Nathan Richard Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Nevada, Missouri.
- Location
- 700 East Highland Avenue, Nevada, Missouri 64772
- CMS Provider Number
- 265558
- Inspections on file
- 19
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Nathan Richard Health Care Center during CMS and state inspections, most recent first.
Two residents were involved in a verbal altercation where one threatened to kill the other, and staff recognized this as verbal and emotional abuse. Despite facility policy and regulatory requirements to report such allegations to DHSS within two hours, the DON and Administrator did not report the incident, as they did not initially consider the threat serious. Multiple staff interviews confirmed awareness of reporting protocols, but the mandated process was not followed.
A resident experienced a significant decline in condition, becoming unresponsive and unable to care for themselves. Despite this, the LTC facility staff failed to promptly send the resident to the hospital, did not follow up with the physician, and neglected to contact the medical director. The resident was eventually hospitalized for high potassium and elevated labs. Facility policies on notifying clinicians and documenting changes were not followed, contributing to the delay in care.
A resident developed a facility-acquired wound due to inadequate pressure ulcer care and documentation. The staff failed to conduct consistent wound assessments, track wounds weekly, and administer treatments as ordered. The resident, initially at risk but without pressure ulcers, developed cellulitis and blisters after a fall and improper use of an elastic bandage. The condition worsened to a stage IV ulcer with exposed tendon, leading to a wound care consultation and consideration for amputation.
The facility failed to provide sufficient RN and DON hours, requiring the DON to work as a charge nurse, which hindered her ability to fulfill her primary duties. The DON was responsible for various tasks, including wound care and infection prevention, but was unable to complete documentation and competency evaluations due to staffing shortages. The administrator was aware of the situation but expected the DON to complete her duties.
The facility failed to maintain proper food safety and sanitation practices, including inadequate labeling and dating of food, lack of hair and beard restraints for kitchen staff, and insufficient hand hygiene and equipment sanitation. Additionally, resident room refrigerators contained expired and spoiled food, indicating a lack of regular monitoring. These deficiencies pose potential health risks to residents.
The facility did not have a written transfer agreement with a hospital, which is essential for ensuring residents' timely hospital admission and information exchange. Despite attempts to establish agreements with local hospitals after a change in ownership, the facility received no response. Instead, it maintained agreements with other nursing homes and churches for emergency evacuation.
The facility failed to conduct competency evaluations for CNAs as part of the required in-service education. Despite having mandatory in-services and online training, there was no record of completed competencies. Interviews with staff, including a CNA, the DON, and the Administrator, confirmed the absence of competency evaluations, such as handwashing demonstrations.
The facility failed to conduct required criminal background checks and other screenings for several staff members, including two RNs and a dietary aide, before they began working with residents. This oversight violated the facility's abuse and neglect prevention policies, as checks were either delayed or not documented. Interviews revealed a lack of awareness and oversight in ensuring compliance with these policies.
The facility failed to maintain an effective infection control program, with staff not practicing proper hand hygiene and infection practices during wound and catheter care. Enhanced Barrier Precautions (EBP) were not consistently followed, and there were delays in TB testing for new staff. Observations showed improper handling of catheter bags and inconsistent use of gowns and gloves, with staff interviews revealing a lack of understanding of EBP protocols.
The facility failed to implement an effective antibiotic stewardship program, as it did not track or monitor antibiotic usage for residents on antibiotics for various infections. A resident with lymphoma and diabetes was on antibiotics for cellulitis, another with chronic respiratory failure and diabetes was on antibiotics for UTI prevention, and a third with UTI and bacteremia was on antibiotics for UTI and pneumonia. The Director of Nursing admitted to not maintaining an infection log after a physician left the facility.
A facility failed to obtain timely blood tests for a resident with schizophrenia, hypertension, and COPD, as per physician orders. The facility's policy required diagnostic services to be provided and results communicated within 24 hours, but staff did not document the completion or results of several ordered tests. Interviews revealed issues with lab order processes and communication, contributing to the oversight.
A resident with chronic kidney disease did not receive prescribed bumetanide due to its unavailability in the facility. Staff failed to reorder the medication or notify the physician about missed doses. The DON was unaware of the issue, and the facility lacked a clear policy for obtaining medications, leading to a deficiency in pharmaceutical services.
A facility failed to ensure timely physician response to pharmacist recommendations for a resident's medication review. The pharmacist suggested discontinuing oxybutynin chloride due to its anticholinergic side effects and switching to Gemtesa, but the physician did not address this. The resident, with multiple diagnoses, experienced a fall, and there was no documentation of follow-up in the medical record for several months.
