Odessa Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Odessa, Missouri.
- Location
- 609 Golf Street, Odessa, Missouri 64076
- CMS Provider Number
- 265501
- Inspections on file
- 15
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Odessa Health Care Center during CMS and state inspections, most recent first.
The facility failed to provide sufficient nursing staff to meet residents’ daily care needs, resulting in repeated reports of slow call light response, unmade beds, unchanged linens, and residents not receiving their scheduled twice-weekly baths. Over several months, resident council minutes documented ongoing concerns about inadequate staffing and missed showers. A cognitively intact resident and another resident with moderate cognitive impairment, both requiring substantial assistance with bathing, each reported receiving only one bath per week and experiencing delayed call light response, especially on night shift. Staff, including CNAs, a CMT, and the Activity Director, consistently described chronic short staffing, a single bath aide assigned up to 20 showers per day, frequent pulling of the bath aide and other staff to cover basic care tasks, and the need to work early or stay late to complete duties, demonstrating that staffing levels and deployment were insufficient to carry out residents’ care plans.
A resident on hospice with anxiety, personality disorder, severe protein-calorie malnutrition, and multiple psychotropic and PRN lorazepam orders had pharmacist GDR and monthly MRR recommendations documented on pharmacy review forms, including a suggested lorazepam dose reduction and instructions to comply with CMS 14‑day limits for PRN antipsychotic-related orders. The pharmacy forms contained designated areas for the physician to indicate agreement, disagreement, or clinical contraindications to GDR and to discontinue or renew PRN orders per CMS requirements, but all physician response sections were left blank. Nursing notes and physician progress notes contained no evidence that the physician reviewed or responded to these recommendations, and the DON acknowledged that pharmacy DRR/GDR recommendations were not followed up by staff to obtain a physician response, resulting in noncompliance with the facility’s pharmacy services policy and federal requirements.
A hospice resident with multiple chronic conditions, significant ADL dependence, and later bedbound status did not receive the required twice-weekly baths from facility staff as outlined in the facility’s Shower Expectations procedure, which called for two baths from facility staff in addition to two from hospice for a total of four per week. The resident’s care plan did not address bathing needs or resistance, and bath sheets over several months showed refusals and missing documentation, with all documented baths in later weeks provided only by hospice aides. Observations found the resident comfortable and without odor, while interviews with the bath aide, a CNA, and the DON confirmed that hospice residents were expected to receive four baths weekly and that facility staff were not completing their portion due to workload and staffing practices.
The facility did not maintain adequate staffing levels, resulting in residents with complex medical needs experiencing long waits for assistance, missed hygiene care, delayed medications, and late meals. Staff, including CNAs and CMTs, reported being frequently overwhelmed and unable to meet all resident needs, while non-certified personnel were directed to perform care tasks without proper training.
Facility staff did not ensure RN coverage for at least eight consecutive hours per day, seven days a week, and failed to designate a full-time DON for several weeks. Staff interviews and review of time records confirmed the absence of RN coverage, and the Administrator could not provide documentation to verify compliance with staffing requirements.
The facility did not ensure full-time administrative oversight or required RN coverage, as the Administrator frequently acted as charge nurse due to the absence of a DON or RN for several weeks. Staff confirmed the lack of RN presence, and the Administrator could not provide documentation of RN coverage or dedicated administrative hours, potentially affecting all residents.
Three residents requiring assistance with ADLs did not consistently receive scheduled showers or baths, as documented in their care plans and facility records. Residents reported feeling unclean, experiencing body odor, and developing hygiene-related rashes, while staff and the administrator confirmed that chronic short staffing led to missed bathing opportunities and unresolved resident complaints.
Three cognitively intact residents reported receiving cold and unappetizing food, with observations confirming that meals were served at suboptimal temperatures. Staff interviews revealed that short staffing, lack of heated carts and plate covers, and delays in meal delivery contributed to the issue, with some meals prepared hours in advance and not kept warm.
Uncertified staff, including an Environmental Services worker and a dietary aide, were assigned to provide direct ADL care such as transfers, perineal care, and feeding to residents, despite lacking required certification or nurse aide training. This occurred during a shift when no certified nurse aides were present, and the Administrator confirmed noncertified staff were mandated to work to meet fire code requirements, though was unaware they were providing hands-on care.
The facility did not maintain the required minimum of three staff members on the night shift for a census of 54 residents, with only an LPN and a CNA present for several hours on consecutive nights. Staff interviews and schedule reviews confirmed the shortfall, which affected all residents and failed to meet both care and fire safety requirements.
The facility did not ensure RN coverage for at least eight hours daily and lacked a full-time onsite DON for several days, as confirmed by staffing records, staff interviews, and leadership statements. During this period, only LPNs and CNAs were present, and staff were uncertain about how to reach regional nursing support.
The facility did not post required daily nurse staffing information, including staff names, roles, hours worked, and resident census, in areas accessible to residents and visitors. Observations showed that only LPN names were listed, with no RN or DON, and no details on shift hours or census. Staff interviews confirmed that the daily staffing sheet had not been posted for weeks, and the facility could not provide recent staffing documentation or a staffing posting policy.
A CNA cultivated a relationship with a resident diagnosed with mood and affective disorders and solicited a $150 loan under the pretense of needing court cost assistance. The resident, who was cognitively intact, provided the funds but was not repaid and was unable to reach the CNA afterward. The incident was reported by the Activities Director after the resident expressed concern, and an investigation confirmed the misappropriation of the resident's money.
A resident experienced a choking incident requiring the Heimlich Maneuver, followed by new physician orders for a chest x-ray and medication changes. The responsible party was not notified of the incident or subsequent medical interventions, and staff interviews confirmed that required notifications were not completed.
The facility did not have a Registered Nurse (RN) on duty for eight hours per day, seven days a week, as required. Staffing schedules showed a lack of RN coverage on several weekends, confirmed by interviews with staff. The Director of Nursing (DON) admitted that two weekends per month lacked RN presence, affecting the care of 49 residents.
The facility failed to maintain food safety standards, as observed during a survey. A metal pan with residue, lack of a thermometer in the walk-in freezer, and chipped plate warmer covers were noted. These issues persisted during a follow-up inspection. The Dietary Manager acknowledged the need for clean food, thermometers in all cooling units, and replacement of damaged items.
