Parkside Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbia, Missouri.
- Location
- 1201 Hunt Avenue, Columbia, Missouri 65202
- CMS Provider Number
- 265302
- Inspections on file
- 27
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Parkside Manor during CMS and state inspections, most recent first.
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.
Surveyors found that staff failed to follow infection control practices, including hand hygiene, Enhanced Barrier Precautions (EBP), and oxygen equipment management. During perineal care for a resident on EBP, multiple aides did not wear gowns despite door signage, handled oxygen tubing that had been on the floor, touched shoes and other contaminated surfaces, and then placed a nasal cannula, clean briefs, and personal items without changing gloves or performing hand hygiene. Another resident with a wound and EBP signage received perineal care from a CNA who wore gloves but no gown and later reported not noticing the precautions. For three residents using oxygen, surveyors observed undated nasal cannulas, tubing lying on the floor or without storage bags, missing or unclear physician orders for oxygen and tubing changes, and no documentation of required tubing changes in treatment records, despite facility expectations that tubing be dated, documented, changed if contaminated, and stored properly.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failing to ensure that a resident received treatment and supports for daily living in a safe manner.
A resident with a history of anxiety disorder and suicidal ideation expressed not wanting to live, which was overheard by staff and reported to an LPN. The LPN spoke with the resident but did not notify the DON or the resident's physician, nor document the incident, despite facility policy requiring immediate notification and documentation. The DON and administrator confirmed that physician notification was expected but did not occur.
Facility staff did not complete the required admission MDS assessment for a resident within the federally mandated 14-day period. The assessment remained incomplete and unsigned by an RN, and the administrator was unaware of the delay or any additional time for RN signature.
Facility staff did not complete a baseline care plan within 48 hours for a newly admitted resident with a psychiatric history, including recent suicidal ideations. The admitting nurse did not finalize the required documentation, and oversight by the DON and ADON was lacking, resulting in the absence of a person-centered care plan as required by facility protocol.
A resident with a history of anxiety disorder and suicidal ideations expressed suicidal thoughts, but an LPN did not notify the DON or physician as required by policy, nor document the incident at the time. The resident's EHR lacked a care plan for suicidal ideation, and interviews confirmed that key staff were unaware of the incident and diagnosis, resulting in a failure to meet professional standards for suicide threat management.
Staff did not promptly inform a resident's representative when the resident's toilet became unsecured and required a room change, and failed to notify physicians in a timely manner when two residents experienced skin injuries.
An LPN failed to follow physician's orders for water flushes during medication administration for two residents with feeding tubes. One resident with a G-tube received 500 ml of water instead of the prescribed 30 ml before and after medications, while another resident with a PEG tube received 150 ml instead of the ordered 60 ml. The LPN did not verify the orders, leading to a deficiency in professional standards of care.
The facility failed to meet its own staffing requirements on the night shift, as outlined in their Facility Assessment, for a census of 66 residents. From 12/12/24 to 12/17/24, the facility consistently scheduled fewer staff than required, with only one licensed nurse and a maximum of four CNAs, and sometimes only three NAs. Interviews revealed a lack of awareness and misunderstanding of staffing needs, with the administrator and ADON not aligning on the required staffing levels. This resulted in inadequate coverage, particularly in areas like Colonial Hall, compromising resident care and safety.
The facility failed to ensure RN coverage for at least eight consecutive hours daily, as required. The RN staff schedule for October, November, and December 2024 showed multiple days without an RN present for the required hours. The DON, who was the only RN on the schedule, acknowledged the lack of coverage and stated that he/she was salaried and only attended to the facility's needs. The administrator confirmed the deficiency, noting the risk of not having RN expertise available when needed.
The facility failed to ensure that three NAs completed the required training within four months of employment. The facility's policies lacked guidelines for NA qualifications, and employee files for NAs A, C, and E did not show completed training. Interviews revealed that the facility was aware of the certification requirement but faced challenges in finding training locations after losing access to a previous facility.