A facility experienced a medication error rate of 5.56% due to two incidents. A CMT crushed extended-release potassium chloride tablets for a resident with hypokalemia, contrary to policy and drug warnings. Another resident with chronic kidney disease did not receive their prescribed bumetanide due to pharmacy unavailability, and the CMT failed to notify the DON. The Administrator expected staff to ensure medication availability.
A facility failed to document a resident's change in condition and transfer to the hospital, resulting in an incomplete medical record. The resident, with conditions such as hypertension and edema, was discharged to the hospital due to decreased function and decline in activities of living. Interviews with staff confirmed the lack of documentation, which was against the facility's policy.
The facility failed to ensure pneumococcal vaccinations were offered and documented for two residents, despite signed consents. The DON, responsible for administering vaccines, had not provided any since 2021, prioritizing flu vaccines instead. The SSD used a new consent form but lacked follow-up documentation. The Administrator expected vaccines to be ordered if requested, but the deficiency arose from inadequate documentation and administration.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that all allegations of possible abuse were reported to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. Specifically, the facility did not report a verbal altercation and threat involving two residents, despite facility policy and federal regulations requiring immediate reporting of such incidents. The incident involved one resident telling another that they would kill them, which was recognized by multiple staff members as verbal and emotional abuse and a reportable event. The events leading to the deficiency began when two residents, who were previously in a relationship, experienced a breakup that escalated into verbal altercations. One resident reported to staff that the other had threatened to kill them during an argument. This information was communicated to the Director of Nursing (DON), who did not immediately report the incident to the Administrator or DHSS, as required. The DON initially did not consider the threat serious due to the residents' ongoing arguments and relationship history, and only later reconsidered the severity of the incident. The Administrator was eventually informed but also failed to report the incident to DHSS, believing it was not a credible threat. Interviews with staff, including CNAs, a CMT, an LPN, and the Activity Director, revealed that they understood the requirement to report such allegations immediately and considered the threat to be abuse. Despite this, the DON and Administrator did not follow through with the mandated reporting process. The facility's own investigation confirmed that the incident was not reported to DHSS, and staff interviews corroborated that the reporting protocol was not followed as outlined in facility policy and regulatory requirements.
Failure to Address Change in Resident's Condition
Penalty
Summary
The facility failed to address a significant change in condition for a resident, who was initially alert, oriented, and cognitively intact. The resident experienced a decline, becoming unable to respond to questions, feed themselves, or express their desires. Despite these changes, the staff did not send the resident to the hospital immediately, failed to follow up with the physician when a message was not returned, and did not contact the medical director on the day the changes were observed. The resident was eventually sent to the hospital the following day after contact with a Nurse Practitioner, where they were admitted for high potassium and elevated labs. The facility's policies on Notification of Changes and Notifying Clinicians were not adhered to, as staff did not promptly inform the resident's physician or the resident's representative about the significant change in condition. The policies required that the clinician be notified of changes in conditions, emergent situations, and deviations from baseline, which did not occur in this case. The staff also failed to document attempts to contact the physician or the medical director, and there was no evidence of a full assessment of the resident's condition by the DON. Interviews with staff and the resident's family member revealed that the resident had been fluctuating between alertness and lethargy, and there was a known preference for hospital care that was not documented in the care plan. The DON and other staff members were aware of the resident's deteriorating condition but did not take appropriate action to ensure timely medical intervention. The resident's primary care physician and the medical director were not contacted as per protocol, leading to a delay in necessary medical care.
Failure in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident who had a facility-acquired wound. The staff did not have processes in place to ensure consistent, accurate, and thorough wound assessments were completed upon discovery and weekly. Additionally, there was a failure to complete weekly wound tracking, accurate and timely entries of wound treatments, and to complete wound treatments as ordered. This resulted in a resident developing a facility-acquired wound that required treatment by a wound care specialist and was considered for foot amputation. The resident, who was admitted with diagnoses including schizophrenia, chronic kidney disease, and hypertension, was at risk of developing pressure ulcers. Initially, the resident had no unhealed pressure ulcers. However, after a fall, the resident developed an avulsion fracture in the right ankle, which was not initially treated with specific orders. The resident requested an elastic bandage for pain relief, which was applied without a physician's order and left in place for two days, leading to cellulitis and blister formation. The facility staff failed to document the use of the elastic bandage or monitor the skin condition under it. Subsequent assessments by the Director of Nursing (DON) revealed blisters and discoloration on the resident's right foot and heel, but the size of the affected areas was not documented. Orders for wound care and antibiotics were inconsistently transcribed and administered, with several instances of missed documentation and treatment. The resident's condition deteriorated, with the wound progressing to a stage IV ulcer with exposed tendon, leading to a consultation with a wound care clinic where amputation was considered. Throughout this period, the facility failed to update the resident's care plan with the new wound conditions and related treatments.
