Nick's Health Care Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Plattsburg, Missouri.
- Location
- 253 East Highway 116, Plattsburg, Missouri 64477
- CMS Provider Number
- 265698
- Inspections on file
- 23
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Nick's Health Care Center, Llc during CMS and state inspections, most recent first.
A resident with a history of mental health disorders and identified risk for aggression physically assaulted another resident with significant physical limitations, causing facial injuries that required hospital treatment. The aggressor had a care plan noting risks for aggression and the need for protective oversight, but was still able to enter another resident's room and inflict harm. Staff and documentation confirmed the incident, and the injured resident reported feeling unable to defend themselves.
Surveyors found that the facility failed to maintain sanitary food service conditions by allowing a persistent fly infestation in the kitchen and dining areas and not repairing damaged kitchen structures. Flies were observed landing on food being prepped and served, with dead flies on floors and fly strips, and a misaligned back kitchen door left a large gap for insects to enter. The wall behind the cook stove was damaged with missing drywall, and flooring at the serving line was peeling and packed with debris, making cleaning difficult. The Dietary Manager knew about the wall and flooring problems but did not report them, and staff described flies as an ongoing issue despite traps and exterminator services. Two residents reported that flies were bothersome during meals, landing on their food and faces, while the Maintenance Director and Administrator acknowledged a fly problem but were unaware of some structural issues.
The facility failed to maintain an effective pest control program as required by its own policy, resulting in persistent flies in resident areas, including the entrance, dining room, hallways, and kitchen. Flies were repeatedly observed landing on residents, their food, and dining surfaces, with residents swatting them away during meals and activities and reporting that the flies constantly bothered them, especially while eating and in their rooms. In the kitchen, an open staff bathroom door and a fly strip completely coated with dead flies, with more flies flying around it, further demonstrated the infestation. The Housekeeping Services Manager and Administrator both acknowledged the fly problem but were unable to identify when pest control services were last provided or how to effectively manage the issue, and the facility could not produce documentation of recent pest control services.
Surveyors found that the facility did not use the required CMS-10055 Advance Beneficiary Notice of Non-Coverage form when discontinuing Medicare Part A benefits for three residents, including individuals with COPD, acute respiratory failure, muscle weakness, Type II diabetes, tremors, and stroke, and a resident receiving skilled nursing/rehab care. Instead, staff used an outdated CMS-R-131 form that did not document the Medicare Part A end date, and interviews with the Social Service Director and the Administrator revealed they were unaware that the incorrect ABN form was being used.
The facility failed to maintain timely and adequate laundry services, resulting in overflowing barrels of soiled linens and clothing, strong urine odors in the hallway outside the laundry near the dining area, and large amounts of clean laundry left unfolded and undelivered. A resident with intact cognition and multiple chronic conditions, who was independent with ADLs, was repeatedly observed in the dining room wearing a hospital gown because no clean personal clothing was available. An LPN reported that most residents lacked clean laundry due to insufficient laundry staffing, and residents in a group interview voiced concerns about delays in the return of their clothing. The facility could not provide a policy outlining laundry duties.
A resident with intact cognition and independent ADLs, who had multiple chronic conditions, requested transfer to another LTC facility to live closer to a special-needs child. Although an initial referral was reportedly sent by social services, there was no documentation in nursing or social service notes or in the care plan reflecting the resident’s wish to transfer, no recorded follow-up, and no documented communication back to the resident. The SSD and Administrator could not provide records of ongoing efforts, beyond a single text and an undated initial referral, while the receiving facility’s admissions nurse reported repeatedly requesting updated nursing notes and stating the original referral had expired after 30 days and needed to be resubmitted. This resulted in months of inaction on the resident’s transfer request and failure to support the resident’s right to self-determination.
A resident with cognitive deficits was injured after being hit by another resident who was frustrated with them going through their belongings. The injured resident was hospitalized with a nasal bone fracture and a shoulder fracture. The facility's policy on abuse prevention was not effectively implemented, leading to the incident.
A resident with a history of aggression struck another resident, causing a bloody lip, after becoming agitated when their path was blocked. Both residents have moderate cognitive impairments and complex medical histories. The facility's investigation noted the incident but determined it was not abuse, despite policies emphasizing the need to report and prevent such occurrences.