Facility staff failed to implement Enhanced Barrier Precautions (EBP) for residents requiring them. A resident with a wound did not have an EBP sign or PPE available, and an LPN provided wound care without a gown. Another resident with a PEG tube had an EBP sign but no PPE nearby, and an LPN administered medication without PPE. A resident with a tracheostomy had an EBP sign, but a CNA did not wear a gown during care. The IP and administrator acknowledged these oversights, indicating a systemic failure in EBP policy implementation.
The facility failed to implement an Antibiotic Stewardship Program, lacking protocols and a system to monitor antibiotic use. The Infection Preventionist, responsible for the program, documented usage but did not trend or monitor it, citing other responsibilities. The DON and administrator were unaware of the program's incomplete status.
The facility failed to provide a structured program of daily activities for residents in the Memory Care Unit, as observed in four residents with cognitive impairments. The absence of a current activity calendar and lack of engagement in activities were noted, with residents often found wandering or alone. Staff interviews revealed insufficient staffing and locked access to activity materials, contributing to the deficiency.
Facility staff failed to maintain proper communication with a dialysis clinic for a resident receiving dialysis. The required Dialysis Communication Record was not used, and vital signs and weights were not documented in the resident's chart. Interviews revealed that staff were unaware of the form's use, and the Director of Nursing and administrator did not ensure its implementation.
The facility failed to document collaboration of care with hospice providers for two residents receiving hospice services. Reviews of hospice binders and medical records showed missing plans of care and communication documentation. Interviews with staff, including an LPN, the DON, and the administrator, revealed a lack of awareness and oversight regarding the missing documentation, with the DON acknowledging responsibility but citing recent arrival at the facility as a factor.
Facility staff failed to properly sanitize a glucometer and use a protective barrier for supplies, leading to potential cross-contamination among residents with diabetes. A CMT placed the glucometer directly on the medication cart without a barrier and did not sanitize it between uses. Interviews with staff confirmed the lack of adherence to infection control protocols, highlighting the risk of spreading germs.
Facility staff failed to provide a proper mechanical lift transfer for a resident with moderate cognitive impairment and hemiplegia, resulting in an acute left proximal humeral fracture. Despite the care plan requiring two-person assistance, a CNA performed the transfer alone, leading to the injury. Interviews confirmed that the standard procedure was to use two staff members for safety.
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 Follow Hand Hygiene, Enhanced Barrier Precautions, and Oxygen Equipment Protocols
Penalty
Summary
Surveyors identified deficiencies in the facility’s infection prevention and control practices related to hand hygiene, use of Enhanced Barrier Precautions (EBP), and management of oxygen equipment. Facility policies on handwashing and hand cleanser directed staff to cleanse hands between resident contacts and after contact with bodily fluids, but did not clearly address hand hygiene frequency or glove changes between dirty and clean tasks. The perineal care policy instructed staff to remove gloves and wash hands after care, but did not specify hand hygiene and glove changes between dirty and clean portions of the procedure. The EBP policy required use of gown and gloves for high-contact resident care activities, including dressing, bathing, transferring, hygiene, changing briefs, and toileting, for residents with MDRO risk or wounds. The oxygen equipment policy required tubing, masks, and cannulas to be replaced monthly and PRN, labeled with date and initials, and stored appropriately. For one resident with severe cognitive impairment, incontinence, and care plan directions for EBP and oxygen use as needed, staff failed to follow hand hygiene and EBP requirements during perineal care. Observations showed the resident’s nasal cannula and oxygen tubing lying on the floor, with no storage bag attached to the concentrator. Staff entered the room, which had EBP signage requiring gown and gloves, but three aides did not wear gowns. One aide picked up oxygen tubing from the floor and placed it on the concentrator; another aide touched the bottom of the resident’s shoes and then placed the oxygen cannula into the resident’s nose with the same soiled gloves. During perineal care, the aide did not perform hand hygiene or change gloves between cleaning the perineal area and placing a clean brief, applying powder, touching the resident’s drawer, fastening the brief, and handling the mechanical lift sling and oxygen tubing. The aide then removed gloves and handed the call light to the resident without hand hygiene. Another aide placed a bag with a soiled brief on the floor, handled the resident’s personal items, and left the room without performing hand hygiene. Interviews with the aides revealed they were unaware the resident was on EBP, did not