Parkview Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Missouri.
- Location
- 128 North Hardesty, Kansas City, Missouri 64123
- CMS Provider Number
- 265463
- Inspections on file
- 37
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Parkview Healthcare during CMS and state inspections, most recent first.
Two residents with significant medical comorbidities, including CHF, ESRD, CVA with hemiplegia, and documented ADL/self-care deficits, were involved in an unwitnessed physical altercation after one resident allegedly entered the other’s room and took cigarettes. One resident reported being followed back to their room and struck multiple times, including being kicked near a dialysis port and scratched on the face, while the other resident later admitted to punching the first resident three times and then falling when losing balance. The first resident sustained a chest wall contusion and facial abrasion confirmed by hospital evaluation and reported severe pain, and the second resident reported right hip pain after the fall. Staff and leadership acknowledged the event as abuse, and records showed the aggressive potential of one resident had been identified in the care plan, yet the facility failed to prevent this resident-to-resident physical abuse.
Surveyors found that the facility’s call light system did not provide audible or visual alerts beyond a computer screen at the nurse’s station, and staff often did not monitor it, resulting in prolonged response times far exceeding the facility’s 5–10 minute expectation. Several residents with hemiplegia, COPD, acute respiratory failure, multiple sclerosis, severe mobility limitations, incontinence, and continuous O2 reported waiting from tens of minutes to many hours for assistance, sometimes lying in urine or bowel for extended periods, being unable to reach their call lights, or running out of oxygen without timely help. Observations confirmed call lights active for over 30 minutes with no hallway indicators while staff sat at the nurse’s station on cell phones, and device reports documented numerous call responses taking from about 20 minutes to several hours, demonstrating a systemic failure to ensure accessible, functional call lights and prompt staff response.
A resident with COPD, acute respiratory failure with hypoxia, and pneumonia had care plan interventions and physician orders requiring monitoring of respiratory status, oxygen saturation, and PRN oxygen at 2 L/min via nasal cannula for O2 saturation below 90% and/or wheezing and shortness of air. For an entire month, the MAR showed no documentation of oxygen administration or O2 saturation checks, and an oxygen saturation summary showed only two assessments over several months. The resident, who was cognitively intact, reported repeated pneumonia episodes, nighttime shortness of air, and that staff did not check O2 saturation, and there was no oxygen equipment in the room despite an active PRN order. Interviews with an RN, CMTs, CNAs, an LPN, and the Administrator/DON revealed inconsistent understanding of responsibilities, lack of awareness of the resident’s respiratory and oxygen orders, gaps in documentation, and a practice of obtaining vitals only monthly, resulting in failure to follow the ordered respiratory monitoring and PRN oxygen therapy.
The facility failed to assess, care plan, and implement behavioral health and substance use interventions for three residents with known substance use disorders, despite PASRR findings and facility policies requiring person‑centered behavioral health services and care plans addressing illicit drug and alcohol use. One resident with a history of polysubstance abuse had no substance use risk assessment, no documented substance abuse programming, and no care plan addressing illicit drug use or PASRR recommendations; this resident was repeatedly found with drug paraphernalia and placed on various "restrictions" that were not clearly defined, documented, or implemented, and visitor and LOA sign‑out logs were incomplete or absent. Two other residents with documented alcohol and polysubstance dependence and a need for 24‑hour supervision had no substance use risk assessments, no care plan goals or interventions for their substance use disorders, and no documentation of NA/AA resources or education. Subsequently, the resident on restriction obtained fentanyl, used it in a room with the other two residents, and both of those residents became unresponsive after smoking the substance, required multiple doses of Narcan administered by LPNs, and were transported to the hospital for overdose‑related treatment.
A resident with psychiatric and neurologic diagnoses overdosed on fentanyl, received two doses of Narcan, became alert, and was transported by ambulance to the hospital. Although facility records indicated the guardian was notified shortly after the event, the guardian later reported learning of the overdose from the resident and stated that no one had called the provided emergency cell or other on‑call contacts. An LPN reported leaving a voicemail on an office line, and the DON acknowledged that the nurse had not used the correct emergency number and that leaving a voicemail was treated as sufficient notification. As a result, the guardian was not promptly and effectively informed of the resident’s significant change in condition and hospital transfer, contrary to the facility’s own notification policy.
The facility did not follow pest control recommendations or address structural issues such as unsealed holes, gaps under doors, and improperly placed dumpsters, resulting in ongoing rodent activity in multiple resident rooms and common areas. Residents and staff reported frequent mouse sightings and droppings, and observations confirmed numerous entry points for pests throughout the building.
A resident admitted with frostbite and a chronic wound did not receive prescribed opioid pain medication due to incorrect transcription of physician orders and lack of clarification when the medication was not received from the pharmacy. Nursing staff provided alternative non-opioid pain medications, but the opioid was not administered, and there was insufficient follow-up and documentation regarding the missing medication.
A resident with a history of mental illness was physically assaulted by another cognitively intact resident, who struck the victim multiple times on the head with a cane, causing a laceration requiring stitches and additional injuries. The attack was unprovoked, captured on video, and confirmed by witness interviews. Facility staff and policies did not identify or prevent the risk of this altercation, and the victim expressed fear and pain following the incident.
The facility reported excessively low weekend staffing levels, potentially affecting 112 residents' care. Despite continuous hiring efforts, the facility struggled to maintain adequate staffing, particularly on weekends, as confirmed by the Staffing Coordinator and DON. The staffing data for 2024 indicated a one-star rating, highlighting the facility's challenges in meeting its staffing policy requirements.
The facility failed to provide RN coverage for at least eight hours per day during three quarters of 2024, as required by regulations. This deficiency was identified through staffing reports submitted to CMS, indicating no RN hours for the first, second, and fourth quarters. Interviews revealed challenges in hiring RNs for night shifts, despite recruitment efforts. The lack of RN coverage potentially impacted the care of 112 residents.
The facility failed to employ a qualified CDM or professional to manage the dietary department without a full-time Registered Dietitian. The DM lacked formal training, leading to issues with food palatability, unmet resident preferences, and unsanitary food conditions. Complaints were noted in Resident Council Meeting Minutes, and the DON confirmed the DM's lack of qualifications.
The facility failed to maintain sanitary conditions in food storage, preparation, and distribution, affecting all residents. The handwashing sink did not meet FDA temperature standards, and kitchen equipment was found soiled. Staff mishandled clean and soiled items, and food temperatures were not properly recorded, leading to unsafe serving temperatures. Desserts were served uncovered, exposing them to contamination during transport.
The facility failed to properly dispose of garbage and refuse, as the dumpster lid behind the kitchen was repeatedly observed open. The Dietary Manager confirmed that all departments were responsible for closing the lid after discarding trash. This oversight had the potential to increase the risk of pests affecting all 112 residents.
The facility did not have a Quality Assurance and Performance Improvement (QAPI) plan in place, as required to guide care and services for residents. The new Administrator was unaware of the QAPI plan, and the Director of Nursing (DON) could not provide previous meeting records. This deficiency had the potential to affect the care and services for 112 residents.
The facility failed to address grievances voiced by the Resident Council, including issues with food temperature, staff interactions, pest control, and call light response times. Despite repeated documentation of these concerns in council minutes, no actions were taken to resolve them. Interviews with residents and the DON confirmed the lack of follow-up or resolution, indicating a failure to adhere to facility policies on grievance handling.
The facility failed to protect residents from abuse, as evidenced by incidents involving four residents. A cognitively intact resident reported being hit by a roommate with a history of aggression, and another resident felt unsafe due to repeated aggressive encounters with a fellow resident. The facility's policy on abuse prevention was not effectively implemented, leading to these altercations.
The facility failed to report resident-to-resident altercations to the SSA within the required timeframe. Incidents involving physical altercations between residents were not reported, despite facility policies mandating immediate reporting. The Administrator did not report these incidents, resulting in a deficiency in compliance with federal requirements.
The facility failed to investigate allegations of resident-to-resident abuse involving four residents. One incident involved a resident with intact cognition allegedly hitting another with moderately impaired cognition, with no evidence of investigation. Another incident involved a resident with moderately impaired cognition allegedly grabbing and striking another resident, with missing investigation components. The facility did not adhere to its abuse prevention and investigation policy, as evidenced by incomplete investigations and lack of documentation.
