Restorative Nurse. Interviews with staff revealed that the restorative aide was frequently pulled to work as a CNA due to staffing shortages, which contributed to the lack of consistent restorative care for the residents.
Failure to Prevent Fire Hazards in Resident Room
Penalty
Summary
The facility failed to provide protective oversight to prevent residents from having materials to start a fire, leading to two fire incidents in a shared room. On the first occasion, staff detected an odor and discovered a small fire in the bathroom trash can, which a resident claimed to have extinguished with water. Despite a search, no lighter was found, but cigarettes and ashes were discovered in the room. Shortly after, a second fire occurred, originating from a box on one resident's side of the room, prompting a Code Red and evacuation of residents. The residents involved had significant medical and behavioral histories. One resident had diagnoses including depression, schizophrenia, and mild cognitive impairment, with a care plan indicating a need for supervision while smoking. The other resident had paranoid schizophrenia and COPD, with a history of hiding lighters and saving cigarette butts. Despite these risks, both residents were listed as unsupervised smokers, contrary to their care plans and smoking safety evaluations. Interviews with staff revealed lapses in monitoring and enforcement of the facility's smoking contraband policy. Staff were aware of the residents' tendencies to sneak cigarette butts and lighters but failed to maintain adequate supervision or conduct thorough searches. The facility's policy required residents to turn in smoking materials, but this was not effectively enforced, contributing to the incidents.
Failure to Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents to the state agency. The incident occurred when a nurse aide entered a resident's room and found another resident standing beside the bed, zipping up their pants. The staff involved reported the incident to a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON), but the ADON did not instruct the LPN to report the incident to the state agency, believing the situation was exaggerated. Resident #1, who was involved in the incident, had a diagnosis of unspecified dementia and bipolar disorder, and was noted to have communication problems related to dementia. Resident #2, who was new to the facility, had a diagnosis of early onset Alzheimer's disease and dementia. Despite the concerns raised by the staff, the ADON assumed nothing had happened after asking Resident #1 if they felt safe and receiving a positive response. The Director of Nursing and the Administrator both stated that they would expect an allegation of sexual abuse to be reported to the state agency. However, due to the ADON's decision not to report the incident, the facility failed to comply with its policy to report all allegations of abuse immediately to the appropriate authorities.
Failure to Investigate Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation of an alleged sexual abuse incident involving two residents. The incident occurred when a nurse aide entered a resident's room and found another resident standing beside the bed, zipping up their pants. Despite the aides' concerns and reports to the Licensed Practical Nurse (LPN) and Assistant Director of Nursing (ADON), the facility did not conduct interviews with other residents or all staff present at the time of the incident. The facility's policy requires a comprehensive investigation of all abuse allegations, including obtaining personal statements from involved staff and residents, and ensuring the resident's safety and well-being. However, the LPN and ADON dismissed the aides' concerns as exaggerations and did not follow through with the necessary investigative steps. The ADON only asked one resident if they felt safe and assumed nothing had happened without further inquiry. The Director of Nursing and the Administrator were not aware of the incident's seriousness and did not ensure that the facility's abuse policy was followed. The lack of a proper investigation and failure to interview all relevant parties led to a deficiency in addressing the alleged abuse incident, leaving the residents' safety and well-being potentially compromised.
Failure to Secure Resident in Transport Van
Penalty
Summary
The facility failed to ensure the safe transport of a resident in a wheelchair within the facility van, leading to an accident. The resident, who had severely impaired cognition and required moderate assistance for transfers, was being transported from the hospital back to the facility. During the transport, the resident slid out of the wheelchair when the van turned into the facility's parking lot. The resident's wheelchair was not equipped with foot pedals, and the front wheels were not secured, which contributed to the incident. The resident was found lying on their left side in the van, with a skin abrasion on the left elbow and complaints of neck pain. The wheelchair's back wheels were secured, and the shoulder/lap belt was still in place, but the seatbelt was incorrectly positioned over the armrests instead of under them. The transporter, who had been trained by a previous staff member, did not secure the front wheels of the wheelchair, which was a critical oversight. The incident was reported by the transporter, and emergency services were called to assist the resident, who was then taken back to the hospital for evaluation. The hospital report indicated that the resident had no acute injuries but showed signs of degenerative spondylosis in the cervical spine. The facility did not have a policy in place for securing residents in the transport van, which contributed to the deficiency.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect two residents' right to be free from sexual abuse. Staff observed the residents engaging in sexual activities without assessing their capacity to consent. Both residents had legal guardians and cognitive impairments, with one resident having a history of hypersexual behavior. Despite these factors, the facility did not complete the required assessments to determine their ability to consent to sexual activity before the incident occurred. Resident #1 had a history of wandering and incarceration related to sexual behaviors. The resident's quarterly Minimum Data Set (MDS) indicated severely impaired cognition. Staff documented multiple instances of Resident #1 wandering into other residents' rooms and being inappropriate with Resident #2. On the evening of 4/28/24, staff found Resident #1 and Resident #2 naked in bed together. The facility initiated 15-minute checks and completed a capacity to consent assessment only after the incident. Resident #2 had a history of hypersexual behavior and was under guardianship. The resident's medical records indicated periods of mania, disrobing, and delusional beliefs. Staff observed Resident #2 engaging in attention-seeking behaviors towards Resident #1, including holding hands and sitting close together. Despite these observations, no specific interventions were put in place until after the incident. The facility's failure to assess the residents' capacity to consent and implement appropriate interventions led to the deficiency.
Failure to Thoroughly Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of sexual abuse between two residents. The investigation did not include interviews with other residents to assess if they felt safe or had been subjected to or witnessed abuse. Additionally, not all staff present at the time of the alleged incident were interviewed. The facility's census was 89 at the time of the incident. Resident #1, who was admitted with diagnoses including unspecified dementia and vascular dementia, was assessed as having severely impaired cognition and had a history of inappropriate behavior. Resident #2, admitted with diagnoses including bipolar disorder and vascular dementia, had a history of hypersexual behavior and delusional beliefs. On the evening of the incident, both residents were found undressed in Resident #1's bed, engaging in consensual acts according to their statements. The Director of Nursing (DON) was aware of the escalating affectionate behavior between the two residents but did not implement specific interventions. After the incident, the DON interviewed the involved residents and one staff member but did not interview other residents or all staff present. The facility's abuse and neglect policy mandates immediate reporting and thorough investigation of all allegations, which was not fully adhered to in this case.
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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