notice the door signage, and acknowledged missing hand hygiene and glove change opportunities. For a second resident with moderate cognitive impairment, a wound, and a care plan requiring EBP with gown and gloves for high-contact care, staff again failed to follow EBP. The resident’s door displayed EBP signage instructing staff to wear a gown and gloves, but an aide entered to provide perineal care wearing gloves only and no gown. The resident reported having wounds on the buttocks. The aide later stated they did not know the resident had a wound and did not notice the EBP signage until after leaving the room. Facility leadership confirmed that signage is placed on doors for residents on precautions and that staff are educated to use gown, gloves, and mask for residents on EBP. Surveyors also found deficiencies in oxygen equipment management for three residents. For the first resident, physician orders required monthly oxygen tubing changes on Sundays, but the treatment administration records lacked documentation that tubing was changed on the specified dates. The resident’s oxygen tubing was observed on the floor, undated, and without a storage bag on the concentrator. For a third resident, the MDS and physician orders did not indicate oxygen use or orders for tubing changes, yet the resident was observed in bed with a nasal cannula in place, undated tubing, and no storage bag on the concentrator. For a fourth resident, assessments and care plan indicated no routine oxygen use, but there was an order for PRN oxygen at two liters without an order for tubing replacement. This resident was observed wearing an undated nasal cannula, with no documentation of tubing changes in the treatment record and no storage bag on the concentrator. Interviews with nursing staff and administration confirmed that tubing should be labeled with the change date, documented in the TAR, changed if it had been on the floor, and stored in a bag when not in use, but there was no system in place to ensure these tasks were consistently completed.
Failure to Ensure a Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Notify Physician of Resident's Suicidal Ideation
Penalty
Summary
Facility staff failed to notify a resident's physician after the resident expressed suicidal ideation. The resident, who had a history of generalized anxiety disorder and suicidal ideations, was overheard by staff saying on the phone that they did not know if they wanted to live anymore. The staff member reported this to the charge nurse, who then spoke with the resident and suggested hospitalization for emotional support. However, there was no documentation that the resident's physician or responsible party was notified of the incident, as required by facility policy. Further review of the resident's electronic health record revealed the absence of a care plan and no documentation of the incident or any notifications made. Interviews with the LPN and DON confirmed that the physician was not notified, and the incident was not documented at the time. The LPN stated they did not notify the DON or physician because they believed the resident was okay after their conversation. The DON and administrator both indicated that they would expect the physician to be notified in such situations, but this did not occur.
Failure to Complete Admission MDS Assessment Within Required Timeframe
Penalty
Summary
Facility staff failed to complete the federally mandated Minimum Data Set (MDS) admission assessment within the required 14-day timeframe for one resident. Review of the resident's records showed that the admission MDS was not completed or submitted by the due date, as required by the RAI manual and OBRA regulations. Interviews with the DON, MDS Coordinator, and administrator confirmed that the MDS Coordinator was responsible for completing the assessment within 14 days, but the process was delayed, and the assessment was not finalized because it had not been signed by an RN. The administrator was unaware of the incomplete status of the resident's MDS assessment and did not recognize any additional time allowance for RN signature beyond the 14-day requirement.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to develop a comprehensive, person-centered baseline care plan to address a resident's medical, nursing, mental, and psychosocial needs within 48 hours of admission. Review of the resident's medical record showed that, despite facility protocols requiring completion and filing of a baseline care plan within 48 hours, no such care plan was present for the resident. The resident was admitted with a psychiatric history, and staff were not aware of a recent diagnosis of suicidal ideations at the time of admission. Interviews with facility staff revealed that the admitting nurse was responsible for completing the baseline care plan upon admission, with oversight from the DON or ADON. The ADON stated that the baseline care plan template was loaded into the electronic health record at admission, but the admitting nurse did not complete it. The DON, who was on vacation during the admission, acknowledged that the baseline care plan was missed and was unaware of the resident's recent suicidal ideations. The administrator confirmed that the expectation was for the admitting nurse to complete the care plan and for the DON or ADON to follow up on any missing documentation.