Inadequate Staffing Impacts DON's Duties
Penalty
Summary
The facility failed to ensure consistent and sufficient Registered Nurse (RN) and Director of Nursing (DON) hours, which impacted the DON's ability to fulfill her duties effectively. The DON was frequently required to work as the charge nurse due to a shortage of nursing staff, which diverted her from her primary responsibilities. The facility's job description for the DON included overseeing nursing staff, establishing departmental goals, and implementing healthcare policies. However, the DON was unable to complete these tasks as she was also responsible for monitoring wounds, maintaining nursing operations, and overseeing the infection prevention program. The DON reported that she had to perform wound care for all residents and was unable to keep up with documentation and competency evaluations for nursing aides due to the staffing shortage. The DON's additional responsibilities included monitoring the pharmacy and antibiotic stewardship program, tasks that were previously supported by an Assistant Director of Nursing (ADON). The absence of an ADON and the need to cover charge nurse shifts hindered the DON's ability to manage the facility's nursing operations effectively. The facility's administrator was aware of the situation but expected the DON to complete her duties despite the staffing challenges. This deficiency highlights the facility's failure to provide adequate staffing to allow the DON to perform her essential duties, which are critical for maintaining the quality of care and compliance with healthcare regulations.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to proper food storage, preparation, and sanitation practices, leading to potential contamination risks. Observations revealed that food items in the walk-in refrigerator and freezer were not consistently labeled or dated, with some items showing signs of spoilage. Staff interviews confirmed that there was a lack of consistent responsibility for ensuring food items were properly sealed, labeled, and dated, which is crucial for maintaining food safety standards. Additionally, the facility did not enforce the use of hair and beard restraints among kitchen staff, as required by the FDA Food Code. Multiple staff members, including the Dietary Manager, were observed with facial hair not contained in beard nets while in the kitchen. This oversight increases the risk of hair contamination in food, which could compromise the safety and quality of meals served to residents. The facility also failed to maintain proper hand hygiene and equipment sanitation practices. Staff were observed not washing hands or changing gloves between tasks, and equipment such as thermometers and food processors were not adequately sanitized between uses. Furthermore, resident room refrigerators contained expired and spoiled food items, indicating a lack of regular monitoring and cleaning by facility staff. These deficiencies collectively pose significant health risks to residents, as they could lead to foodborne illnesses.
Lack of Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain a written transfer agreement with a hospital, which is necessary to ensure residents' timely admission to a hospital when medically appropriate and to facilitate the exchange of information between providers. The facility, with a census of 59, did not have a policy or a written transfer agreement with a community hospital. During an interview, the Administrator admitted to being unable to locate such an agreement. The facility had attempted to establish agreements with two local hospitals after a change in ownership in 2020 but received no response. Instead, the facility had transfer agreements with other nursing homes and churches for emergency evacuation.
Facility Lacks CNA Competency Evaluations
Penalty
Summary
The facility failed to provide continued training for certified nursing aides (CNAs) that included competency evaluation as part of the required minimum 12 hours of in-service education per year. The facility, with a census of 59, did not have a policy related to in-service training. A review of the facility's in-service training records showed no CNA competency evaluations were conducted. Interviews with staff, including a CNA, the Director of Nursing (DON), the Corporate Nurse, and the Administrator, revealed that while in-services and training were conducted, there were no competency evaluations completed. The DON and Corporate Nurse confirmed that essential competencies, such as handwashing return demonstrations, were not completed at the facility. The Administrator acknowledged that although there were mandatory in-services and online training assigned, there was no record of competencies being completed.