The facility administration failed to manage financial obligations, resulting in unpaid debts to vendors, including utility and fire safety services. This led to potential risks for residents and staff, as essential services and supplies were jeopardized. The administrator was aware of some overdue balances but was unsure of amounts. The facility faced issues with supply orders and service disruptions due to nonpayment, including manual detergent dispensing and temporary cessation of lab services.
The facility failed to establish a comprehensive infection prevention and control program, including deficiencies in preventing Legionella and other pathogens. TB screening policies were not followed for residents and new employees, with inconsistencies in administering and reading TB skin tests. Infection control practices were not consistently followed during medication administration and wound care, with staff failing to cleanse hands and use barriers. The facility also lacked education and implementation of Enhanced Barrier Precautions (EBP).
The facility did not conduct required NA Registry checks for four new employees, missing potential Federal Indicators for abuse, neglect, or misappropriation. The Administrator was unaware of the oversight, as they were not in the position when the checks should have been completed.
The facility failed to maintain sanitary oxygen equipment for three residents, leading to deficiencies in respiratory care. A resident with a stroke was observed without oxygen during breakfast, with undated tubing and humidifier. Another resident with respiratory failure had undated equipment, and a third resident with pulmonary disease had an empty humidifier. Staff interviews revealed non-compliance with protocols for maintaining oxygen equipment, and the facility lacked an Oxygen Policy.
The facility failed to respond to the pharmacist's monthly medication regimen review for three residents, resulting in deficiencies in medication management. A resident had multiple recommendations from the pharmacist regarding cholesterol medication, missing labs, and dose reductions, but no responses were documented. Another resident's care plan lacked documentation of specific psychotropic medications, and a pharmacist's recommendation to review a Lorazepam order was not addressed. A third resident had an unclear Voltaren Gel order and was not evaluated by psychiatric services as ordered. The DON and ADON acknowledged the failure to ensure MRRs were completed and addressed.
A resident was left to self-administer medications without proper assessment or physician's order, and medication carts were found unlocked when not in use. The resident, with diagnoses including dementia and hypertension, was observed with pills on their overbed table without staff supervision. Additionally, a medication cart containing insulin was left unlocked, with residents nearby and no nurse present. Interviews confirmed that medication carts should be locked when not in use.
The facility inaccurately completed the MDS for two residents, reporting nonexistent wound infections and pressure ulcers. Staff interviews and record reviews confirmed these errors, with the MDS Coordinator acknowledging coding mistakes and a lack of direct communication with care staff.
A facility failed to complete, submit, and retain a PASRR for a resident with mental health diagnoses, including dementia and bipolar disorder, upon admission. The SSD, responsible for PASRRs, was unaware of the unavailability of records online after a year. The DON confirmed that PASRRs should be completed before admission.
The facility failed to provide two residents with baseline care plans within 48 hours of admission, as required by policy. One resident, who was cognitively intact, did not recall receiving a care plan, while another resident with cognitive impairments also did not receive one. The ADON admitted to not providing the care plans and was unclear about the responsibility, while the DON confirmed the ADON's role in this task.
A resident on hospice care with dementia and heart failure did not have a comprehensive care plan. The care plan lacked details on the resident's pressure ulcer and dementia, despite existing wound care orders. Staff interviews revealed that care plans were incomplete and behind schedule, with the ADON and social services responsible for updates.
A facility failed to follow physician's orders for a resident's blood pressure medication, administering it despite readings below specified parameters. Additionally, the facility did not obtain necessary physician's orders for another resident's colostomy care, despite the resident's recent surgery and need for specific care instructions. These deficiencies were confirmed through staff interviews and medical record reviews.
A resident was discharged to a group home without proper documentation and communication of their care needs. The facility failed to provide a recapitulation of stay, medication reconciliation, and details of the continuing care provider. Interviews with staff revealed oversights in notifying the Ombudsman and documenting follow-up care, medications, and belongings. The discharge summary was delayed, and the facility lacked a discharge policy, leading to a deficiency in ensuring a safe transition.
A resident with chronic venous hypertension and CHF experienced significant weight gain and edema due to the facility's failure to consistently apply a lymphedema compression device and monitor their condition. Despite physician notes and resident reports of inconsistent device use, the facility did not ensure proper intervention or documentation, leading to a deficiency in care.
A facility failed to provide necessary addiction recovery and psychological services for a resident needing to participate in a recovery program for a liver transplant. The resident, with a history of alcoholic cirrhosis, anxiety, and depression, was unable to attend suitable AA meetings due to the religious nature of the available option. The facility did not follow up to find alternative meetings and failed to ensure the resident received psychological services, despite physician orders. This resulted in the resident's inability to comply with liver transplant program requirements.
A facility failed to monitor antipsychotic drugs and ensure PRN psychotropic orders did not extend beyond 14 days without physician rationale for a resident with dementia, depression, and anxiety. The care plan lacked specific medication details, and behavior monitoring was incomplete. Staff interviews revealed a lack of awareness and completion of necessary monitoring tasks.
A resident with diabetes received Novolog insulin despite blood glucose levels being below the physician-ordered threshold. The facility's MAR and TAR showed multiple instances of this error. Interviews with an LPN and the DON confirmed that the nursing staff did not follow the physician's orders, and the facility lacked a policy addressing this issue.