Failure to Follow Suicide Threat Protocol and Notify Appropriate Staff
Penalty
Summary
Facility staff failed to follow established policy and professional standards when a resident with a history of generalized anxiety disorder and suicidal ideations expressed suicidal thoughts. The resident was overheard by a staff member stating on the phone that they did not know if they wanted to live anymore. The staff member reported this to an LPN, who spoke with the resident, assessed for a suicide plan, and monitored the resident at intervals. However, the LPN did not notify the Director of Nursing (DON) or the resident's physician, as required by facility policy, and did not document the incident at the time it occurred. The resident's electronic health record lacked a care plan addressing suicidal ideation, and there was no documentation of the date and time of the incident, DON notification, or physician notification. Interviews with the LPN, DON, and administrator confirmed that the DON and physician were not notified of the resident's suicidal statements, and that the incident was not documented according to policy. The DON and administrator both stated they were unaware of the resident's suicidal ideations and would have expected to be notified and for the incident to be documented. The physician's office also confirmed there was no record of notification regarding the resident's suicidal comments or emotional distress. These failures resulted in the facility not meeting professional standards of quality for addressing suicide threats.
Failure to Notify Representatives and Physicians of Significant Resident Events
Penalty
Summary
Facility staff failed to notify a resident's representative when the resident's toilet became unsecured from the floor, tipped, and required the resident to be moved to a different room. Additionally, staff did not notify the physicians of two residents in a timely manner when those residents experienced a skin injury. These failures were identified through observation, interview, and record review during the survey, with a facility census of 73 residents. The deficiencies involved lack of timely communication to both resident representatives and physicians regarding significant events affecting the residents, including environmental hazards and changes in medical condition.
Failure to Follow Physician's Orders for Water Flushes
Penalty
Summary
Facility staff failed to maintain professional standards of care by not adhering to physician's orders regarding water flushes during medication administration for two residents with feeding tubes. Resident #38, who was assessed as a nutritional risk with a G-tube, had physician orders to flush the tube with 30 ml of water before and after medication administration. However, an LPN administered medications and flushed the tube with a total of 500 ml of water, exceeding the prescribed amount. Similarly, Resident #12, who had a PEG tube with continuous night feedings, was ordered to have the tube flushed with 60 ml of water before and after medications. The LPN administered medications and flushed the tube with 150 ml of water, again not following the physician's orders. Interviews with the LPN and the Director of Nursing revealed that the LPN was unsure of the correct water flush amounts and did not verify the physician's orders before administering medications. The Director of Nursing and the facility administrator both stated that they expected nurses to follow physician's orders and verify them if unsure. This failure to adhere to physician's orders for water flushes during medication administration was observed and documented by surveyors, indicating a deficiency in maintaining professional standards of care.
Inadequate Night Shift Staffing in LTC Facility
Penalty
Summary
The facility failed to provide adequate nursing staff on the night shift as per their Facility Assessment, which required two licensed nurses and five to eight CNAs for a census of 65-70 residents. The facility's actual staffing during the period from 12/12/24 to 12/17/24 consistently fell short, with only one licensed nurse and a maximum of four CNAs scheduled, and on some nights, only three NAs were present. This staffing level did not meet the documented requirements, and the facility's time-keeping records confirmed that the actual number of staff working was even lower than scheduled, with some shifts having only one licensed nurse and two CNAs. Interviews with the facility's administrator and ADON revealed a lack of awareness and misunderstanding of the staffing requirements. The administrator expected the ADON to schedule at least four CNAs and one licensed nurse, but the ADON believed this met the staffing requirement, despite the Facility Assessment indicating otherwise. Additionally, there were instances where no CNA was assigned to specific areas like Colonial Hall, leading to potential gaps in resident care. The administrator acknowledged the staffing challenges and the inability to consistently meet the required staffing levels, which compromised the safety and care needs of the residents.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. The facility's RN staff schedule for October, November, and December 2024 showed multiple days where there was no RN present for the required hours. Specifically, the facility did not have an RN on duty for eight consecutive hours on numerous dates across these months. The Director of Nursing (DON) confirmed that he/she was the only RN on the schedule and acknowledged the absence of RN coverage on several days. The DON stated that he/she was salaried and only attended to the facility's needs, not specifically to fulfill the RN coverage hours. The administrator also confirmed the lack of RN coverage, stating that the facility currently had only one RN on the schedule. Both the DON and the administrator recognized the risk of not having an RN present for the required hours, which includes the absence of RN knowledge and experience in case of an emergency or when specific nursing expertise is needed. The facility did not have a policy in place for RN coverage, contributing to the deficiency in meeting the regulatory requirement.