The facility failed to ensure accurate documentation of narcotic administration for three residents, leading to discrepancies between the electronic MAR and the Controlled Drug Administration Record. Despite being administered, several doses of oxycodone and buprenorphine were not recorded on the MAR, increasing the risk of medication errors. Interviews with staff revealed that while narcotics were documented on paper logs, they were not consistently recorded in the electronic MAR, contrary to facility policy.
The facility failed to properly label and store medications, including insulin pens, on two medication carts. Observations revealed unlabeled and undated insulin pens, expired medications, and improper storage of personal items and food with medications. Both an LPN and an RN acknowledged the issues, and the DON confirmed the expectations for labeling and storage.
The facility failed to provide palatable and appetizing meals, with food served at inadequate temperatures, affecting all residents reviewed for food concerns. Observations showed food temperatures were lower than recorded, impacting taste. Residents consistently reported dissatisfaction with cold and unappetizing meals, and the facility did not address ongoing grievances from the Resident Council, risking weight loss among residents.
The facility did not inform 29 residents and/or their representatives that signing a binding arbitration agreement was not a condition for admission or continued care. The arbitration agreement lacked a statement clarifying this, placing residents at risk of involuntary agreement. The Admissions Coordinator confirmed the omission, and the facility's policy required such a statement, which was not followed.
The facility failed to inform 29 residents about their right to select a neutral arbitrator agreed upon by both parties in the binding arbitration agreement. The facility's Arbitration Agreement Rider did not include this provision, as confirmed by the Admissions Coordinator. This oversight was identified through interviews and policy reviews, placing residents at risk of misunderstanding the arbitration process.
The facility failed to assess, educate, and offer the pneumococcal vaccine to five residents with various medical conditions, including paraplegia and heart disease. The Infection Preventionist, new to the role, confirmed the absence of documentation for offering or administering the vaccine, contrary to the facility's policy requiring such actions within a specified timeframe.
The facility failed to maintain a safe and comfortable environment, with issues such as disrepair in walls, broken heating vents, and missing mirrors affecting several residents. A newly hired Regional Maintenance Consultant noted these problems, and residents reported discomfort due to the conditions. The facility's policy on maintaining a homelike environment was not followed, as maintenance issues were not promptly addressed.
The facility failed to implement effective pest control measures, leading to a mouse infestation affecting several residents and common areas. Despite repeated recommendations from pest control reports to fix entry points and remove trash, the facility did not act, resulting in ongoing rodent activity. Residents reported seeing mice and finding droppings in their rooms, causing distress. The Regional Maintenance Consultant noted the facility's inaction and the Maintenance Director's need for training.
The facility failed to respect residents' rights to privacy and autonomy, affecting three residents. One resident experienced a breach of privacy when staff entered without knocking, while another was disturbed by loud, inappropriate language from staff. A third resident's refusal of a meal tray was ignored, despite their right to refuse. These incidents indicate a lack of communication and awareness among staff regarding residents' rights.
The facility failed to provide the correct Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS-10055, to three residents whose Medicare Part A services were no longer covered. Two residents did not receive the form, and one received an expired version. The Social Service Director was unaware of the requirement and did not notice the expiration, leading to a lack of proper notification for residents to make informed decisions about their care.
A resident with multiple medical conditions experienced a significant weight loss of 7.88% over one month, which was not accurately reflected in the MDS assessment. The Dietary Manager failed to use the most recent weight, leading to an incorrect recording of the resident's weight. Interviews revealed a lack of awareness of the weight loss, despite the facility's policy on accurate assessments.
A facility failed to complete a PASARR Level I screening for a resident admitted with major depressive disorder, schizoaffective disorder, PTSD, and substance abuse. The absence of this screening, confirmed by the Social Service Director, violated the facility's policy requiring pre-admission screening for serious mental disorders. This oversight meant the resident could be residing in the facility without the necessary state mental health authority's determination of appropriateness for admission.
The facility failed to implement safety interventions for two residents with substance use disorders. One resident tested positive for fentanyl and was implicated in providing drugs to others, while another was hospitalized for an opioid overdose. Both residents' care plans lacked necessary interventions for monitoring and prevention of substance use, despite staff expectations and facility policy.
The facility failed to safely store portable compressed oxygen cylinders and maintain respiratory equipment in a sanitary manner. Observations revealed unsecured oxygen cylinders in the hallway and storage room, posing a risk of explosion. Additionally, a resident's oxygen tubing was found on the floor with outdated markings, and the concentrator filter was dusty. Staff interviews confirmed the lack of adherence to safety policies, highlighting potential dangers.
The facility failed to ensure pharmacy recommendations were reviewed and signed by a physician for two residents. A pharmacist recommended medication reductions for both residents, but these were not addressed due to a lapse in the process after the former ADON left. The Medical Director and DON acknowledged the oversight, noting the expectation for recommendations to be addressed within 30 days.
A resident with intact cognition and specific dietary preferences was not receiving a sandwich with meals as documented on meal tickets. Despite the resident's requests and tray ticket instructions, observations confirmed the absence of the sandwich, which was acknowledged by the Dietary Manager.
A facility failed to implement proper infection control measures during a medication pass, as a CMT did not sanitize a blood pressure cuff before use on three residents and neglected hand hygiene before preparing medications for one resident. Staff interviews revealed inconsistencies in understanding cleaning protocols, with the DON confirming that equipment should be cleaned between each resident use.
A resident received antibiotic eye drops without a specified stop date following cataract surgery, leading to prolonged administration without medical necessity. Facility staff, including the LPN, DON, and IP, were unaware of the ongoing use, and the order was not included in the antibiotic tracking list, contrary to the facility's antibiotic stewardship policy.
The facility failed to provide a personalized dialysis contract for a resident with end-stage dialysis, despite physician orders for dialysis services. The resident was cognitively intact, and the facility was unable to locate the contract, waiting for a copy from the dialysis center. This deficiency could impact all residents receiving dialysis services.
A resident was discharged to a hospital following an unplanned emergency, but only a verbal discharge notice was given to the resident's guardian by the DON. No written discharge notice was found in the medical or hospital records, and staff interviews revealed uncertainty about who was responsible for ensuring written notification. The facility could not verify that the required written discharge notice was provided.
A resident was denied re-admission to the facility after a hospital stay that exceeded the bed-hold policy, despite being ready for discharge and multiple referral attempts by the hospital and the resident's guardian. The facility's administration and clinical team decided not to allow the resident back, citing inability to meet the resident's needs, and acknowledged this action was against regulatory requirements.
A facility's call light system malfunctioned, leading to significant delays in responding to residents' needs. A resident with a history of ventricular tachycardia and other conditions experienced a 20-minute delay in having their call light answered. The system only alerted at the nurse's station, and CAT phones were not in use, leaving staff unaware of activated call lights. Interviews revealed a lack of awareness and communication about the system's status, resulting in unmet expectations for timely responses.
A resident's dignity was compromised when a CNA pulled down their pants, exposing their buttocks to bystanders during an episode of aggression. The incident was captured on camera, and the resident, who was cognitively intact, felt embarrassed. The facility's dignity policy was not upheld, and the CNA involved was assigned to monitor the resident due to self-harming behaviors earlier that day.
The facility failed to manage the weight of two residents with PEG tubes, leading to discrepancies in weight records. One resident lost 21 pounds in 34 days without re-weighing or care plan updates, while another was not weighed for two months. Staff interviews revealed a lack of awareness and protocol for addressing weight changes, compounded by scale calibration issues.
A facility failed to properly manage and document tube feeding for a resident with a PEG tube. The resident, with conditions including paraplegia and dysphagia, did not have physician's orders for tube feeding intake, and there was no documentation on the MAR/TAR for two months. Observations showed the tube feeding bag was not changed every 24 hours, and the flush bag was unlabeled. Interviews revealed inconsistencies in staff understanding and documentation practices, with the ADON noting a possible issue with the resident's diet change affecting the order's presence on the TAR.