Insufficient Nursing Staff Leading to Missed Baths and Delayed Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs, particularly related to timely response to call lights and provision of scheduled baths/showers. The facility’s own Sufficient Staff Policy requires adequate numbers of licensed nurses and CNAs on a 24-hour basis, consideration of census and acuity, and ensuring staff have the competencies to carry out resident care plans. Resident council minutes over three consecutive months documented repeated resident reports that there were not enough workers, call lights were not answered promptly, beds were not being made, linens were not being changed without reminders, and residents were not receiving two showers per week as expected. One cognitively intact resident required substantial/maximal assistance with bathing and dressing and reported that staff were slow to answer call lights at all times of day and that only one bath per week was being provided instead of the two baths ordered. Another resident with moderate cognitive impairment, who required substantial/maximal assistance with bathing and supervision or touching assistance for dressing, similarly reported that night shift staff were slow to answer call lights and that only one weekly bath was being received instead of the expected two. The DON confirmed that these residents should have received two baths/showers per week and that call lights were to be answered within 10 minutes, but the residents’ statements and council minutes showed these expectations were not being met. Multiple staff interviews further demonstrated that staffing levels and assignments were insufficient to consistently complete required care. The designated bath aide reported being the only person assigned to baths/showers, with responsibility for about 20 showers per day for a 60-resident census, and stated that residents sometimes did not receive baths if the aide was pulled to help with feeding, transfers, or if residents had appointments. CNAs and a CMT reported that the facility was short staffed on all shifts, that they were unable to complete all assigned work without coming in early or staying late, and that when the bath aide was absent, floor CNAs were expected to cover baths in addition to regular duties. Staff also described delays in obtaining assistance for mechanical lift transfers and the Activity Director reported being pulled from scheduled activities to assist with direct care tasks, resulting in missed activities. These observations and interviews collectively show that the facility did not maintain sufficient nursing staff to ensure residents consistently received timely call light response and two baths per week as care-planned.
Lack of Physician Response to Pharmacist GDR and MRR Recommendations for Psychotropic/PRN Antipsychotic Use
Penalty
Summary
Surveyors identified a failure to ensure physician response to a pharmacist’s Gradual Dose Reduction (GDR) and Medication/Drug Regimen Review (MRR/DRR) recommendations for a resident receiving multiple psychotropic and PRN antipsychotic-related medications. The facility’s Pharmacy Services policy required pharmaceutical services that meet each resident’s needs and comply with state and federal requirements, including pharmacist collaboration and guidance on medication issues. Despite this, the pharmacist’s documented recommendations and regulatory reminders were not followed up with documented physician review or response as required by facility procedures. The resident involved was admitted with anxiety, a personality disorder, and hospice care for severe protein-calorie malnutrition, and had multiple psychotropic and related medications ordered, including lorazepam (scheduled and PRN), olanzapine, quetiapine, and escitalopram. A pharmacy review note dated 12/18/25 documented that the resident was receiving several psychotropic medications due for review and included a specific GDR recommendation to decrease lorazepam, along with multiple sections for the physician to indicate whether a GDR was clinically contraindicated or whether target symptoms had returned or worsened. All physician response sections on this form were left blank, and there was no documentation in nursing notes or physician progress notes indicating that the physician had reviewed or agreed/disagreed with the pharmacist’s GDR recommendations. A subsequent pharmacy review note dated 1/21/26 documented that the resident had been recently started on PRN lorazepam orders and that this was a second attempt to reduce the PRN medication. The pharmacist cited CMS regulation 483.45(e)(5) regarding the 14-day maximum duration for PRN antipsychotic orders and requested discontinuation of the current PRN antipsychotic-related orders unless specific evaluation and documentation requirements were met. The form again contained blank lines for the physician to discontinue the PRN medication or otherwise comply with CMS guidelines, but there was no documentation in the resident’s nursing notes or physician progress notes that the physician reviewed or responded to these recommendations. The physician’s monthly progress note for the resident contained no medication changes and no indication that the pharmacy recommendations or GDR had been reviewed. During interviews, the DON acknowledged responsibility for oversight of the pharmacy monthly review and confirmed that pharmacy DRR and GDR recommendations had not been followed up by nursing staff to obtain a physician response, and that the facility did not have a physician’s response documented for the resident’s GDR recommendations.
Failure to Provide Required Twice-Weekly Facility Baths for Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a hospice resident received the required number of baths per the facility’s own Shower Expectations procedure. That procedure required that residents on hospice be offered two showers per week from facility staff in addition to two baths from hospice staff, for a total of four baths weekly. The procedure also required that bed baths be limited and approved, that all shower declines be immediately reported to the charge nurse and, if ongoing, to the DON or Administrator, and that all showers and refusals be documented and signed on shower sheets. For the sampled hospice resident, the care plan did not address the resident’s bathing capabilities, level of assistance needed for bathing, or any resistance to bathing, despite documenting extensive assistance needs for other ADLs. The resident had multiple diagnoses including heart failure, hypertension, diabetes, hyperlipidemia, GERD, arthritis, stroke, traumatic brain injury, anxiety, and depression, and was alert with minimal cognitive impairment. The MDS showed the resident required maximum assistance with bathing, dressing, toileting, hygiene, and transfers, used a wheelchair, and was receiving hospice care. Later hospice documentation indicated the resident became bedbound, required at least 40% assistance with ADLs, no longer got out of bed, used a full-body mechanical lift, had increased confusion, poor appetite, and required oxygen. Hospice notes stated that the hospice bath aide visited daily to complete care, bathing, and feeding/drinking assistance. Review of bath sheets showed that in November one bath was refused and another scheduled bath had no documentation of being offered or given. In December, one bath was refused and multiple baths were documented as completed by hospice staff, with no evidence that facility staff provided their required baths. In January, all documented baths were completed by the hospice aide, with no documentation that facility nursing staff or the bath aide provided any baths, and the resident did not receive the minimum number of baths required by facility policy. Observations on two separate days showed the resident in bed, dressed appropriately, on oxygen, resting comfortably, and without odor. Interviews with the bath aide, a CNA, and the DON confirmed that hospice residents were expected to receive four baths weekly (two from hospice and two from facility staff), that the bath aide prioritized non-hospice residents due to workload, that CNAs and nursing staff were supposed to assist with baths when the bath aide could not complete them, and that the baths facility staff were supposed to provide to hospice residents were not being completed.