Failure to Ensure Timely Certification of Nurse Aides
Penalty
Summary
The facility failed to ensure that three nurse aides (NAs) completed the required nurse aide training program within four months of their employment. The facility's policies did not provide clear guidelines for NA qualifications, and the employee files for NAs A, C, and E lacked documentation of completed training programs. NA C, who was rehired in January 2024, stated that they were informed about the need for certification within 90 days but had not taken any classes due to the unavailability of training at the previous facility. The Assistant Director of Nursing (ADON) acknowledged the issue, citing the lack of available training locations as the reason for the delay. Interviews with the ADON, the administrator, and the Director of Nursing (DON) revealed that the facility was aware of the requirement for NAs to be certified within 120 days of hire. However, they were unable to provide documentation of attempts to enroll the NAs in training programs. The facility previously relied on another facility for training, but this option was no longer available due to a change in ownership. The ADON was tasked with finding an alternative training location, but no progress had been documented at the time of the report.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility staff failed to implement the Enhanced Barrier Precautions (EBP) policy effectively, as evidenced by multiple observations and interviews. Resident #8, who was at risk for skin integrity issues and had a wound, did not have an EBP sign on the door, nor was there personal protective equipment (PPE) in close proximity. Licensed Practical Nurse (LPN) F was observed providing wound care without wearing a gown, contrary to the facility's policy. The infection preventionist (IP) and the administrator acknowledged the oversight, indicating a lack of awareness and adherence to the EBP policy. Resident #12, who had a PEG tube, had an EBP sign on the door, but PPE was not available nearby. LPN G administered medication through the PEG tube without using PPE, and during an interview, expressed uncertainty about the EBP sign's significance. The IP and the administrator confirmed that the resident should have PPE available and that staff should use it when providing care. Resident #18, with a tracheostomy, had an EBP sign on the door, but CNA K did not wear a gown while performing personal hygiene tasks. The Director of Nursing (DON) was unsure if the resident should still be on EBP but expected staff to follow the posted precautions. Resident #38, also with a feeding tube, had similar issues with the absence of PPE and staff not using it during care. The IP and the administrator reiterated the expectation for PPE use, highlighting a systemic failure in implementing the EBP policy across the facility.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility staff failed to implement an Antibiotic Stewardship Program with necessary protocols and a system to monitor and track antibiotic use. The facility, with a census of 66, did not have a policy for Antibiotic Stewardship, and the staff did not track antibiotic trends. The Infection Preventionist, responsible for the program, acknowledged documenting antibiotic usage in the electronic medical record but admitted to not having a system in place to trend and monitor usage. Despite being aware of the program's expectations, the Infection Preventionist had not implemented them, citing additional responsibilities as the Minimum Data Set coordinator and care plan coordinator. The Director of Nursing, new to the facility since August, was unaware of the program's incomplete status, and the administrator, responsible for oversight, was also unaware of the deficiency.
Failure to Provide Adequate Activities in Memory Care Unit
Penalty
Summary
The facility staff failed to provide an ongoing program of daily activities designed to meet the residents' interests for four residents residing in the Memory Care Unit (MCU). The facility did not have a policy for activities, and the activity calendar for November 2024 showed limited activities, primarily an 'activity cart available' on weekends. Observations in December 2024 revealed the absence of a current activity calendar, and residents were often found without engagement in activities, either asleep or wandering the hallways. Resident #1, with severe cognitive impairment, was assessed to enjoy reading, music, group activities, and religious practices. However, the care plan lacked direction for religious activities, and observations showed the resident was not engaged in any activities, often found asleep or alone. Similarly, Resident #55, with moderate cognitive impairment, expressed the importance of music and group activities but was not informed about ongoing activities, missing opportunities like listening to carolers. Residents #67 and #270, both with severe cognitive impairments, were also not provided with activities as per their care plans. Observations showed them wandering the hallways without engagement. Interviews with staff, including the Activities Director (AD) and Certified Nursing Assistants (CNAs), revealed a lack of structured activities, insufficient staffing, and locked access to activity materials. The AD admitted to not assessing residents' specific interests and not participating in the MDS process for activities, contributing to the deficiency in meeting residents' activity needs.