The facility served tough roast beef to residents, as confirmed by a test tray and resident council feedback. The Dietary Supervisor acknowledged the issue after tasting the meat, and the DON expected food to be easy to eat and visually appealing.
The facility failed to discard expired food items, improperly stored food in the walk-in refrigerator, and placed boxes on the floor of the walk-in freezer, contrary to its policies. Despite staff training, these deficiencies were observed, indicating a lapse in adherence to food safety standards.
The facility failed to control a fly infestation, affecting all 69 residents. Flies were observed in residents' rooms and at the nurses' station, with staff attempting to swat them away. A resident reported the flies as a significant nuisance, and staff confirmed the issue despite monthly pest control services. The Maintenance Director had not sought additional services to address the problem.
The facility failed to conduct required care plan meetings for two residents with moderate cognitive impairment. One resident did not have documented meetings from January to April, while the other missed a quarterly review after a September assessment. The DON and MDS Coordinator acknowledged these oversights.
The facility failed to timely report abuse allegations for two residents. One resident with moderate cognitive impairment reported inappropriate language from a staff member, and another with severe cognitive impairment reported verbal abuse by a peer. The Administrator delayed reporting these incidents to the state agency, contrary to facility policy requiring immediate notification.
The facility failed to develop comprehensive care plans for two residents, one with type two diabetes mellitus and another with Alzheimer's disease, hypertension, and mixed hyperlipidemia. The first resident's care plan did not address diabetes management, while the second resident lacked a care plan entirely. The MDS Coordinator and DON confirmed these oversights, which did not align with facility policy.
The facility did not adhere to its policy of posting daily nurse staffing information. Observations revealed missing or incorrectly dated staffing sheets over several days. Interviews indicated that the MR staff was responsible for posting but failed to do so consistently, leading to the deficiency.
The facility failed to maintain a clean environment in the main dining room, with dead bugs and cobwebs observed in the windowsill. A resident with intact cognition expressed concerns about the dining room's cleanliness. Interviews revealed confusion among staff about cleaning responsibilities, with the dietary department identified as responsible for the dining room. The DON and Administrator acknowledged the unsanitary conditions.
A facility failed to complete a PASARR for a resident who received new mental health diagnoses, contrary to its policy. The resident, admitted with major depressive disorder and anxiety disorder, was later diagnosed with PTSD and impulse disorder. Staff interviews revealed a lack of awareness about the need for a new PASARR, with the MDS Coordinator acknowledging the oversight and the DON mistakenly believing the diagnosis was pre-existing.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Hospitalization
Penalty
Summary
A deficiency occurred when a resident with a history of schizophrenia, antisocial personality disorder, intermittent explosive disorder, and other mental health conditions physically assaulted another resident, resulting in significant facial injuries that required hospitalization. The aggressor resident was known to have mild cognitive impairment and a care plan that identified risks for physical or verbal aggression, delusions, hallucinations, and irritability. The care plan also noted the need for staff to be aware of the resident's body language and to provide protective oversight while maintaining the least restrictive environment. Despite these identified risks, the resident was able to enter another resident's room and inflict harm. The assaulted resident had intact cognition but significant physical limitations, including a left leg above-the-knee amputation and diagnoses such as Parkinson's disease, osteomyelitis, and HIV. This resident required substantial assistance with activities of daily living and was unable to defend themselves during the incident. The attack resulted in lacerations and facial fractures, as documented by both facility and hospital records. The injured resident reported feeling scared and unable to defend themselves due to physical weakness. Staff documentation and interviews confirmed that the aggressor resident self-reported the incident to staff, who then found the injured resident with facial wounds and bleeding. Prior to the incident, there had been no reported issues between the two residents, and staff had not observed any prior aggressive behavior from the aggressor. The facility's policies required identification and intervention in situations where abuse was likely, as well as protective oversight for residents at risk of aggressive behavior. However, the incident demonstrated a failure to prevent resident-to-resident abuse, resulting in harm.