Failure to Maintain Sufficient Staffing to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient staffing on a 24-hour basis to meet the basic needs and ensure the safety of all residents, as evidenced by staff schedules, time punches, and multiple interviews. On several nights, staffing levels fell below the facility's own minimum requirements, with as few as one or two staff members present for 56 residents during overnight shifts. There were instances where only non-certified staff or a single CNA was present, and on some nights, the only staff in the building were not certified to provide direct resident care. The written schedules often did not match the actual staff present, and non-certified staff were instructed to perform resident care tasks for which they had not been trained. Residents with significant care needs, including those with Parkinson's Disease, a history of falls, rheumatoid arthritis, spinal stenosis, and cognitive communication deficits, reported long waits for call lights to be answered, missed or delayed baths, and delays in receiving medications and meals. Residents described waiting 30-45 minutes or longer for assistance, not receiving regular hygiene care, and experiencing late or cold meals due to insufficient staff to distribute trays. Staff interviews corroborated these accounts, with CNAs and CMTs reporting that they were frequently the only caregivers on the floor, leading to delays in care, missed medications, and residents not being laid down or changed in a timely manner. Non-certified staff, including housekeepers and environmental services personnel, were directed to assist with resident care tasks such as transferring and feeding residents, despite lacking proper training or certification. Staff described being overwhelmed, unable to complete all required tasks, and sometimes having to perform two-person transfers alone. Observations confirmed that many residents remained in bed past scheduled times for breakfast, and soiled linens were noted by laundry staff. The administrator acknowledged the staffing shortages and stated that he or she had to cover shifts as a charge nurse and come in at night when no nurse was available.
Failure to Provide Required RN Coverage and Designate Full-Time DON
Penalty
Summary
Facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, and did not designate a Director of Nursing (DON) on a full-time basis, as required by facility policy and federal regulations. Review of facility records, including the Facility Assessment Tool and daily punch records, showed that the facility had been without RN coverage for approximately three weeks prior to the new DON starting. Multiple staff interviews confirmed the absence of RN coverage during this period, with both LPN and CNA staff stating they had not observed an RN in the building. The Administrator was unable to provide proof of RN coverage and acknowledged that the previous DON had left some time ago, with the new DON only starting recently. Payroll and time records further substantiated the lack of RN presence, with no RN clock-ins documented on multiple days and shifts over several weeks. The facility's own policy required RN coverage for at least eight consecutive hours daily and a full-time DON, but these requirements were not met. The Administrator also failed to provide the requested Payroll Based Journal (PBJ) documentation to verify RN staffing. The deficiency was identified during a complaint investigation with a facility census of 56 residents.
Failure to Provide Full-Time Administrative and RN Coverage
Penalty
Summary
The facility failed to provide administrative oversight and required RN coverage, resulting in a lack of full-time administration and nursing supervision for an extended period. The facility was without a Director of Nursing (DON) or RN coverage for approximately three weeks, during which time the Administrator frequently assumed the role of charge nurse for both day and night shifts. Interviews with staff, including LPNs and CNAs, confirmed that there was no RN present in the building during this period, and the Administrator was often observed performing multiple roles, including charge nurse, social worker, and Administrator. The facility's own policies required RN coverage for at least 8 consecutive hours per day, 7 days a week, and designated a full-time DON, but these requirements were not met. Review of the facility's daily schedules and staff interviews corroborated that the Administrator regularly covered nursing shifts due to the absence of RNs, and there was no documentation to prove that RN coverage was provided as required. The Administrator was unable to provide proof of RN coverage or evidence of dedicating 40 hours per week to administrative duties. Additionally, a Payroll Based Journal (PBJ) was requested by the surveyor but was not provided. The lack of administrative and RN presence had the potential to affect all 56 residents in the facility.
Failure to Provide Scheduled Bathing and Hygiene Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically in maintaining grooming and personal hygiene, for three residents who required varying levels of support with bathing. Facility records and interviews revealed that these residents, all cognitively intact and with documented physical limitations such as Parkinson's disease, impaired balance, and muscle weakness, did not consistently receive showers or baths as outlined in their care plans. Documentation showed multiple missed opportunities for scheduled showers over several weeks, with some residents missing up to six out of nine scheduled showers in a month. Residents reported not receiving the required twice-weekly showers, despite requesting assistance from staff. They described feeling unclean, experiencing embarrassment due to body odor, and, in one case, developing yeast rashes attributed to inadequate hygiene. Staff interviews confirmed that residents were not being bathed as required, citing chronic short staffing as the primary reason. CNAs and LPNs acknowledged that some residents went weeks without bathing, and that complaints from residents about missed showers were ongoing and unresolved. The facility's own policies required that residents unable to perform ADLs independently receive necessary services to maintain hygiene, and that showers be provided according to resident needs and facility protocols. However, both staff and the facility administrator confirmed that there were no assigned staff to ensure residents received their scheduled baths or showers, resulting in unmet care needs and repeated resident complaints. The Ombudsman also reported receiving numerous complaints regarding lack of bathing at the facility.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at a safe and appetizing temperature to three out of four sampled residents, all of whom were cognitively intact. Multiple residents reported receiving cold and unappetizing food, with some stating that the temperature of the food influenced their willingness to eat. Observations confirmed that food items such as beef stroganoff, steamed broccoli, mashed potatoes, and hamburgers were served at temperatures below what is generally considered safe and appetizing. Additionally, pudding was served at a temperature of 67.3 degrees F. The facility was unable to provide its Food Temperature policy when requested. Interviews with staff revealed systemic issues contributing to the deficiency, including chronic short staffing, delays in meal delivery, and insufficient equipment such as plate covers and heated carts. Dietary staff reported that meal trays often waited up to 30 minutes before being picked up for delivery, and that not all trays could be covered or kept warm. Some meals were prepared up to three hours in advance and left sitting out until mealtime. Staff also noted that steam tables were not consistently used to keep food warm, and disciplinary actions had been taken against some kitchen staff for improper meal preparation and service.
Uncertified Staff Provided Direct Resident Care
Penalty
Summary
The facility failed to ensure that only certified or trained personnel provided Activities of Daily Living (ADL) care to residents, as required by state law and facility policy. On a specific evening/night shift, an Environmental Services staff member, who was not certified and had never received nurse aide training, was instructed by the previous DON to assist with resident cares, including transfers, changing briefs, perineal care, and feeding. This staff member reported feeling uncomfortable performing these tasks but did so to avoid leaving residents in need. Review of staffing records confirmed that there were no certified nurse aides on the floor during this shift, despite a census of 56 residents, many of whom required assistance with ADLs. Additionally, a dietary aide under the age of 18, hired to assist with food service, was placed on a mandatory staffing calendar to meet fire code requirements and worked overnight shifts, during which they passed ice and answered call lights. The dietary aide's job description did not include resident care duties, and their qualifications did not meet the requirements for providing hands-on care. The Administrator acknowledged mandating noncertified staff to work night shifts to meet fire code regulations but was not aware that these staff were instructed to provide direct resident care. Employee files and job descriptions reviewed did not show evidence of appropriate training or certification for resident care among the noncertified staff involved.