Failure to Conduct Required Background Checks for Staff
Penalty
Summary
The facility failed to implement its abuse and neglect prevention policies by not completing required criminal background checks (CBC) and other necessary screenings for several staff members. Specifically, the facility did not conduct CBCs for five staff members, including a maintenance worker, two registered nurses, a dietary aide, and a housekeeper. Additionally, the facility failed to perform Employee Disqualification List (EDL) checks for three staff members and did not complete Nurse Aide (NA) Registry checks for two registered nurses. These checks are crucial to ensure that staff members do not have a history of abuse, neglect, or other disqualifying offenses. The facility's policy mandates that the Human Resources Department conduct pre-employment screenings, including CBCs, EDL checks, and NA Registry checks, before hiring any staff. However, the review of personnel records revealed that these checks were either delayed or not documented as completed before the staff began working with residents. For instance, the CBC for Maintenance J was documented after the start date, and the EDL and NA Registry checks for RN E and RN F were either completed late or not documented at all. Interviews with the Business Office Manager and the Administrator highlighted a lack of awareness and oversight in ensuring that all necessary checks were completed before staff began working with residents. The Business Office Manager admitted to not completing the NA Registry checks for nurses and acknowledged delays in printing and documenting the results of background checks. The Administrator was unaware of these lapses, indicating a breakdown in communication and adherence to the facility's policies designed to prevent abuse and neglect.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to establish and maintain an effective infection control program, as evidenced by multiple instances of improper hand hygiene and infection practices. During wound care for three residents, the Director of Nursing (DON) did not consistently wash or sanitize hands before donning gloves, failed to don a gown, and did not follow proper procedures for handling wound care supplies. For instance, the DON entered residents' rooms without washing hands, placed wound care supplies on unsanitized surfaces, and changed gloves without sanitizing hands in between. Additionally, there was a lack of signage for Enhanced Barrier Precautions (EBP) on resident doors, and gowns were not consistently worn during high-contact care activities. The facility also failed to adhere to EBP protocols for residents with multidrug-resistant organisms (MDROs) or those with chronic wounds and indwelling medical devices. Staff did not consistently use gowns and gloves as required during high-contact care activities, such as wound care and catheter care. Observations showed that catheter bags were improperly placed on the floor, and staff handled them without washing hands or donning gloves. Interviews with staff revealed a lack of understanding and inconsistent implementation of EBP, with some staff unaware of the requirements for wearing gowns during certain care activities. Furthermore, the facility did not complete the first step of a two-step tuberculosis (TB) skin screening test in a timely manner for four staff members before they began working with residents. Personnel records showed delays in administering and reading TB tests, contrary to the facility's policy that requires testing before staff start work. Interviews with the Business Office Manager, MDS Coordinator, and Administrator highlighted a lack of clarity and adherence to the policy regarding TB testing for new hires.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of tracking and monitoring of residents on antibiotics. The facility's policy required the antibiotic steward to maintain an infection log and track antibiotic usage, but this was not done for three residents who were on antibiotics for various infections. The Director of Nursing, who was also the Infection Preventionist, admitted to not keeping a record of antibiotics after a former physician left the facility. Resident #13 had a history of lymphoma, peripheral vascular disease, type 2 diabetes mellitus, and schizophrenia. The resident was on antibiotics for a right foot cellulitis and infection, but the facility did not maintain an infection log or tracking documentation for the antibiotic usage. Similarly, Resident #31, with a history of chronic respiratory failure, type 2 diabetes mellitus, heart failure, and UTIs, was on antibiotics for UTI prevention and treatment, but the facility failed to provide tracking documentation. Resident #45, diagnosed with UTI, type 2 diabetes mellitus, bacteremia, and cellulitis, was also on antibiotics for a UTI and pneumonia. The facility did not maintain an infection log or tracking documentation for this resident's antibiotic usage. The Director of Nursing acknowledged the lack of antibiotic review and tracking, attributing it to the absence of an Assistant Director of Nursing and the departure of a former physician.
Failure to Obtain Timely Blood Tests for Resident
Penalty
Summary
The facility failed to ensure that all residents received care according to professional standards of practice, specifically in obtaining ordered blood tests in a timely manner for one resident. The facility's policy required that diagnostic services be provided as per physician orders and that results be communicated to the ordering physician within 24 hours. However, for one resident, the facility did not document obtaining or the results of several ordered blood tests, including a complete blood count, comprehensive metabolic panel, A1C, depakote level, lipid panel, and hepatic panel. The resident involved had diagnoses including schizophrenia, hypertension, and chronic obstructive pulmonary disease. Despite having orders for specific blood tests to be conducted at regular intervals, the facility staff failed to document the completion or results of these tests. Interviews with staff revealed a lack of clear processes and communication regarding the entry and tracking of lab orders, contributing to the oversight. The Director of Nursing (DON) and Licensed Practical Nurse (LPN) interviews highlighted issues with the lab order process, including the entry of orders into the computer system and communication with the lab company. The DON noted that the facility had a new physician who entered their own lab orders without informing her, leading to missed entries in the lab website. The facility's process for managing lab orders was inconsistent, resulting in the failure to perform the necessary diagnostic tests for the resident as ordered.