A bedbound resident with multiple medical conditions was found without an accessible call light, relying instead on a virtual assistant to call for help, which was ineffective. Staff acknowledged the issue, and the facility's new call light system was not fully operational, requiring staff to check a monitor for alerts.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse during an unwitnessed altercation. One resident with chronic pulmonary edema, end stage renal disease, congestive heart failure, chronic kidney disease, ADL self-care deficits, limitations in physical mobility, and moderate cognitive impairment reported that another resident entered the room via the shared bathroom and physically assaulted them. The resident stated that the other resident hit them an unknown number of times, including kicking the dialysis port and scratching the face, leading to significant pain and a request for hospital evaluation. The other resident involved had a history of CVA with hemiplegia, idiopathic peripheral autonomic neuropathy, congestive heart failure, muscle wasting and atrophy, and major depressive disorder, and was care planned as having potential for verbal and physical aggression. This resident initially wrote that the first resident entered their room through the bathroom and took cigarettes, prompting them to stand up and chase the first resident back to their room, where the first resident allegedly threw a walker, causing a fall. In a later interview, this resident admitted to punching the other resident three times because of the alleged theft of cigarettes, and reported losing balance and falling, resulting in right hip pain for about a day. Clinical documentation and hospital records confirmed injuries to the first resident, including a chest wall contusion and facial abrasion attributed to a physical assault, with pain levels documented as high as 8–9 out of 10 on subsequent shifts and treatment with oxycodone. A skin assessment noted a scratch with scab near the right nostril. The second resident reported right hip pain after the fall. Staff interviews confirmed that the incident was considered abuse, that it was unwitnessed and over before staff entered the room, and that the residents had engaged in a physical altercation resulting in injuries to both, demonstrating that the facility did not prevent resident-to-resident physical abuse as required by its abuse, neglect, and exploitation policy.
Failure to Maintain Functional Call Light System and Timely Response to Resident Calls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the call light system operated as designed, that call lights were accessible to residents, and that call lights were answered in a timely manner, as required by facility policy and resident care plans. The facility’s written policy required a functioning call system at each bedside, toilet, and bathing area, with alerts either directly to staff or to a centralized location, and required staff to keep call lights within reach and respond promptly. Review of the Device Activity Report for one hall over several weeks showed an average call light response time of approximately 70 minutes, with many individual calls taking from over 20 minutes to many hours, including one documented response time of over 1,100 minutes. Staff interviews confirmed that there were no audible or visual hallway alerts, that staff relied solely on a computer screen at the nurse’s station, and that the sound on the system was often turned down. Multiple residents with significant mobility, respiratory, and ADL deficits reported prolonged waits for assistance and difficulty accessing call lights. One cognitively intact resident with hemiplegia, polyneuropathy, foot drop, generalized muscle weakness, unsteadiness, and a history of falls stated that call lights were sometimes not answered for hours, including waits of up to 5 hours, and reported having to call 911 from a cell phone because staff did not respond. Device Activity Reports for this resident documented several extended response times, including one of 350 minutes. Another cognitively intact resident with COPD, anxiety, and depression, on continuous oxygen, reported waiting up to 3 hours for call lights to be answered, including episodes where oxygen ran out and assistance was delayed until the next shift. A third cognitively intact resident with hemiplegia, COPD, acute respiratory failure with hypoxia, and a history of falls reported that staff took hours to answer call lights, that family and friends had to seek staff for help with shortness of air, and that there were times when no one came until the next shift; this resident also reported incontinence episodes because staff did not respond. Additional residents with significant physical and cognitive impairments experienced similar issues. One cognitively intact resident with hemiplegia, difficulty walking, muscle weakness, need for personal care assistance, and repeated falls reported waiting hours for call lights to be answered, sometimes being unable to reach the call light, and remaining in urine and/or bowel for hours before being changed; this resident was observed attempting to transfer from a wheelchair to bed without being able to reach the call light. A resident with severe cognitive impairment, COPD, dysphagia, incontinence, and continuous oxygen was observed in bed with the door closed, unable to reach the call light, coughing, choking on saliva, and short of breath; this resident reported often being unable to reach the call light, waiting hours for help, and lying in urine and bowel for hours when staff did not respond. Another resident with multiple sclerosis, muscle weakness, reduced mobility, hemiplegia, and need for total assistance reported that call lights were on for over 30 minutes and often for multiple hours, including one episode where a call light activated at about 1:00 a.m. was not answered until nearly 8:00 a.m., during which the resident lay in urine. During observation, this resident’s call light had been on for over 30 minutes with no hallway light or audible alert, while a CNA sat at the nurse’s station using a cell phone until prompted by another CNA to answer the light. Staff interviews corroborated that the call light system did not provide adequate audible or visual alerts and that response expectations were not met. A CNA stated that the call light system was broken, that staff only knew a call was active if they were looking at the computer screen at the nurse’s station, and that there were no lights above resident rooms or sounds in the hallways when call lights were activated. An RN reported that CNAs were expected to answer call lights within 10 minutes but that staff only knew about calls by looking at the nurse’s station screen, with no lights or sounds elsewhere, and acknowledged extended call light times. An LPN stated that policy required call lights to be answered within 10 minutes, that the computers at the nurse’s station were the only alert mechanism, and that the sound on the system was often turned down. These observations, interviews, and records demonstrate that the facility failed to maintain a functional, accessible call light system and failed to ensure timely staff response to call lights for multiple residents with significant ADL, mobility, and respiratory needs.
Failure to Monitor and Administer PRN Oxygen for Resident With COPD and Respiratory History
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen as ordered and to assess and monitor oxygen saturation levels and respiratory status for a resident with significant pulmonary diagnoses. The resident was readmitted with COPD, acute respiratory failure with hypoxia, and pneumonia, and had a care plan identifying potential for decline in respiratory status related to COPD exacerbations. The care plan interventions included administering medications and inhalers as ordered, monitoring for effectiveness and side effects, and monitoring and documenting changes such as increased restlessness, anxiety, air hunger, and signs and symptoms of respiratory distress to be reported to the physician. A physician’s progress note directed staff to monitor for recurrent respiratory symptoms, monitor oxygen saturation and respiratory rate, and assess the need for supplemental oxygen if clinically indicated. The resident had an active physician order for supplemental oxygen at 2 L/min via nasal cannula as needed for oxygen saturation less than 90% and/or wheezing and shortness of air. However, the Medication Administration Record for the entire month showed no documentation of oxygen administration and no oxygen saturation assessments; all opportunities for oxygen administration and oxygen saturation assessments were blank. The facility’s own oxygen administration and vital signs policies required that oxygen be administered under physician orders, that staff document initial and ongoing assessments and responses to oxygen therapy, and that oxygen saturation be assessed for residents requiring oxygen at intervals specified by the physician. The vital signs policy also identified oxygen saturation as a vital sign, with an acceptable range above 90%, and required vital signs when a resident’s general condition changed or when nonspecific symptoms of physical distress were reported. Interviews and observations further demonstrated that the resident’s respiratory needs and orders were not being implemented or monitored as required. The resident, who was cognitively intact, reported having pneumonia three times since admission, having oxygen ordered by the physician, experiencing shortness of air at night, and that staff did not check oxygen saturation levels. An oxygen saturation summary showed the resident’s oxygen saturation was assessed on one date in early September and not again until early March, indicating a long gap in monitoring. During observation, the resident stated they were not being administered oxygen, and there was no oxygen concentrator or portable oxygen tank in the room, despite the as-needed oxygen order and reported shortness of air. Staff interviews revealed inconsistent practices and lack of awareness of the resident’s respiratory orders and monitoring needs. An RN stated it was standard practice to obtain vitals once per month, acknowledged not always documenting vitals in the EMR, had not assessed the resident’s oxygen saturation level, did not know when it was last assessed, did not know if the resident had an oxygen concentrator, and was unaware of the resident’s respiratory assessment and monitoring orders, despite knowing the resident had COPD and recent pneumonia. A CMT reported the resident complained of shortness of air and that this was reported to the RN, but the CMT did not assess oxygen saturation and stated CMTs had no place to document oxygen saturation in the EMR and were not aware of the resident’s respiratory and oxygen orders because those appeared only on the nurse’s side of the EMR. CNAs reported that nurses or CMTs were responsible for vitals, that they did not know how to access care plans or resident-specific oxygen and monitoring orders, and that they did not monitor oxygen saturation levels. An LPN described a practice of checking oxygen saturation and administering oxygen if saturation was below 90%, but this was not reflected in the resident’s documentation. The Administrator/DON confirmed expectations that vitals be obtained monthly, that physician orders be followed, that respiratory assessments including vitals be completed when residents report shortness of air, and that residents with COPD have vitals and oxygen saturation monitored as needed, expectations that were not met in this resident’s case.