Uncontrolled Fly Infestation and Poor Kitchen Maintenance Affecting Food Sanitation
Penalty
Summary
Surveyors identified a deficiency in sanitary food service conditions when the facility failed to control a persistent fly problem in the kitchen and dining areas and did not maintain kitchen surfaces, flooring, and doors in good repair. Observations showed flies in the kitchen landing on peaches in bowls and on salads being prepped, as well as clusters of flies on all surfaces and on food being prepared and served. Dead flies were seen on the floors by all prep areas and on a fly sticky strip hanging in the kitchen bathroom with the door open. The wall behind the cook stove had a section of the corner pushed in with missing drywall, and the kitchen flooring at the serving line was peeling away from the floor, with caked-on debris lodged between the laminate and the concrete, creating an area that could not be adequately cleaned. The back delivery door to the kitchen was lopsided in the frame, leaving a 1.5–2 inch gap that allowed flies and insects to enter the kitchen. The Dietary Manager reported being aware for about a week that the wall behind the stove was falling in but had not reported it to maintenance, and also knew the flooring by the serving line had been steadily coming up and was hard to keep clean, yet had not reported the floor issues. The Dietary Manager stated the exit door did not fit correctly, believed this was the main reason for the fly problem, and acknowledged the issue had been reported to maintenance at some point but had not submitted a new work order. A staff member stated flies were always a problem in the kitchen and that they were constantly swatting flies off food and prep areas, describing the fly problem as ongoing despite fly traps and exterminator involvement. Two residents reported that flies while eating were “ridiculous,” annoying, and that they did not like flies landing on their food or touching their faces while they tried to eat. The Maintenance Director, who had started two weeks prior, was unaware of the wall, floor, or door issues but acknowledged a fly problem, especially in the kitchen and dining room. The Administrator was aware of the fly problem and the misaligned kitchen door but was unaware of the wall and flooring issues, and stated residents have the right to live in a home without flies continually landing on them and their food.
Failure to Maintain Effective Pest Control Resulting in Persistent Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its Pest Control Program policy dated 5/14/24, which states the facility will eradicate common household pests such as flies. Surveyors observed flies throughout resident areas, including the main entrance, dining room, hallways, and on residents themselves during meals, cares, and activities. Flies were seen landing on residents’ food during the noon meal, on dining tables, and on residents’ faces and hands, with residents repeatedly swatting them away while trying to eat and drink. In the kitchen, a staff bathroom door was left open, and a sticky fly strip hanging from the ceiling was completely coated with dead flies, with additional flies flying around it. The facility was unable to provide documentation of the last pest control services performed. Residents reported that flies were a persistent problem, especially during meals and in their rooms, with one resident stating that flies were always bothering them and another stating that the flies “drive me crazy” when trying to eat. The Housekeeping Services Manager stated that the facility previously had a pest control company that came monthly but was unsure when they last serviced the building, did not know how to manage the fly problem, and did not know where to find pest control information. The Administrator acknowledged awareness of the fly problem and stated that pest control comes monthly but was unsure when the company last provided service for flies, noting the issue is worse in the summer months. The facility’s inability to verify current pest control services and the ongoing presence of flies on residents and their food demonstrate a failure to implement and maintain an effective pest control program as outlined in facility policy.
Failure to Use Correct ABN Form for Medicare Part A Discontinuation
Penalty
Summary
The facility failed to properly notify residents of changes in Medicare Part A coverage by not using the correct Advance Beneficiary Notice of Non-Coverage (ABN) form and by omitting required information. Facility policy, last revised on 11/05/24, stated that residents are to be informed in advance when changes occur to their bills and that CMS form 10055 would be provided prior to discharge from Medicare Part A. Record review showed that one resident admitted to Medicare Part A with COPD, acute respiratory failure, muscle weakness, and Type II diabetes was discharged from Medicare Part A on 05/07/25; another resident admitted for skilled nursing and/or rehabilitation care was discharged from Medicare Part A on 07/13/25; and a third resident admitted with COPD, tremors, and stroke was discharged from Medicare Part A on 08/28/25. Instead of using the required CMS-10055 ABN form, the facility used an outdated ABN form titled CMS-R-131 for all three residents. The outdated form did not include the date that Medicare Part A coverage would be ending for these residents, and review of the medical records confirmed that the current CMS-10055 ABN form was not present for any of them. During interviews, the Social Service Director stated she was unaware she was using the incorrect CMS form to notify residents about the discontinuance of Medicare Part A benefits and that CMS-10055 should have been used, and the Administrator stated he was unaware the correct ABN form was not being utilized.