Failure to Administer Medication Due to Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with chronic kidney disease stage 5, who was prescribed bumetanide, a diuretic medication. The medication was not administered as ordered on multiple occasions due to its unavailability in the facility. Staff documented the absence of the medication on the Medication Administration Record (MAR) but did not document any steps taken to obtain the medication or notify the physician about the missed doses. Interviews revealed that the Certified Medication Technicians (CMTs) were responsible for reordering medications, but there was a lack of clarity and communication regarding the process, leading to the medication not being reordered or obtained in a timely manner. The Director of Nursing (DON) was unaware of the missed doses and stated that if informed, she would have contacted the facility pharmacy to obtain the medication. The facility did not have a policy regarding pharmacy services or obtaining medications, contributing to the oversight. The Administrator expected staff to notify the DON if a medication was unavailable, but this protocol was not followed. The lack of a systematic approach to medication management and communication breakdowns among staff led to the deficiency in pharmaceutical services for the resident.
Failure to Address Pharmacist Recommendations for Medication Review
Penalty
Summary
The facility failed to ensure timely physician response to pharmacist recommendations during the monthly drug regimen review for a resident. The pharmacist recommended discontinuing oxybutynin chloride, an anticholinergic medication not recommended for the elderly due to its side effects, and suggested switching to Gemtesa. However, the physician did not address this recommendation, and there was no documentation of follow-up by the staff in the resident's medical record for several months. The resident, who had multiple diagnoses including cervical disc disorder, heart failure, and chronic pain, experienced a fall with no injury, which was documented in the care plan. Despite the pharmacist's repeated recommendations and the resident's risk for falls due to the medication, the facility did not have a policy in place for the pharmacy medication review and recommendation process, and the Director of Nursing was unaware of the specific recommendation until much later.
Medication Administration Errors Lead to 5.56% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 5.56%. This was due to two specific incidents involving medication administration errors. In the first incident, a Certified Medication Technician (CMT) crushed extended-release potassium chloride tablets for a resident with hypokalemia, despite facility policy and drug warnings indicating that such tablets should not be crushed. The CMT was unaware of a list of medications that should not be crushed, and the Director of Nursing (DON) confirmed that potassium chloride should be administered in liquid or powder form instead. In the second incident, another resident with chronic kidney disease did not receive their prescribed bumetanide medication because it was unavailable from the pharmacy. The CMT administering the medication did not notify the DON about the unavailability, and the DON was unaware of the missed administration. The facility's Administrator expected staff to notify the DON and ensure the medication was obtained for administration.
Failure to Document Resident's Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to maintain a complete medical record for a resident when staff did not document a change in condition and subsequent transfer to the hospital. The resident, who had diagnoses including essential hypertension, edema, and the presence of a cardiac pacemaker, was discharged to the hospital for a medical reason, decreased level of function, and recent decline in activities of living functioning physically. However, the staff did not document this change of condition or the transfer in the resident's progress notes. Interviews with the Care Plan Coordinator, Director of Nursing, and the Administrator confirmed that the nurse should have documented the change in condition and the transfer to the hospital in the progress notes. The facility's policy requires documentation of the reason for any facility-initiated transfer or discharge, but this was not adhered to in this instance, leading to an incomplete medical record for the resident.
Failure to Document and Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to develop and implement policies to ensure that all residents were offered pneumococcal vaccinations, as evidenced by the lack of documentation for two residents. Resident #11, who was admitted with diagnoses including diabetes mellitus, high blood pressure, anemia, and muscle weakness, had a signed consent for the pneumococcal vaccine. However, there was no documentation of the vaccine being administered or any orders for its administration between the due date and the survey date. Similarly, Resident #31, with diagnoses including chronic respiratory failure, type 2 diabetes mellitus, heart failure, high blood pressure, and acute kidney failure, had signed consent for the vaccine, but there was no documentation of administration or orders for the vaccine. Interviews with the Director of Nursing (DON) revealed that although consents were signed, the facility had not administered any pneumococcal vaccines since 2021. The DON, who was also the Infection Preventionist, stated that the facility prioritized flu vaccines and had not yet administered pneumonia vaccines. The DON mentioned that if residents requested the vaccine elsewhere, such as at a VA clinic, they would facilitate this, but there was no documentation to support these actions. The Social Service Director (SSD) indicated that a new vaccine consent form was being used, but there was confusion about its implementation. The SSD mentioned that they filled out the new form and asked residents if they wanted the vaccine, but there was no follow-up documentation. The Administrator expected vaccines to be ordered and provided if requested by residents, but the lack of documentation and follow-through on vaccine administration led to the deficiency.
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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