Failure to Provide Behavioral Health Services and Substance Use Care Planning Resulting in Resident Overdoses
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services, including assessment and care planning, for three residents with known substance use disorders, as required by facility policy and PASRR recommendations. The facility’s Illicit Drug and Alcohol policy and Behavioral Health Services policy required that residents with substance use disorders receive person-centered behavioral health assessments, care plans, and interventions, including care plans addressing illicit drug, marijuana, or alcohol use, increased monitoring when substance use was suspected, and access to substance abuse programming and supports. For Resident #3, the PASRR documented serious mental illness, polysubstance dependence, recent methamphetamine use, and recommendations for substance abuse programming such as community-based treatment, 12-step programs, and residential/intensive treatment. Despite this, the medical record contained no risk assessments related to substance use/abuse, no documentation of substance abuse programming or NA/AA resources, and no care plan problem, goal, or interventions addressing illicit substance use or the PASRR recommendations. The facility also failed to clearly define, document, and implement restrictions and monitoring measures it imposed on Resident #3 after repeated findings of drug paraphernalia. Progress notes documented that Resident #3 was found with illicit drug paraphernalia and was placed on a 30‑day restriction, later on supervised visitation and LOA restriction, and then on a 60‑day restriction with a 30‑day discharge notice. However, there was no documentation describing what these restrictions entailed, no clear staff instructions or education on how to implement them, and no assessment of the resident’s substance use needs or resources. The care plan referenced behavior problems with possession of illegal substances, restriction, re‑education on policy, and LOA restriction, but did not specify staff interventions for LOA or supervised visitation. Facility sign‑in/sign‑out sheets for multiple dates showed no records of visitor logs or resident sign‑outs, even though staff and administration stated that Resident #3 was supposed to have someone sign him/her out and show ID when leaving the building. For Residents #1 and #2, both had documented histories of substance use disorders and serious mental illness in their PASRRs, including alcohol dependence, cocaine dependence, polysubstance abuse, and a need for 24‑hour supervision and structured oversight to prevent relapse. Resident #1’s PASRR and admission information reflected alcohol dependence, chronic psychiatric conditions, and the need for around‑the‑clock nursing care, while Resident #2’s PASRR documented recent substance use, polysubstance abuse, and a requirement for continuous protective oversight. Despite these histories, neither resident had risk assessments related to substance use/abuse, and their care plans lacked any focus, goals, or interventions addressing alcohol or other substance dependence. There was also no documentation of NA/AA resources, education, or attendance for either resident. These failures in assessment, care planning, and implementation of behavioral health and substance use interventions preceded an incident in which Resident #3, who had a known history of polysubstance abuse and was on restriction, obtained fentanyl and used it in his/her room. According to the facility’s Suspected Abuse Investigation and nursing notes, on the evening in question Resident #3 was actively using a substance in his/her room when Residents #1 and #2 entered. Resident #3 told them to take a hit of the illicit substance, Resident #2 held the foil, and both Residents #1 and #2 used the substance and then became unconscious. Resident #3 later went to the nurses’ station requesting Narcan, and staff found one resident unresponsive in a wheelchair and the other unresponsive on the floor, both with pulses but not responding. LPNs administered Narcan to both residents, who responded after second doses, and EMS transported them to the hospital. Hospital records for Resident #1 documented an admission for overdose, with a history that he/she had been smoking fentanyl with another resident, accidentally overdosed, and was found unresponsive, and that he/she had never used fentanyl before but wanted to experience the high. Hospital records for Resident #2 documented an admission for pulmonary edema and drug overdose, with a history of polysubstance abuse and current use of liquor, cocaine, methamphetamines, and fentanyl, and that he/she reported planning to smoke methamphetamines with a friend but instead was given fentanyl and overdosed. Interviews with Residents #1 and #2 confirmed that they smoked what they believed to be methamphetamine with Resident #3, later learned it was fentanyl, and lost consciousness. Interviews with staff and residents also confirmed that Resident #3 had been on restriction due to prior paraphernalia findings, that staff did not search residents on return from LOA, that sign‑out procedures were not consistently documented, and that there was no special monitoring beyond the expectation that someone sign the resident out, which was not reflected in the facility’s sign‑in/sign‑out records.
Failure to Properly Notify Guardian After Resident Fentanyl Overdose and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court‑appointed guardian in a timely and effective manner after the resident overdosed on fentanyl, required emergency treatment, and was sent to the hospital. The resident had diagnoses including paranoid schizophrenia, bipolar disorder, and a history of traumatic brain injury, and had a court‑appointed guardian whose phone number, email, and address were listed in the admission record. On the date of the incident, progress notes documented that Narcan nasal spray was administered at 6:48 p.m. and again at 6:53 p.m., after which the resident took a deep breath, and the guardian was documented as notified at 6:58 p.m. The facility’s suspected abuse investigation documented that at approximately 6:40 p.m. the resident overdosed on an illicit substance, received two doses of Narcan, became alert and oriented, and was transported by ambulance to the hospital for further evaluation. Agencies notified were listed as the Department of Health and Senior Services, the provider, and the resident’s guardian. However, subsequent email communications showed that when the Social Services Director later emailed the guardian about an appointment, the guardian responded that the resident had personally informed the guardian about being sent to the hospital for a fentanyl overdose and that no one from the facility had contacted the guardian’s emergency cell or any deputy to report the overdose or hospital transfer. The guardian reported that only a voicemail had been left on the office line in the evening, with no indication that a return call was needed, and that there was no follow‑up contact from the facility the following day. The Administrator and DON later acknowledged that the nurse on duty had called a number and left a voicemail, but it was not the emergency number, and that the nurse had been unable to locate the emergency number at the time. The DON stated that leaving a voicemail was considered a notification and that the original public administrator was the only emergency number listed, while the guardian stated that multiple emergency contact options, including an emergency cell and a main switchboard, had been provided previously. These actions and omissions resulted in the guardian not being promptly and effectively notified of the resident’s fentanyl overdose and transfer to the hospital, contrary to the facility’s notification policy requiring prompt notification of the resident’s representative for significant changes in condition and transfers.
Failure to Implement Effective Pest Control Measures
Penalty
Summary
The facility failed to implement and maintain an effective pest control program as required by its own policy and as recommended by the pest control technician. Multiple pest control service invoices over several months documented repeated findings of rodent activity both inside and outside the building, including in resident rooms, the medication room, and common areas. The pest control technician consistently identified structural deficiencies such as holes in resident rooms, gaps under exterior doors, misaligned door frames, and cracks in walls and floors, all of which created potential entry points for rodents. Despite these findings, the facility did not address the technician's recommendations, such as sealing holes, repairing doors, and moving dumpsters further from the building. Observations during an environmental tour confirmed the presence of numerous unsealed holes and cracks in resident rooms, hallways, and exterior areas. Mouse droppings, glue traps, and direct sightings of mice were noted in several resident rooms and common areas. Residents reported frequent encounters with mice, including mice running in rooms, being caught in traps, and eating through personal food items. Staff interviews corroborated these observations, with housekeepers and CNAs reporting regular findings of mouse droppings, especially in rooms where food was stored, and documenting pest issues in the pest control log. The facility's Room Readiness checklists did not document the presence of wall holes in resident rooms, and maintenance staff acknowledged that pest control recommendations had not been prioritized or fully addressed. The maintenance director cited challenges such as the age of the building, misaligned door frames, and difficulties in moving dumpsters due to yard terrain. The administrator confirmed that pest control issues had not been the facility's top priority, and that protocols for regular room checks were only recently initiated. As a result, the facility failed to take aggressive and timely measures to prevent or minimize rodent infestation, potentially affecting all residents.