Failure to Maintain Timely, Adequate Laundry Services and Homelike Environment
Penalty
Summary
The facility failed to honor residents’ right to a safe, clean, comfortable, and homelike environment by not providing adequate laundry services and by allowing strong urine odors to persist near the dining area. Surveyor observations on multiple days showed the laundry room, located off the hallway leading to the dining room, had a strong urine odor in the hallway and inside the room. Large barrels were overflowing with dirty linen and clothing, including soiled wet items, and both washing machines were full. Clean clothes were stacked approximately three feet high, waiting to be folded, hung, and sorted, and at times no laundry staff were present in the laundry room. The facility was unable to provide a policy regarding laundry duties. One resident, identified as Resident #49, had an intact cognition per a recent Quarterly MDS and diagnoses including schizoaffective disorder, COPD, and diabetes, and was independent with ADLs. This resident was observed in the main dining room on more than one occasion wearing a hospital gown with pants because there were no clean personal clothes available. An LPN stated that the resident did not have any clean personal clothing and had to wear a facility gown until clothes were cleaned, and further reported that the facility failed to maintain clean laundry for most residents due to lack of help in the laundry room. The resident reported hating wearing hospital gowns, preferring personal clothes, and stated this situation happened often and made the resident reluctant to leave the room without personal clothing. In a group interview, residents voiced concerns about delays in having their laundry returned.
Failure to Honor Resident’s Request to Transfer Closer to Family
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to self-determination and choice regarding transfer to another LTC facility closer to the resident’s family. The resident, who had intact cognition, was independent in ADLs, and had diagnoses including insulin-dependent diabetes, kidney disease, cervical cancer, and heart disease, had lived in the facility for three years and requested to move to a neighboring facility to be closer to a special-needs child living in a group home. The resident reported having made this request months earlier to social services and administrative staff, stating that no one had followed up and expressing emotional distress, saying that their rights had been violated. Record review from June through October showed no nursing or social service documentation of the resident’s wish to discharge to another LTC facility, no follow-up on the request, and no communication to the resident about the status of the transfer. The care plan contained no documentation of the resident’s desire to move closer to the child. The Social Services Director stated that an initial admission referral had been sent in May to the requested facility but could not locate documentation of the request, referral, follow-up, or timeline, and acknowledged that the referral had not been followed up, documented, or communicated to the resident. The Administrator was aware of the request and had only a single text message to the neighboring facility asking about referral status, with no further documentation of active work on the referral. The admissions nurse at the neighboring facility reported that updated nursing notes had been requested more than once, that referrals expired after 30 days, and that they were still waiting on an updated referral, with the original referral having been sent four months earlier.
Resident Assault and Injury Due to Inadequate Protection
Penalty
Summary
The facility failed to protect a resident from abuse when another resident hit them in the face, causing bodily injury. The incident involved two residents, one with significant cognitive deficits and a history of rummaging and taking items, and the other with moderate cognitive loss and no previous aggressive behaviors. The altercation occurred after the second resident became frustrated with the first resident going through their belongings, leading to the physical assault. The injured resident was found on the floor with a bloody nose and complained of shoulder pain. They were sent to the hospital for evaluation, where they were diagnosed with a non-displaced fracture of the humeral head and neck and a right nasal bone fracture. The resident's medical records indicated a history of behaviors not directed at others, such as rummaging and pacing, and rejection of care. The facility's policy on abuse and neglect emphasizes the prevention of abuse by identifying residents with increased vulnerability and providing interventions. However, the policy was not effectively implemented in this case, as the staff did not anticipate the conflict between the two residents. The incident was reported immediately to the Administrator and Director of Nursing, and the residents were separated following the event.