Failure in Dialysis Communication and Documentation
Penalty
Summary
Facility staff failed to maintain a system for ongoing communication with a dialysis clinic for a resident receiving dialysis. The facility's policy required a Dialysis Communication Record to be sent with the resident on each dialysis visit, detailing care concerns, medications, and contact information. The dialysis unit was expected to complete the form with relevant information and return it to the facility. However, the resident's medical record lacked these communication records, and the care plan did not reflect the resident's dialysis treatment. Interviews revealed that staff were not using the designated communication form. Instead, vital signs and weights were written on an index card, which was not retained or documented in the resident's chart. The Director of Nursing and the administrator were unaware that the form was not being used, and the responsibility for ensuring its use was not being fulfilled. This lack of communication and documentation could lead to staff being unaware of the effects of dialysis on the resident.
Lack of Hospice Care Documentation for Residents
Penalty
Summary
The facility failed to document collaboration of care with hospice providers for two residents receiving hospice services. The facility's Nursing Facility Hospice Services Agreement and Patient Hospice Chart Guide outlined the requirements for documentation, including a coordinated plan of care and communication between the facility and hospice providers. However, reviews of the hospice binder and medical records for the two residents revealed the absence of a plan of care and communication documentation, indicating a lack of adherence to the established protocols. Interviews with facility staff, including an LPN, the Director of Nursing, and the administrator, revealed a lack of awareness and oversight regarding the missing documentation. The LPN acknowledged the absence of communication in the hospice binders and mentioned the need to contact the hospice agency for resident care information. The Director of Nursing and the administrator both expressed expectations for the hospice binders to contain up-to-date care plans and communication, but they were unaware of the deficiencies. The Director of Nursing admitted responsibility for ensuring the documentation was complete, but noted their recent arrival at the facility as a factor in the oversight.
Inadequate Glucometer Sanitization and Barrier Use
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols concerning the use of glucometers for four residents diagnosed with diabetes. Observations revealed that a Certified Medication Technician (CMT) did not use a protective barrier for the glucometer supplies and failed to properly sanitize the glucometer between uses. The glucometer was placed directly on the medication cart without a barrier, and the CMT only partially cleaned it with an alcohol prep pad before placing it back on the cart. This occurred for four residents, with the CMT admitting to missing the opportunity to sanitize the glucometer due to being distracted by conversation. Interviews with facility staff, including a Licensed Practical Nurse (LPN), the Assistant Director of Nursing (ADON), and the administrator, confirmed that the glucometer is used on multiple residents and should be sanitized between uses with approved disinfecting wipes. However, the CMT was not trained to use a protective barrier under the glucometer, which could lead to potential cross-contamination. The staff acknowledged the potential for spreading disease or germs if the glucometer is not properly sanitized between uses.
Improper Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
Facility staff failed to provide a proper mechanical lift transfer for a resident, resulting in an injury. The resident, who had moderate cognitive impairment, hemiplegia, and was totally dependent on staff for transfers, required a mechanical lift with two-person assistance as per their care plan. However, a CNA performed the transfer alone, during which the resident's arm was not properly positioned, leading to a bruise and inflammation. Subsequent nurse notes indicated the resident's arm was swollen and immobile, and an X-ray confirmed an acute left proximal humeral fracture. The resident was then sent to the hospital for further treatment. Interviews with facility staff, including CNAs, LPNs, the DON, ADON, and the administrator, revealed that the standard procedure was to use two staff members for mechanical lift transfers to ensure safety. Despite this, the CNA involved in the incident admitted to performing the lift alone, which was not in accordance with the facility's policy or the resident's care plan. The DON and other staff members confirmed that the use of two staff members for such transfers was a known and expected practice within the facility.
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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