Failure to Transcribe and Clarify Opioid Pain Medication Orders
Penalty
Summary
A deficiency occurred when the facility failed to correctly transcribe and clarify physician orders for an opioid pain medication for a resident admitted with frostbite and necrosis of the left foot, as well as a non-pressure chronic wound. The hospital discharge instructions specified an order for Oxycodone 5 mg every six hours as needed for severe pain, but the facility's physician order sheet listed Oxycodone-Acetaminophen 2.5 mg-325 mg instead. This discrepancy led to the medication not being received from the pharmacy, and the resident did not receive the prescribed opioid pain medication. The resident's medication administration record showed that the ordered opioid medication was not administered because it was not received from the pharmacy. Nursing staff provided alternative non-opioid pain medications, and documentation indicated that the resident's pain was controlled during the day, though the resident reported increased pain at night. The resident did not request pain medication during the night shift and did not notify staff of uncontrolled pain at that time. Interviews with nursing staff and the DON revealed that the facility did not have an emergency medication kit for new admissions or medication changes, and there was a lack of follow-up and documentation regarding attempts to obtain the opioid medication. The pharmacy required a written or electronic prescription from the physician, which was not initially provided, and the discrepancy in dosage further delayed the process. The physician was not made aware that the resident had not received the prescribed medication until several days after admission.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in a serious altercation between two residents. One resident, who had a history of paranoid schizophrenia and generalized anxiety disorder and was moderately cognitively impaired, was attacked by another resident who was cognitively intact and had diagnoses including psychoactive substance abuse, liver cell carcinoma, and adjustment disorder with anxiety. The aggressor followed the victim into a vending machine room, approached from behind, and struck the victim multiple times on the head with a solid wood and metal cane, causing a laceration that required stitches, bruising to the eye socket, and defensive injuries to the fingers. The incident was captured on facility video, which showed the aggressor holding the cane in a batting position and striking the victim without provocation. Witnesses and interviews confirmed that the victim did not engage with the aggressor prior to the attack and attempted to defend themselves only after being struck. The victim expressed fear of the aggressor and reported pain and difficulty using the injured fingers. The aggressor admitted to intentionally hitting the victim and stated this was a deliberate act, despite initially providing conflicting accounts of the event. Facility records and interviews indicated there were no prior documented conflicts or behavioral indicators between the two residents that would have predicted the assault. Staff were not alarmed by the aggressor's behavior prior to the incident, and the cane used in the attack was not previously seen with the aggressor. The facility's policies required ongoing assessment and monitoring of residents with behaviors that might lead to conflict, but these measures did not prevent the incident. The event resulted in significant physical harm to the victim and required intervention by law enforcement and medical personnel.
Excessively Low Weekend Staffing Levels
Penalty
Summary
The facility reported excessively low weekend staffing levels to the Centers for Medicare and Medicaid Services (CMS) through the mandatory submission of staffing information in the Payroll-Based Journal (PBJ). This deficiency had the potential to impact 112 residents by not providing the necessary care and services required. The facility's policy on nursing services and sufficient staff emphasizes the need to provide adequate staffing with appropriate competencies to ensure resident safety and well-being, considering the facility's census, acuity, and resident diagnoses. However, the staffing data report for the third and fourth quarters of 2024 indicated excessively low weekend staffing, with the facility receiving a one-star staffing rating. Interviews with facility staff revealed ongoing challenges in meeting staffing needs, particularly on weekends. The Staffing Coordinator/Human Resources (SC/HR) acknowledged the difficulty in maintaining adequate staffing levels, citing issues with staff not showing up despite continuous hiring efforts. Similarly, the Director of Nursing (DON) confirmed the challenges in scheduling and covering weekend shifts. These staffing deficiencies were documented through interviews and policy reviews, highlighting the facility's struggle to comply with its own staffing policy and the potential impact on resident care.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight hours per day, as required by regulations. This deficiency was identified through the facility's mandatory submission of staffing information to the Centers for Medicare and Medicaid Services (CMS) via the Payroll-Based Journal (PBJ). The report indicated that there were no RN hours recorded for three out of four quarters in 2024, specifically the first, second, and fourth quarters. This lack of RN coverage had the potential to impact the care and services provided to 112 residents. Interviews conducted during the investigation revealed challenges in staffing. The Staffing Coordinator/Human Resources (SC/HR) acknowledged difficulties in hiring RNs for the night shift, despite efforts to recruit through various channels such as newspapers, media sites, and the facility's website. The Director of Nursing (DON) confirmed the absence of RN coverage for the specified quarters, corroborating the findings from the PBJ reports. The facility's policy on nursing services emphasized the importance of sufficient staffing to ensure resident safety and well-being, yet the facility failed to meet this standard during the identified periods.
Deficiency in Dietary Management and Food Service
Penalty
Summary
The facility failed to employ a Certified Dietary Manager (CDM) or other qualified professional to manage the dietary department in the absence of a full-time Registered Dietitian. This deficiency was identified through observation, interviews, and document reviews. The Dietary Manager (DM) admitted to not having completed a certification course for dietary managers or any formal training in food or nutrition services, having assumed the role after working as a cook for two years. The facility also failed to ensure that food was palatable and served at appetizing temperatures, as evidenced by consistent complaints in the Resident Council Meeting Minutes over five months. Additionally, the facility did not honor a resident's preference for a sandwich to be included in lunch and dinner meals. Furthermore, the facility did not maintain sanitary conditions for food storage, preparation, and distribution, as confirmed by the Director of Nursing (DON), who acknowledged that the DM did not meet the necessary criteria.
Sanitation Deficiencies in Food Handling and Service
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and distribution, potentially affecting all 112 residents who consumed food from the kitchen. During an inspection, the handwashing sink in the kitchen was found to provide only cold water, not meeting the FDA's recommended temperature of 85 degrees Fahrenheit. Additionally, several pieces of kitchen equipment, including a food processor, can opener, juice dispenser, and microwave, were observed to be soiled with food residue and not properly cleaned. The walk-in refrigerator contained undated and unlabeled food items, such as health shakes and cooked pork loins, which were not stored according to the facility's policy. Staff practices further contributed to the unsanitary conditions. A dietary aide was observed handling clean water pitchers with the same gloves used for soiled dishes, and did not properly wash hands with soap and friction as required. During meal service, the Assistant Dietary Manager failed to record temperatures for certain food items, which were later found to be below the safe temperature range, necessitating reheating. On another occasion, food items on the tray line were also found to be held at unsafe temperatures and required reheating. The delivery of meal trays to residents' rooms was also problematic, as desserts were served uncovered, exposing them to potential contamination. This occurred on multiple occasions, with staff, including the Director of Nursing, acknowledging the issue. The lack of proper food covering during transport and the use of an uncovered cart further compromised the sanitary conditions of the meals served to residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of refuse and garbage, as observed by surveyors. During multiple observations on different dates, the lid of the dumpster located behind the kitchen was found open. This was confirmed through an interview with the Dietary Manager, who stated that all departments in the facility were responsible for discarding garbage in this area and were expected to close the lid after use. The open dumpster lid had the potential to increase the risk of rodents and other pests, which could affect all 112 residents residing at the facility.
Facility Lacks QAPI Plan for Resident Care Improvement
Penalty
Summary
The facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan that outlines the process for guiding care and services provided to residents and measuring improvement. This deficiency was identified during a survey when the Director of Nursing (DON) and the Administrator were unable to provide a QAPI plan upon request. The facility's policy, revised in March 2020, states that the QAPI program is overseen by a committee that reports to the administrator and governing body. However, the Administrator, who was new as of January 2025, admitted to not knowing what a QAPI plan is and confirmed that the facility did not have one. The DON mentioned that there had only been one meeting with staff regarding clinical pathways, but no specific improvement programs were identified, and previous meeting records with the former Administrator could not be found. This lack of a QAPI plan had the potential to impact the care and services for 112 residents.
Facility Fails to Address Resident Council Grievances
Penalty
Summary
The facility failed to address and resolve grievances repeatedly voiced by the Resident Council, which included concerns about food palatability, staff-to-resident interactions, pest control, and call light response times. During a group meeting, residents expressed dissatisfaction with the temperature of food served in their rooms, noting it was often cold. They also reported issues with staff being distracted by personal activities, such as using cell phones, and a persistent mouse problem within the facility. The Resident Council minutes from September 2024 through February 2025 documented these concerns repeatedly, yet no actions were taken to address them. The minutes highlighted ongoing issues with cold food, rude staff interactions, mouse sightings, and delayed call light responses. Despite these documented grievances, the facility did not provide any follow-up or resolution to the council, leading to feelings of being ignored among the residents. Interviews with residents, including the Resident Council President, confirmed that their concerns were not acted upon, and no resolutions were presented. The Director of Nursing acknowledged the lack of grievance forms or resolutions related to these issues and admitted that no actions had been taken to address the residents' concerns. The facility's policies on Resident Council and grievance handling were not followed, as no tracking or corrective actions were implemented.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by incidents involving four residents. Resident 52, who was cognitively intact, reported being hit by their former roommate, Resident 26, who had a diagnosis of vascular dementia and a history of physical aggression. The altercation was not witnessed, but the police were called, and both residents were separated. Resident 26's care plan included interventions for managing aggressive behavior, but the incident still occurred. Another incident involved Resident 31 and Resident 24. Resident 24, who had mild cognitive impairment and a history of physical and verbal behavioral symptoms, approached Resident 31 in the dining room and grabbed their arm. Staff intervened, but Resident 24 struck a staff member while being wheeled away. Resident 31, who was cognitively intact, later reported feeling that the interactions with Resident 24 were abusive, as Resident 24 continued to approach them aggressively in subsequent encounters. The facility's policy on abuse prevention emphasizes protecting residents from abuse by anyone, including other residents. However, the incidents involving Residents 52, 26, 31, and 24 indicate a failure to effectively implement this policy, as evidenced by the repeated altercations and the residents' feelings of being unsafe. The facility's administrator acknowledged that resident-to-resident altercations could be considered abusive if there was intent to harm, but the investigation into these incidents did not consistently recognize them as abuse.