Failure to Maintain Minimum Night Shift Staffing Levels
Penalty
Summary
The facility failed to provide sufficient staffing on a 24-hour basis to meet the needs of all residents and to comply with minimum staffing requirements for fire safety. According to the facility's own policy, with a census of 54 residents, at least three staff members were required on the night shift. However, review of staff time punches and schedules for two consecutive nights showed that only two staff members, an LPN and a CNA, were present in the building for significant portions of the night shift, specifically from approximately 11:00 P.M. to 4:00 A.M. There was no third staff member present during these hours, and this was confirmed by staff interviews and schedule reviews. Additional staff, such as a CMT or another CNA, were only present for part of the evening and left before the required night shift coverage was met. Interviews with facility staff, including the LPN, CNA, Social Services Designee, and Interim DON, confirmed awareness of the staffing shortfall and that the required number of staff was not maintained during the night shift. The Regional CNO was not aware of the deficiency until it was reported during a call. The deficiency affected all 54 residents in the facility, as the lack of adequate staffing could impact both resident care and fire safety compliance. No specific residents were identified as being directly harmed in the report, but the deficiency was systemic and ongoing over at least two consecutive nights.
Failure to Maintain Required RN and DON Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) on duty for at least eight hours per day, seven days per week, and did not have a Director of Nursing (DON) or interim DON onsite full-time for a minimum of 40 hours per week. Review of staffing records and facility assessment revealed that there was no RN or DON coverage on multiple days, specifically on 4/7/25 and 4/8/25, despite a census of 54 residents. Observations confirmed that only LPNs and CNAs were present during these times, with no RN or DON listed on posted staff rosters. The facility's staffing policy for RN and DON requirements was requested but not provided. Interviews with staff and regional leadership confirmed that the DON had resigned without notice, and there was no RN coverage on the days in question. Staff reported uncertainty about RN or DON presence and lacked contact information for regional nursing support. The interim DON arrived only after the period of non-compliance, and regional and corporate leaders acknowledged gaps in RN coverage and the absence of an acting DON onsite during the deficiency period. No residents requiring RN-specific care were identified at the time, but the required RN and DON coverage was not maintained as per regulatory requirements.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in a location that was easily accessible to residents and visitors. Observations revealed that the required staffing data, including the facility name, daily census, and actual hours worked per shift for RNs, LPNs, and CNAs/CMTs, was not posted in public areas such as the nursing station or lobby. The posted list only included the names of four LPNs, with no RNs or Director of Nursing (DON) listed, and did not display the number of staff scheduled or the hours worked for each shift. At the time of observation, the facility had one LPN and two CNAs on duty for a census of 54 residents, with no RN present in the building. Interviews with staff indicated that the daily staff sheet had not been visibly posted for several weeks or months, and the previous practice of handwriting staffing information on a whiteboard had ceased. The interim DON confirmed the expectation that daily staffing ratios should be posted in public view. When requested, the facility was unable to provide documentation of daily staffing ratios for the previous days or weeks, and the facility's staffing posting policy was not provided upon request.
CNA Solicits and Fails to Repay Loan from Resident, Resulting in Misappropriation
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) developed a personal relationship with a resident and solicited a loan of $150.00 from the resident. The CNA explained to the resident that the money was needed to pay court costs, and the resident, who was cognitively intact but had a history of mood and affective disorders, provided the funds. The resident later attempted to contact the CNA for repayment but received no response. The incident came to light when the resident expressed concern to the Activities Director about not being repaid, stating that it took a long time to save that amount of money given their limited monthly income. The Activities Director immediately reported the situation to the facility Administrator, who initiated an investigation. Statements were collected from the resident and staff, and the police were notified, although law enforcement indicated they could not take action since the money was given as a loan. The CNA in question had already been terminated for unrelated attendance issues prior to the discovery of the misappropriation. The facility's review of the incident confirmed that the CNA had borrowed money from the resident, which constituted misappropriation and exploitation as defined by the facility's abuse and neglect policy. The resident was left without the funds until the facility intervened.
Failure to Notify Responsible Party After Resident Choking Incident and Medical Changes
Penalty
Summary
Facility staff failed to notify a resident's responsible party after a significant change in condition occurred, specifically when the resident experienced a choking incident during supper. The resident, who was cognitively intact and independent with meals, had no prior signs or symptoms of swallowing issues. During the incident, the resident became blue/purple in color, was unable to speak or move air, and required the Heimlich Maneuver and back thrusts to dislodge the obstruction. Following the event, the physician ordered a chest x-ray, which indicated possible bronchitis or pneumonia, and made changes to the resident's medication regimen, including doubling Torsemide and starting azithromycin. Despite these significant changes and interventions, there was no documentation that the resident's representative was notified of the choking incident, the new physician orders, or the medication changes. The responsible party only became aware of the incident after being informed by the resident's spouse. Interviews with staff, including an LPN and the DON, confirmed that the charge nurse was responsible for such notifications but failed to do so in this case.
Failure to Ensure RN Coverage on Weekends
Penalty
Summary
The facility failed to ensure the services of a Registered Nurse (RN) were utilized for eight hours per day, seven days a week, as required by their policy. A review of the facility's daily staffing schedules from March 1, 2024, to May 24, 2024, revealed that there was no RN on duty on several Saturdays and Sundays during this period. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Staffing Coordinator, confirmed that RNs were not scheduled on weekends, and the facility had been unable to schedule RNs for weekend shifts for some time. The Director of Nursing (DON) acknowledged that the facility employed only two RNs, including themselves, and admitted that there were two weekends per month when no RN was present for the required eight consecutive hours. The DON stated that staff were aware they could contact them with any issues when no RN was on duty. This deficiency had the potential to affect all 49 residents of the facility, as the absence of an RN on weekends could impact the quality of care provided.