Resident-to-Resident Altercation Results in Injury
Penalty
Summary
The facility failed to protect a resident from abuse when one resident struck another in the face, resulting in a bloody lip. The incident involved two residents with moderate cognitive impairments and complex medical histories, including conditions such as Alzheimer's Disease, dementia, and schizophrenia for the aggressor, and cerebral palsy and quadriplegia for the victim. The aggressor, who has a history of potential verbal and physical aggression, became agitated when the victim, in a wheelchair, blocked their path to the bathroom. This led to the aggressor striking the victim in the face. The facility's investigation noted that the victim reported the incident to staff, who observed a small amount of blood on the victim's lip and an abrasion on the aggressor's hand. Both residents were separated, and physical assessments were conducted. The facility's policy on abuse and neglect emphasizes the need to report all allegations of abuse immediately and to identify residents with increased vulnerability for abuse. Despite these policies, the facility determined that the event was not a result of abuse, and the Director of Nursing and Administrator stated that the incident could not have been prevented by staff.
Tough Roast Beef Served to Residents
Penalty
Summary
The facility failed to ensure that the roast beef served for lunch was palatable and easy to eat for five residents who attended a resident council meeting. On the specified date, the planned menu included roast beef, mashed potatoes, mixed vegetables, and a mud cake. A test tray received by the surveyor contained the same meal, and it was noted that the roast beef was seasoned but tough and hard to cut. During the resident council meeting, five residents reported that the meat was tough. The Dietary Supervisor confirmed the residents' complaints after tasting the roast beef herself and acknowledged its toughness. The Director of Nursing expressed an expectation that the dietary staff should provide food that is visually appealing and easy for residents to eat, indicating that the food should not be tough.
Deficiencies in Food Storage and Handling
Penalty
Summary
The facility failed to adhere to its policy on food storage and handling, which led to several deficiencies observed by the surveyor. During an inspection of the dry goods storage area, expired food items were found, including two packs of bread and a gallon bottle of hot sauce. Additionally, an unsealed five-pound box of pancake mix was noted. In the walk-in refrigerator, food items such as tuna salad and shredded cheese were past their use-by dates, and a five-pound bag of brown iceberg lettuce was improperly stored. Furthermore, in the walk-in freezer, five boxes of tater tots were found stored directly on the floor, contrary to the facility's policy that requires food to be stored off the floor and away from walls. Interviews with the Dietary Supervisor, Director of Nursing, and the Administrator revealed that the kitchen staff had been trained to discard expired food items, ensure all items were sealed, and avoid storing items on the floor. Despite this training, the deficiencies were still present, indicating a lapse in following the established procedures. The Director of Nursing and the Administrator both expressed their expectations that the kitchen staff should serve food that is fresh and safe to eat, highlighting a disconnect between the facility's policies and the actual practices observed during the survey.
Failure to Control Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program for the prevention and control of flies, which had the potential to affect all 69 residents. Observations revealed flies in residents' rooms and at the nurses' station, with staff attempting to swat them away. A resident with intact cognition reported that flies were a significant nuisance, crawling on them while they tried to rest, and expressed that the facility had not taken any measures to control or eliminate the flies. Interviews with staff, including an LPN and a housekeeper, confirmed the presence of a fly problem, despite the facility having a contract with a pest control company for routine services. The pest control representative confirmed that the facility received basic fly insect service monthly, but additional services were available if requested. The Maintenance Director acknowledged the presence of flies and stated that the pest control company only placed fly traps on the walls. Despite the monthly pest control visits, the Maintenance Director had not discussed any additional services to address the fly issue. The Director of Nursing and the Administrator were aware of resident complaints about the flies, but no effective action had been taken to resolve the problem.