Failure to Report Resident Altercations
Penalty
Summary
The facility failed to implement policies and procedures for reporting suspected abuse, neglect, or theft in accordance with section 1150B of the Act. This deficiency was identified for four residents during a review of abuse cases. The facility did not report incidents involving resident-to-resident altercations to the state survey agency (SSA) within the required timeframe. For instance, an altercation between two residents, where one resident punched the other, was not reported to the SSA within two hours as required for abuse occurrences. In another case, a resident reported having issues with another resident, which led to a physical altercation in the dining room. The incident involved one resident grabbing and striking another resident's arm, as well as hitting a staff member. Despite these events, the facility's Administrator did not report the incidents to the SSA, citing that neither resident felt threatened or scared. This lack of reporting was contrary to the facility's policy, which mandates immediate reporting of such incidents. The facility's policies on abuse, neglect, exploitation, and misappropriation require that any allegations be investigated and reported within specific timeframes. However, the facility failed to adhere to these policies, as evidenced by the unreported incidents involving the residents. The Administrator, who is responsible for reporting abuse, did not fulfill this obligation, resulting in a deficiency in the facility's compliance with federal requirements.
Failure to Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to investigate allegations of resident-to-resident abuse involving four residents. One incident involved a resident with intact cognition who allegedly hit another resident with moderately impaired cognition. The facility's incident report noted physical aggression, but there was no evidence of an investigation, including statements from the involved residents or interviews with staff and other residents. The administrator acknowledged the lack of investigation and stated it should have been conducted thoroughly. Another incident involved a resident with moderately impaired cognitive capabilities who allegedly grabbed and struck another resident with intact cognitive ability. The Director of Nursing initially claimed the investigation was complete, but upon further questioning, it was revealed that essential components such as witness statements and root cause analysis were missing. The investigation documents were only printed on the day the investigation was requested, indicating a lack of timely and thorough investigation. The facility's policy on abuse prevention and investigation requires a comprehensive approach, including reviewing documentation, interviewing involved parties, and observing interactions. However, the facility did not adhere to these guidelines, as evidenced by the incomplete investigations and lack of documentation. The administrator's statement that the incident was not considered abuse because neither resident felt threatened further highlights the facility's failure to follow its own policies and federal requirements for investigating and reporting abuse allegations.
Documentation Discrepancies in Narcotic Administration
Penalty
Summary
The facility failed to ensure that the electronic medication administration record (MAR) matched the Controlled Drug Administration Record Tablet for three residents, leading to discrepancies in the documentation of administered narcotic medications. Resident 65, who was admitted with a diagnosis of chronic pain syndrome, experienced multiple instances where doses of oxycodone and buprenorphine were not documented on the MAR despite being administered. This inconsistency was observed over several days, with some doses not being recorded at all, and others being out of stock, increasing the risk of medication errors. Similarly, Resident 97, admitted with chronic pain, had several doses of oxycodone not documented on the MAR, despite being administered according to the Controlled Drug Administration Record. The discrepancies occurred on multiple occasions, indicating a pattern of incomplete documentation. Resident 86, with diagnoses including abdominal pain and neuropathy, also had numerous instances where doses of oxycodone were not recorded on the MAR, despite being administered as per the Controlled Drug Administration Record. Interviews with facility staff, including an LPN and an RN, revealed that while narcotics were documented on the paper narcotics log, they were not consistently recorded in the electronic MAR. The Director of Nursing confirmed that the EMR is the required administration record and that all medications should be documented there when administered. The facility's policies on controlled substances and medication administration emphasize the importance of accurate documentation, which was not adhered to in these cases.
Improper Labeling and Storage of Medications
Penalty
Summary
The facility failed to properly label and store medications, specifically insulin pens, on two medication carts. During an observation, it was found that two Humalog insulin pens were not labeled with the resident's name, and five Lantus insulin pens were open and not dated. Additionally, a Levemir insulin pen and a Lantus vial were found with expired open dates. Personal items such as lipstick and makeup, as well as food items like applesauce, were improperly stored with medications. The LPN responsible for the cart confirmed the pens were opened and used. In another observation, three insulin pens were opened and not dated, and a bottle of liquid Gabapentin oral solution was also opened without a date. Personal items, including a purse and cell phone, were found stored with patient medications, along with two containers of pudding. Two bottles of sterile water were found to be expired. The RN acknowledged that food should not be stored with medications and that liquids need to be dated when opened. The Director of Nursing confirmed that insulin pens should be labeled with the resident's name and dated when opened, and that food and personal items should not be stored in medication carts.
Facility Fails to Ensure Palatable and Appetizing Meals
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for all residents reviewed for food concerns. During a meal service observation, the temperatures of the food items were recorded between 170 and 190 degrees Fahrenheit before tray service. However, a test tray revealed that the food temperatures were significantly lower when served, with chicken parmesan at 123 degrees F, creamy rice at 121 degrees F, and broccoli at 110 degrees F, which affected the palatability of the food. The Dietary Manager confirmed that the temperatures impacted the taste of the food. Interviews with multiple residents revealed consistent complaints about the food being served cold and unappetizing. Residents expressed dissatisfaction with the taste and appearance of the meals, and some noted that they were not allowed to use microwaves to reheat their food. Additionally, the Resident Council Meeting Minutes indicated ongoing grievances related to food palatability over five months, which the facility failed to address adequately. This lack of action placed all residents at risk for weight loss due to unpalatable meals.
Failure to Inform Residents of Arbitration Agreement Conditions
Penalty
Summary
The facility failed to inform 29 residents and/or their representatives that signing a binding arbitration agreement was not a condition for admission or continued care. This oversight was identified through interviews, record reviews, and policy reviews. The facility's Arbitration Agreement Rider to the Admission Contract did not include a statement clarifying that residents or their representatives were not required to sign the agreement as a condition of admission. This omission placed the residents at risk of signing the agreement involuntarily. During an interview, the Admissions Coordinator confirmed that the arbitration agreement lacked the necessary statement and acknowledged that residents were not required to sign the agreement upon admission, despite the form not having a section to decline. The facility's policy on binding arbitration agreements also stipulated that the agreement must explicitly state that signing was not a condition for admission or continued care, which was not adhered to in practice.
Failure to Inform Residents of Right to Neutral Arbitrator
Penalty
Summary
The facility failed to inform 29 residents and/or their representatives about their right to select a neutral arbitrator agreed upon by both parties when signing a binding arbitration agreement. This oversight was identified through interviews, record reviews, and policy reviews conducted by the survey team. The facility's Arbitration Agreement Rider to the Admission Contract did not include provisions for the selection of a neutral arbitrator, which is a requirement according to the facility's own policy on binding arbitration agreements. During the investigation, it was revealed that the facility's Admissions Coordinator acknowledged the absence of this provision in the arbitration agreement. The undated document titled 'Signed & Uploaded Arbitration Agreements' confirmed that 29 residents had entered into these agreements without being informed of their right to a mutually agreed-upon neutral arbitrator. This deficiency placed these residents at risk of misunderstanding the arbitration process.