Deficiencies in Food Safety and Equipment Maintenance
Penalty
Summary
The facility failed to maintain proper food safety standards as observed during a survey. During an initial kitchen inspection, a blue-handled metal pan was found on the bottom shelf of a metal pot/pan rack with heavy black residue on the inside rim. Additionally, the walk-in freezer lacked a thermometer, which is necessary to confirm adequate temperature ranges. Three maroon plate warmer covers with chipped edges were found in a dishwasher rack, ready for use, posing a risk of cross-contamination. A test lunch plate was observed covered with a chipped blue plate warmer lid, further indicating a lack of adherence to food safety protocols. A follow-up inspection revealed that the issues had not been addressed, as the blue-handled metal pan with residue remained on the storage rack, and the walk-in freezer still lacked a thermometer. Another test lunch plate was covered with a heavily chipped maroon plate warmer lid. During an interview, the Dietary Manager acknowledged that food should be free of foreign substances, all refrigerators and freezers should have thermometers, and damaged kitchen items should be discarded and replaced. These deficiencies had the potential to affect all residents, visitors, volunteers, and staff consuming food from the kitchen.
Facility Administration Fails to Manage Financial Obligations, Jeopardizing Services
Penalty
Summary
The facility administration failed to manage its financial obligations effectively, resulting in unpaid debts to various vendors, including utility and fire safety services. This failure to pay debts led to potential risks for residents and staff, as essential services and supplies were jeopardized. The facility's administrator did not have a policy outlining their duties, and there was no policy regarding the payment of vendors. The administrator, who had been at the facility for only a couple of months, was aware of some overdue balances but was unsure of the amounts and unaware of any service stoppages. The facility had significant past due amounts with several vendors, including an imaging vendor, food vendor, respiratory supply vendor, utility supplier, fire sprinkler vendor, and a chemical supply company. Payments for some of these debts were made only after surveyors began their annual survey. The chemical supply company had placed the corporate account on credit hold due to nonpayment, leading to the removal of laundry pumps and the cessation of services. This resulted in laundry staff manually dispensing detergent without proper instructions, as they were unsure of the correct amounts to use. Interviews with staff revealed that the facility had faced issues with supply orders and service disruptions due to nonpayment. The laundry staff struggled with manual detergent dispensing, and the laboratory company had temporarily stopped providing services, requiring residents to be sent to the hospital for lab draws. Additionally, there were instances where trash was not picked up due to unpaid bills. The Director of Nursing confirmed that the facility was behind on paying bills, and the administrator was responsible for sending bills to the corporate office, which was behind on payments.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to establish a comprehensive infection prevention and control program, which included deficiencies in preventing the development and transmission of Legionella and other water-borne pathogens. The facility lacked a documented risk management plan assessment and infection prevention program to address potential outbreaks. Additionally, there were no facility-specific testing protocols or public water utility reports on chemicals in the water, and the Maintenance Supervisor and Administrator had limited education on Legionella program requirements. The facility also failed to properly screen and follow tuberculosis (TB) policies for residents and new employees. Several residents did not have their TB skin tests (TST) administered or read according to the facility's policy, and there were inconsistencies in the documentation of TSTs. Similarly, new employees did not receive their TSTs in a timely manner, with some tests being administered or read late, and others not receiving a second TST as required. Infection control practices were not consistently followed during medication administration and wound care. Staff failed to cleanse their hands between administering medications, did not use barriers for wound care supplies, and did not follow Enhanced Barrier Precautions (EBP) guidelines. Additionally, there were issues with the handling of intravenous lines and wound VACs, with equipment being placed on unclean surfaces without proper barriers. The facility also lacked education and implementation of EBP, with staff unaware of the guidelines and their importance in infection prevention.
Failure to Conduct NA Registry Checks
Penalty
Summary
The facility failed to include a policy to check the Nurses' Aide (NA) Registry for Federal Indicators, which are markers for abuse, neglect, or misappropriation of property, for all employees prior to hire. This deficiency was identified during a review of the facility's hiring practices, where it was found that the NA Registry checks were not completed for four out of ten sampled new employees. The employees in question were hired between February and March 2024, and their files lacked documentation of the required NA Registry checks. During an interview, the Administrator acknowledged the oversight, stating that they were not in the position when the checks should have been completed and were unaware that some background checks did not include the NA Registry check.
Deficiency in Maintaining Sanitary Oxygen Equipment
Penalty
Summary
The facility failed to maintain oxygen equipment in a sanitary condition for three residents, leading to deficiencies in respiratory care. Resident #9, who was cognitively intact and on continuous oxygen therapy due to a stroke, was observed eating breakfast without oxygen. The oxygen tubing was improperly stored, with no date indicating when it was last changed, and the humidifier lacked a date as well. Resident #41, with acute respiratory failure and an upper respiratory infection, had oxygen orders that were not reflected in the care plan. Observations showed the oxygen tubing was left on the bed while running, and both the tubing and humidifier were undated. Resident #5, with pulmonary disease and moderate cognitive impairment, was found with undated oxygen tubing and an empty humidifier. Interviews with staff revealed a lack of adherence to protocols for maintaining oxygen equipment. Certified Medication Technician A and Licensed Practical Nurse A confirmed that oxygen tubing should be stored in a bag with the date of change written on it, and the humidifier should be filled with distilled water weekly, with the date noted. The Director of Nursing reiterated these expectations, emphasizing the responsibility of the night shift CNA and charge nurse to ensure compliance. However, the facility did not provide an Oxygen Policy by the end of the survey, indicating a systemic issue in managing respiratory care equipment.