Failure to Conduct Required Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings for two residents, as required by their policy. Resident #15, who was admitted in 2018 and has a medical history including spinal stenosis and moderate cognitive impairment, did not have care plan meetings documented from January to April 2024. The Director of Nursing and the MDS Coordinator confirmed that only one care plan meeting was held in July 2024, despite the requirement for quarterly meetings. Similarly, Resident #56, admitted in 2022 with diagnoses of adjustment disorder and moderate cognitive impairment, did not have a care plan review after the quarterly MDS assessment in September 2024. The resident's care plan was last revised in December 2023, and there was no evidence of a care plan meeting for 2024. Both the MDS Coordinator and the Director of Nursing acknowledged the oversight, and the Administrator confirmed that care plan meetings should occur quarterly.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to timely report allegations of abuse to the state agency for two residents. Resident #19, who has a medical history including schizoaffective disorder and moderate cognitive impairment, reported to a surveyor that a Certified Medication Technician used inappropriate language when instructing them to take their medications. This allegation was reported to the Administrator by the surveyor, but the Administrator did not report it to the state agency, mistakenly believing that the presence of the survey team negated the need for immediate reporting. The Director of Nursing later confirmed that such allegations should be reported immediately, but no later than two hours after notification. Resident #21, with severe cognitive impairment and a history of antisocial personality disorder, reported feeling verbally abused by another resident. This allegation was also reported to the Administrator by a surveyor. However, the Administrator delayed reporting the incident to the state agency, citing previous experiences where in-person reports were made during surveyor visits. The report was eventually made two days later. These actions were contrary to the facility's policy, which mandates immediate reporting of abuse allegations to the appropriate agencies.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. Resident #57, who was admitted with a diagnosis of type two diabetes mellitus, did not have this condition addressed in their comprehensive care plan. Despite having a moderate cognitive impairment and receiving insulin, the care plan lacked measurable goals and interventions related to diabetes management. This oversight was confirmed by the MDS Coordinator, who acknowledged the importance of including diabetes in the care plan to guide staff in monitoring the resident's condition. Resident #66, admitted with Alzheimer's disease, hypertension, and mixed hyperlipidemia, did not have a comprehensive care plan developed at all. The MDS Coordinator and the Director of Nursing both confirmed that a care plan should have been completed within seven days of the MDS assessment reference date. The absence of a care plan for Resident #66 was not in line with the facility's policy, as confirmed by the Administrator, who stated that the MDS Coordinator was responsible for completing care plans.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily, as required by their policy. The policy, last revised on June 26, 2024, mandates that the Nurse Staffing Sheet be posted at the beginning of each shift, containing specific information such as the facility name, current date, resident census, and the total number and actual hours worked by different categories of nursing staff. However, during observations on October 7 and 8, 2024, the nurse staffing sheet was not found, and on October 9, 2024, the sheet was dated incorrectly. Interviews revealed that the medical records (MR) staff person was responsible for posting the nurse staffing sheet daily but admitted to not posting it on October 7, 2024, and posting the wrong sheet on October 8, 2024. The Director of Nursing expected the MR staff or social services to handle the posting, while the Administrator acknowledged that the posting was inconsistent. This lack of adherence to the policy resulted in the deficiency noted during the survey.
Failure to Maintain Cleanliness in Dining Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the main dining room, as evidenced by the presence of dead bugs and cobwebs in the windowsill. This deficiency was observed during multiple inspections, and a resident with intact cognition expressed concerns about the cleanliness of the dining room. The facility's policy on environmental cleaning aims to minimize exposure to potentially infectious microorganisms, yet the dining room's condition did not align with this policy. Interviews with staff revealed a lack of clarity regarding cleaning responsibilities. A CNA mentioned that housekeeping services were not available daily, while a housekeeper stated that the dietary department was responsible for cleaning the dining room. The Dietary Supervisor confirmed this responsibility but was unsure about who should clean specific areas like window blinds and walls. The Director of Nursing and the Administrator both acknowledged the unsanitary conditions, with the Administrator noting similar issues in the lobby.
Failure to Complete PASARR for New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a preadmission screening and resident review (PASARR) was completed for a resident who received new mental illness diagnoses. The facility's PASARR policy, last revised in July 2021, mandates the use of PASARR assessments to develop a care plan that reflects continuity from the resident's previous history of behaviors and placement. However, the medical record of the resident, who was admitted in January 2024 with a history of major depressive disorder and anxiety disorder, showed no evidence of a PASARR being completed after the resident was diagnosed with post-traumatic stress disorder and impulse disorder in April 2024. Interviews with facility staff revealed a lack of awareness and action regarding the need for a new PASARR following the resident's updated mental health diagnoses. The MDS Coordinator acknowledged that a new PASARR should have been completed, while the Director of Nursing mistakenly believed the mental illness diagnosis was pre-existing. This oversight indicates a failure to adhere to the facility's policy and ensure appropriate assessments were conducted in response to changes in the resident's mental health status.
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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