Failure to Offer Pneumococcal Vaccination to Residents
Penalty
Summary
The facility failed to ensure that five residents were assessed for eligibility, educated on the risks and benefits, and offered the pneumococcal vaccination. This deficiency was identified during a review of the medical records and interviews with the Infection Preventionist (IP). The IP, who had recently taken over the position, acknowledged that there was no documentation of offering, refusal, or administration of the pneumococcal vaccine for these residents. The residents involved had various medical conditions, including paraplegia, vascular disorders, peripheral vascular disease, heart disease, acute respiratory failure, and congestive heart failure. The facility's policy, dated October 2019, required that all residents be offered the pneumococcal vaccine to prevent pneumonia and pneumococcal infections. The policy stipulated that assessments of vaccination status should be conducted within five working days of admission, and the vaccine should be offered within thirty days unless contraindicated or previously administered. However, the review revealed that there was no historical documentation of the vaccine being offered or administered to the residents in question, placing them at risk for contracting pneumonia unnecessarily.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for several residents, as evidenced by multiple maintenance issues observed in six rooms. The Regional Maintenance Consultant (RMC), who was recently hired, acknowledged the presence of walls in disrepair, broken heating vents, and light fixtures, among other issues. The facility had implemented a new reporting program through their electronic medical records (EMR) system for staff to report maintenance needs, but it had only been used a few times. The RMC noted that the Maintenance Director, who had been at the facility for about a year and a half, required training on time management and prioritization. In one instance, a resident with intact cognition expressed discomfort due to the poor condition of the walls in their room, which were covered with screws, nails, chipped paint, and discolored patches. Another resident, also with intact cognition, reported the absence of a mirror in their bathroom, requiring them to walk to the shower room to see themselves. This room also had multiple small holes and unpainted patches on the walls. Additionally, the door exiting to the smoking area had a baseboard that was peeling off, exposing crumbling concrete and dirt, which the RMC confirmed could potentially allow pest access. Two residents reported a lack of heat in their room throughout the winter, forcing them to wear additional clothing for warmth. They were offered a room change, which they declined, and noted that the facility had promised to replace the heater. Their bathroom also had a ceiling vent with the cover off, holes in ceiling tiles, and walls. Other rooms had issues such as a heater cover sitting on the floor, a broken mirror, closet doors off hinges, and a broken light cover hanging over a resident's bed. The facility's policy on maintaining a safe and homelike environment was not adhered to, as these maintenance issues were not promptly addressed or reported to the Administrator as required.
Facility Fails to Address Mouse Infestation
Penalty
Summary
The facility failed to implement effective pest control measures to prevent a mouse infestation, affecting four residents and common areas. Weekly pest control service inspection reports from March 2024 to December 2024 documented ongoing treatment for mice and repeated recommendations to prevent their entry. These recommendations included fixing holes near heat registers and baseboards, rodent-proofing kitchen doors, eliminating gaps under the front door, and removing trash around the facility. Despite these recommendations, the facility did not address the issues, leading to continued rodent activity. The pest control service inspection report from January 2025 confirmed evidence of rodent activity and recorded captures. It highlighted open conditions such as a gap under the kitchen exterior entryway door sweep, trash and debris near the back door, and the need for rodent-proofing of the kitchen and front doors. These conditions were marked as high severity, with the responsibility for correction assigned to the facility. The facility's failure to act on these recommendations resulted in ongoing rodent presence. Interviews with residents revealed their distress over the mouse infestation. One resident reported seeing mice in the hall and having mouse traps in their room, while another found mouse droppings behind their nightstand and experienced mice running over their feet at night. A third resident discovered a dead mouse in their room, and a fourth found mice eating their food. The Regional Maintenance Consultant acknowledged that the facility had not addressed the pest control recommendations and noted the Maintenance Director's need for training in time management and prioritization.
Failure to Respect Residents' Rights and Privacy
Penalty
Summary
The facility failed to uphold residents' rights to privacy, dignity, and autonomy, affecting three residents. One resident, with intact cognition, experienced a breach of privacy when a housekeeping staff member entered the room without knocking, which the resident found bothersome and potentially harmful. Additionally, staff were observed speaking loudly and using inappropriate language in common areas, which disrupted another resident's privacy during a phone call. This resident also reported that the noise and language were disrespectful, and the Social Services Director was unaware of these issues. Another resident, also with intact cognition, expressed a desire not to have a meal tray left in their room, as it would not be picked up promptly. Despite the resident's repeated refusals, the Social Services Director left the tray, citing a need to offer meals, although the Director of Nursing later clarified that residents' rights to refuse meals should be respected. These incidents highlight a failure to respect residents' choices and privacy, as well as a lack of communication and awareness among staff regarding residents' rights and facility policies.
Failure to Provide Correct SNFABN Forms to Residents
Penalty
Summary
The facility failed to provide the correct Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS-10055, to residents whose Medicare Part A services were no longer covered or whose coverage was ending. This deficiency was identified for three residents. For two residents, R61 and R114, there was no documentation or evidence that the SNFABN form was provided, and no communication was recorded in their electronic medical records regarding potential additional costs if they chose to continue receiving services. For the third resident, R110, although a form was provided, it was the incorrect and expired version of the SNFABN form. During an interview, the Social Service Director (SSD) acknowledged the oversight, stating that they were unaware of the requirement to provide the correct form and did not notice the expiration of the form given to R110. The SSD confirmed that the forms should have been provided and that copies should have been available. This lack of proper notification had the potential to prevent residents from making informed decisions about their care and financial responsibilities.
Inaccurate Weight Assessment Leads to Unreported Significant Weight Loss
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's weight and significant weight loss. The resident, who was admitted with multiple medical conditions including acute kidney failure, chronic kidney disease, and type 1 diabetes mellitus, experienced a significant weight loss of 7.88% over one month. However, the quarterly Minimum Data Set (MDS) assessment inaccurately recorded the resident's weight as 195 pounds, failing to reflect the actual weight of 177.8 pounds, which should have been noted as a significant weight loss. Interviews revealed that the Dietary Manager (DM) was responsible for completing the Nutrition and Weight section of the MDS and should have used the most recent weight. The MDS Coordinator confirmed that the weight loss met the criteria for significant weight loss and should have been coded on the MDS. The DM was unaware of the significant weight loss and could not explain the discrepancy in the recorded weight. The facility's policy on conducting accurate resident assessments emphasizes the importance of correctly documenting medical and functional problems, which was not adhered to in this case.
Failure to Complete PASARR Level I Screening for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure the completion of a Pre-Admission Screening and Resident Review (PASARR) Level I screening for a resident with mental disorders, which is a requirement prior to admission. The resident, identified as R36, was admitted with diagnoses including major depressive disorder, schizoaffective disorder, post-traumatic stress disorder (PTSD), and substance abuse issues. Despite these significant mental health diagnoses, there was no evidence of a completed PASARR Level I screening in the resident's electronic medical record (EMR), which is necessary to determine the appropriateness of admission by the State mental health authority. During an interview, the Social Service Director (SSD) confirmed the absence of the PASARR Level I screening for the resident and acknowledged that it should have been completed and available in the EMR before admission. The facility's policy mandates that all applicants be screened for serious mental disorders or intellectual disabilities in accordance with State Medicaid rules, and a record of this pre-screening should be maintained in the resident's medical record. The failure to complete this screening could result in the resident residing in the facility without the necessary determination of appropriateness for admission.
Failure to Implement Safety Interventions for Residents with Substance Use Disorders
Penalty
Summary
The facility failed to develop and implement safety interventions for two residents with substance use disorders, leading to deficiencies in care. Resident 2 was admitted with diagnoses including anxiety, nicotine dependence, PTSD, alcohol abuse, and bipolar disorder. Despite testing positive for fentanyl and being implicated in providing drugs to other residents, the resident's care plan did not address their history of substance abuse or include interventions to prevent substance use within the facility. The Director of Nursing was unable to find any incident report or investigation related to the resident's substance use. Resident 32, admitted with chronic obstructive pulmonary disease, anxiety, alcohol dependence, and major depression, was found with decreased level of consciousness and tested positive for fentanyl, morphine, and suboxone. The resident was hospitalized for an opioid overdose, and it was suspected that they obtained drugs from another resident. Similar to Resident 2, Resident 32's care plan did not address their history of substance abuse or include necessary interventions for monitoring and prevention of substance use. Interviews with facility staff, including the Director of Nursing and Social Services Director, revealed an expectation for care plans to address residents' substance use disorders and include interventions such as increased monitoring, drug screening, and participation in cessation groups. The facility's policy on safety for residents with substance use disorders was not effectively implemented, as evidenced by the lack of care plan interventions for both residents.