Failure to Address Pharmacist's Medication Regimen Review
Penalty
Summary
The facility failed to respond to the pharmacist's monthly medication regimen review (MRR) for three residents, leading to deficiencies in medication management. Resident #38 had multiple recommendations from the pharmacist regarding cholesterol medication, missing labs, and gradual dose reductions, but there were no MRR reports or responses documented in the resident's medical record. The Director of Nursing (DON) was responsible for overseeing the MRR process but admitted to not receiving the reports from the pharmacy, resulting in a lack of response to the pharmacist's recommendations. Resident #8's care plan indicated the use of psychotropic medications, but the specific medications and reasons for use were not documented. The pharmacist recommended reviewing the Lorazepam order, but there was no response to this recommendation, and the resident's medical record lacked MRR reports or responses. The Assistant Director of Nursing (ADON) acknowledged that the MRRs were not being completed as required, and the recommendations were not being addressed by the physician. Resident #18 had an active order for Voltaren Gel without a specified dosage, and the pharmacist requested clarification to ensure proper administration. However, there was no response to this request, and the order remained unclear. Additionally, there was an order for the resident to be evaluated by psychiatric services, but this was not documented as completed. The DON and ADON both acknowledged the failure to ensure the MRRs were completed and addressed, leading to deficiencies in medication management for the residents involved.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration and storage protocols were followed, resulting in two deficiencies. Firstly, a resident who had not been assessed for self-administration of medications and did not have a physician's order for self-administration was observed with a medicine cup containing multiple pills on their overbed table. The resident, who had been residing at the facility for about one and a half years, had diagnoses including pain, hypothyroidism, dementia, and hypertension. Despite being cognitively intact, the resident had impaired range of motion in both upper extremities and used a wheelchair. The resident's care plan included instructions to administer medications as ordered, yet the resident was left to take medications without staff supervision, as confirmed by an LPN and the DON. In a separate incident, the facility failed to ensure medication carts were locked when not in use. Observations revealed that a medication cart marked 'Diabetic' was left unlocked on two occasions, with residents in close proximity and no nurse present. The cart contained insulin, a medication used to decrease blood sugar. Interviews with a CMT, the ADON, and the DON confirmed that medication carts should be locked if not actively in use and that the responsibility for ensuring this lay with the staff using the cart and the charge nurse. These deficiencies highlight lapses in the facility's adherence to medication administration and storage protocols, potentially compromising resident safety. The facility's policy on resident self-administration of medication requires an interdisciplinary team assessment, which was not conducted for the resident in question. Additionally, the lack of a policy regarding keeping medication carts locked contributed to the oversight in securing the medication cart.
Inaccurate MDS Completion for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for two residents, leading to discrepancies in their medical records. For one resident, the MDS inaccurately indicated the presence of a wound infection and unhealed pressure ulcers, despite the resident's skin being intact and no orders for wound treatments or antibiotics being present. Interviews with nursing staff confirmed that the resident did not have any wounds, and the MDS Coordinator acknowledged a coding error. The MDS Coordinator completed assessments remotely and did not communicate directly with the care staff, relying instead on electronic health records and remote meetings. Similarly, another resident's MDS inaccurately reported a wound infection, although no evidence of such a condition was found in the resident's care plan, medical records, or skin assessments. The corporate MDS Coordinator confirmed the coding error, noting that the resident's skin was intact during the assessment period. The Director of Nursing also confirmed that neither resident had wounds or infections, highlighting a failure in the facility's assessment and documentation processes.
Failure to Complete and Retain PASRR for Resident
Penalty
Summary
The facility failed to ensure the completion, submission, and retention of a Level I Nursing Facility Pre-Admission Screening for Mental Illness, Intellectual Disability, or Related Condition (PASRR) for a resident. This screening is a federally mandated process for individuals with serious mental illness or intellectual disability who apply or reside in Medicaid-certified beds. The deficiency was identified for a resident who was admitted to the facility without a completed PASRR, as required by the facility's policy and state Medicaid rules. The resident's diagnoses included dementia, anxiety disorder, depression, and bipolar disorder, and the care plan indicated impaired cognitive function and the use of medications to treat mental illnesses. The Social Services Director (SSD) acknowledged during an interview that they had been responsible for PASRRs for the last few months but were not in charge when the resident was admitted. The SSD was unaware that PASRRs were not available online after a year and stated an intention to start printing and scanning them. The Director of Nursing confirmed that the SSD and a corporate staff member were responsible for completing PASRRs and that they should be completed before a resident's admission. The absence of a PASRR record in the resident's electronic health record highlighted the facility's failure to adhere to the required screening process.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to provide two residents, Resident #43 and Resident #44, with a baseline care plan within 48 hours of their admission, as required by the facility's policy. Resident #43, who was cognitively intact, was admitted on an unspecified date, but there was no documentation that the resident or their responsible party received a copy of the baseline care plan. The resident's admission Minimum Data Set (MDS) confirmed their cognitive status, yet during an interview, the resident did not recall receiving any baseline care plan. Similarly, Resident #44, who had short-term and long-term memory problems and severely impaired cognitive skills, was also not provided with a baseline care plan within the required timeframe. The Assistant Director of Nursing (ADON) admitted to not giving residents or their responsible parties the baseline care plans and was unclear about the responsibility for this task. The Director of Nursing (DON) confirmed that the ADON was responsible for the baseline care plans but had not been involved in providing them to residents or their representatives.
Incomplete Care Plan for Hospice Resident
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident who was on hospice care and had diagnoses of dementia and heart failure. The resident's admission Minimum Data Set (MDS) and Care Area Assessment (CAA) indicated the presence of a pressure ulcer, but the care plan lacked specific information about the location or stage of the ulcer. Additionally, the care plan did not include any focus items related to the resident's wounds or dementia, despite the presence of wound care orders for the pressure ulcer on the buttock and the wound to the left lower extremity. Interviews with facility staff revealed that the care plans were incomplete and behind schedule. The Registered Nurse (RN) acknowledged the lack of pertinent information in the care plan, and the Assistant Director of Nursing (ADON) admitted to not knowing who was responsible for updating the care plans. The Director of Nursing (DON) confirmed that the ADON and social services were responsible for adding information to the care plans and expressed an expectation for a completed comprehensive care plan for the resident. The absence of a comprehensive care plan could lead to staff not knowing how to properly care for the resident.
Failure to Follow Physician's Orders for Medication and Colostomy Care
Penalty
Summary
The facility failed to adhere to physician's orders regarding the administration of medications for a resident with high blood pressure. The resident, who was cognitively intact but had a diagnosis of dementia, was prescribed Losartan and Carvedilol with specific instructions to hold the medication if blood pressure or pulse readings were below certain parameters. Despite these instructions, the medications were administered on multiple occasions when the resident's blood pressure readings were below the specified thresholds, as documented in the Medication Administration Record (MAR) for April and May 2024. Interviews with the LPN and the Director of Nursing confirmed that the nursing staff should not have administered the medications when the vital signs were out of the parameters set by the physician's orders. Additionally, the facility did not obtain physician's orders for the care of a colostomy for another resident who had recently undergone surgery on the digestive system. The resident, who was cognitively intact, had a colostomy and was at the facility to regain strength and learn how to care for the colostomy. The care plan included instructions for colostomy care, but the Physician's Order Sheet for May 2024 lacked any orders regarding the colostomy. Observations confirmed the presence of a colostomy bag, and interviews with the LPN and the DON indicated that there should have been specific orders for the care and management of the colostomy bag. These deficiencies highlight the facility's failure to follow physician's orders for medication administration and to obtain necessary orders for colostomy care, which are critical for ensuring the safety and well-being of the residents. The lack of adherence to these protocols was confirmed through interviews with facility staff and a review of the residents' medical records.
Deficient Discharge Procedures for Resident
Penalty
Summary
The facility failed to ensure proper discharge procedures for a resident, identified as Resident #53, who was discharged to a group home. The resident's medical records lacked critical information, including a recapitulation of stay, a reconciliation of medications, and documentation of the continuing care provider. The discharge summary was signed 10 days after the resident left the facility, and there was no evidence of communication with the group home regarding the resident's care needs or follow-up appointments. Interviews with facility staff, including the Social Service Designee (SSD), Licensed Practical Nurse (LPN), and Director of Nursing (DON), revealed several oversights. The SSD admitted to missing the notification to the Ombudsman and acknowledged the absence of documentation regarding the resident's follow-up care and the handling of medications and belongings. The LPN and DON confirmed that the discharge summary should have included a comprehensive list of medications, details of the resident's care while in the facility, and information about the physician taking over the resident's care. The resident's care plan and medical chart further highlighted the deficiencies, showing no documentation of the resident's belongings, medications, or follow-up care arrangements. The facility's failure to provide a policy for discharges at the time of exit contributed to the lack of proper discharge planning and communication, resulting in a deficiency in ensuring the resident's safe transition to the group home.
Failure to Monitor and Address Resident's Edema and Weight Gain
Penalty
Summary
The facility failed to adequately monitor and intervene in the decline of a resident's condition who was suffering from chronic venous hypertension and congestive heart failure. The resident's care plan, dated July 2023, indicated a need for staff assistance with lower body dressing due to lymphedema and a risk of worsening CHF, with interventions to monitor and report signs of edema. However, the care plan lacked specific information regarding the resident's venous hypertension or lymphedema. Despite physician notes documenting severe lymphadenopathy and the resident's reports of inconsistent application of a lymphedema compression device, the facility did not ensure consistent use of the device as ordered. Throughout the months from February to May 2024, the resident experienced significant weight gain, indicative of fluid retention, yet there was no documentation of actions taken in response to this change. The Treatment Administration Record (TAR) showed multiple instances where the lymphedema compression pump was not documented as applied during night shifts. Observations in May 2024 revealed the resident's legs were consistently edematous, red, and uncovered, with no compression devices in use. Interviews with the resident and staff confirmed the irregular use of the compression device and a lack of awareness or response to the resident's weight gain. The Director of Nursing acknowledged that there should have been parameters for reporting weight gain to the physician and orders to reduce edema, such as compression stockings and leg elevation. The DON expected staff to apply the lymphedema compression device as ordered and document its use, but this was not consistently done. The failure to monitor and address the resident's weight gain and edema, as well as the inconsistent application of the compression device, contributed to the deficiency in care provided to the resident.
Failure to Provide Addiction Recovery and Psychological Services
Penalty
Summary
The facility failed to provide necessary addiction recovery and psychological services for a resident who required participation in a recovery program to be eligible for a liver transplant. The resident, who had been admitted to the facility approximately two years prior, had a history of alcoholic cirrhosis of the liver, anxiety disorder, depression, and alcohol abuse in remission. Despite the resident's expressed desire to attend Alcoholics Anonymous (AA) meetings and the need for psychological services, the facility did not have a policy regarding support groups and failed to facilitate appropriate recovery support. The resident attempted to attend AA meetings but found the available option too religious and not suitable for their needs. The Social Services Designee (SSD) initially attempted to arrange transportation to a local church for AA meetings, but the resident expressed dissatisfaction with the religious nature of the meetings. The SSD did not follow up to find alternative AA meetings that aligned with the resident's preferences. Additionally, there was a lack of communication and coordination between the SSD and the resident, resulting in the resident not receiving the necessary support to meet the liver transplant program requirements. Furthermore, the facility did not ensure that the resident received psychological services for anxiety and depression, despite having physician orders for such services. The resident was only seen for psychotropic medication management and not for counseling. The Director of Nursing (DON) was unaware that the psychological services provider was not documenting in the facility's electronic health records, leading to a lack of proper documentation and follow-up on the resident's psychological needs. The facility's failure to provide adequate addiction recovery and psychological services resulted in the resident's inability to comply with the liver transplant program requirements.
Failure to Monitor Antipsychotic Drugs and PRN Orders
Penalty
Summary
The facility failed to appropriately monitor antipsychotic drugs and ensure PRN psychotropic drug orders did not extend beyond 14 days without physician rationale for a resident. The resident, who was severely cognitively impaired, was admitted with diagnoses of dementia with behavioral disturbance, depression, and anxiety. Despite receiving an antipsychotic medication daily, there was no documentation of behaviors or adverse effects, and the care plan lacked specific details about the psychotropic medications used and their purposes. The facility's policy required ongoing reassessments of changes in behavior, mood, and function, but this was not adhered to. The resident's behavior monitoring documentation was incomplete, with missing entries and unspecified behaviors to monitor. Additionally, the PRN order for Lorazepam was not discontinued after 14 days as required. Interviews with staff revealed a lack of awareness and completion of necessary monitoring tasks, indicating a systemic issue in medication management and documentation.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to physician's orders regarding the administration of insulin for a resident diagnosed with diabetes. The resident's care plan included instructions to administer diabetes medication as ordered, and the resident's Minimum Data Set confirmed the diagnosis and receipt of insulin shots. However, the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that Novolog, a rapid-acting insulin, was administered multiple times when the resident's blood glucose levels were below the specified threshold of 150, contrary to the physician's order to hold the medication in such cases. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed that the nursing staff did not follow the physician's orders. The LPN acknowledged that medications outside of administration parameters should not have been administered, and the DON reiterated that the nursing staff needed to adhere to physician's orders, particularly when blood glucose levels were out of the specified parameters. The facility lacked a policy regarding this specific citation, contributing to the oversight.
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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