Unsafe Storage and Unsanitary Conditions of Oxygen Equipment
Penalty
Summary
The facility failed to ensure the safe storage of portable compressed oxygen cylinders, as observed during a survey. Three oxygen cylinders were found not secured in a stand or attached to medical equipment designed to hold compressed gas cylinders. One cylinder was observed in front of the East Nurses Station, free-standing and with oxygen tubing lying on the floor, while another was found in the oxygen storage room, also unsecured. Staff interviews revealed a lack of awareness regarding the proper storage of these cylinders, with an LPN acknowledging the risk of explosion if a cylinder were to be knocked over. Additionally, the facility did not maintain respiratory equipment in a clean and sanitary manner for a resident using supplemental oxygen. The resident's oxygen tubing was found lying directly on the floor with two different dates marked on it, and the humidifier bottle was dated over three weeks prior. The oxygen concentrator filter was heavily coated with gray dust. An LPN confirmed that the tubing should not be on the floor due to contamination risks and that the equipment should be changed weekly, but the tubing was not dated to indicate when it was last changed. The facility's policies on oxygen safety were not adhered to, as evidenced by the unsecured oxygen cylinders and the unsanitary condition of the respiratory equipment. Interviews with staff, including an RN and the DON, highlighted the potential dangers of leaving oxygen cylinders free-standing, such as the risk of explosion or the cylinder becoming a projectile if the gauge were to break. The deficiencies observed pose a significant risk to the safety and well-being of residents and staff.
Failure to Address Pharmacy Recommendations for Two Residents
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were reviewed and signed by the physician for two residents, R19 and R60. R19's electronic medical record showed that the resident was admitted with diagnoses of major depression and anxiety. The pharmacist recommended a reduction in clonazepam and doxepin on 07/24/24 and sertraline on 12/23/24, but there was no response from the physician. R60's record indicated diagnoses of anxiety and major depressive disorder, with a recommendation from the pharmacist to consider a trial reduction of Ativan on 3/21/24 and 09/23/24, which also went unaddressed by the physician. Interviews revealed that the facility's process for handling pharmacy recommendations was disrupted after the departure of the former Assistant Director of Nursing (ADON), who previously managed these reviews. The Medical Director stated that recommendations, especially those concerning psychotropic medications, were typically addressed by a psychologist or nurse practitioner, with an expectation of being addressed within 30 days. However, the Director of Nursing (DON) confirmed that after the former ADON left, the facility could not locate the recommendations, leading to the oversight.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, specifically the inclusion of a sandwich with lunch and dinner meals, as documented on the resident's meal tickets. The resident, who was admitted with diagnoses including peripheral vascular disease, heart disease, and amputation of toes, had a BIMS score indicating intact cognition. Despite the resident's clear preference and the documentation on the meal tickets, the resident consistently did not receive the requested sandwich with meals. Observations and interviews confirmed the deficiency. On multiple occasions, the resident received meals without the requested sandwich, despite the tray tickets indicating that a sandwich should be included. The Dietary Manager acknowledged noticing that the resident was not receiving sandwiches as per the tray ticket instructions. This oversight in meal service could potentially impact the resident's nutritional intake, as the resident expressed that the regular meals were insufficient without the additional sandwich.
Infection Control Lapses During Medication Pass
Penalty
Summary
The facility failed to implement effective infection prevention strategies during a medication pass, as observed with three residents out of a sample of 27. Specifically, a Certified Medication Technician (CMT6) did not sanitize the blood pressure cuff before taking the blood pressure of three residents. Additionally, during medication administration, CMT6 did not perform handwashing or hand hygiene before preparing medications for one of the residents. Interviews with staff revealed inconsistencies in understanding the protocol for cleaning equipment, with the Registered Nurse (RN) stating that blood pressure cuffs should be cleaned after each use, while CMT6 initially believed it was after every 4-5 residents. The Director of Nursing (DON) confirmed that vital signs equipment should be cleaned between every resident use and that hands should be sanitized between each resident contact.
Failure to Specify Duration of Antibiotic Therapy
Penalty
Summary
The facility failed to ensure that a resident's antibiotic therapy had a specified duration and did not continue without medical necessity. The resident, who was admitted with a diagnosis of chronic obstructive pulmonary disease, received Ofloxacin Ophthalmic Solution, an antibiotic eye drop, following cataract surgery. The physician's order for the antibiotic eye drops did not include a stop date, and the medication was administered from January 10, 2024, to February 18, 2025, without reassessment of its necessity. Interviews with facility staff revealed a lack of awareness and oversight regarding the continuation of the antibiotic therapy. The LPN confirmed the absence of a stop date in the order, and the DON acknowledged the need to contact the resident's physician for clarification. The Medical Director stated that the order should have included a stop date, as the eye drops are typically used only for several weeks post-surgery. The Infection Preventionist was unaware of the ongoing administration of the antibiotic and noted that it should have been included in the facility's antibiotic tracking list, which it was not. The facility's antibiotic stewardship policy requires that all antibiotic orders include a start and stop date, which was not adhered to in this case.
Failure to Provide Dialysis Contract for Resident
Penalty
Summary
The facility failed to provide a personalized dialysis contract for a resident, identified as R31, who required dialysis services. R31 was admitted with a diagnosis of end-stage dialysis and was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident's electronic medical record (EMR) included physician orders for dialysis at the facility on specific days of the week. However, upon review, it was found that the facility did not have a signed dialysis contract in place for R31. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility was unable to locate the dialysis contract and was waiting for a copy from the dialysis center. Despite multiple requests, the facility confirmed that they had not received the necessary contract from the dialysis center. This deficiency in maintaining a dialysis contract had the potential to affect all residents receiving dialysis services at the facility.
Failure to Provide Written Discharge Notice After Emergency Transfer
Penalty
Summary
The facility failed to provide a written discharge notice to a resident and their guardian upon the resident's unplanned emergency discharge. The resident called Emergency Medical Services (EMS) and was transported to a local hospital. Documentation showed that only a verbal emergency discharge notice was given to the resident's guardian by the Director of Nursing (DON), with the intention to fax a written notice during business hours the following day. However, there was no evidence in the resident's electronic medical record or hospital records that a written discharge notice was ever provided. The resident's care plan did not include any discharge planning, and the guardian was unsure if a written notice had been received, with no record of it available. Interviews with facility staff revealed confusion regarding responsibility for completing and providing written discharge notices. The DON and acting Administrator both indicated that they believed a written notice had been or would be sent, but neither could locate a copy. The Social Services Designee stated that the Administrator was responsible for written discharge notices, and the LPN was unclear about the process. Ultimately, the facility could not verify that the required written discharge notice was given to the resident or their guardian as required by policy.
Failure to Permit Resident Re-Admission After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return following a hospitalization that exceeded the bed-hold policy, despite the facility's own policy stating that a resident should be allowed to return to an available bed in their previous location or another part of the facility if necessary. The resident was discharged to a hospital after calling EMS and was ready for discharge from the hospital, but the facility refused to re-admit the resident. Multiple attempts were made by the hospital and the resident's guardian to facilitate the resident's return, but the facility's administration and clinical team consistently denied re-admission, stating they could no longer meet the resident's needs. The Director of Nursing, Administrator, and other staff confirmed their decision not to allow the resident back, even acknowledging awareness of the regulatory requirement to permit re-admission. The resident remained in the hospital for an extended period as no other facilities accepted the referral, and the facility declined multiple referrals from the hospital. Interviews with staff revealed that the decision to deny re-admission was made by the clinical team and administration, and that the facility was aware this action was contrary to regulation. The Acting Administrator later stated that, due to the length of the resident's absence, the facility believed the resident was no longer their responsibility, despite ongoing attempts to refer the resident back within the 30-day period.
Deficient Call Light System Leads to Delayed Responses
Penalty
Summary
The facility failed to maintain an effective call light system, resulting in a significant delay in responding to a resident's call light. The call light system was not functioning properly, as evidenced by multiple instances where call lights went unanswered for extended periods, ranging from 20 minutes to over 700 minutes. The facility's policy required timely responses to call lights, but the system's failure led to a resident's call light being unanswered for approximately 20 minutes. This deficiency was observed during a survey, where it was noted that the call light system only alerted at the nurse's station, and the indicator lights outside the rooms were not working. A resident, who was cognitively intact and had a history of ventricular tachycardia, chronic obstructive pulmonary disease, and repeated falls, experienced this deficiency firsthand. The resident's call light was activated, but neither the Activities Director nor LPN A were aware of it due to the malfunctioning system. The resident expressed feelings of being ignored and unimportant to the staff. The call light system's failure was further compounded by the fact that the CAT phones, which were supposed to notify staff of activated call lights, were not in use, and the Maintenance Director was unaware of the system's status. Interviews with staff, including the Maintenance Director, DON, and Regional Director, revealed a lack of awareness and communication regarding the call light system's operational status. The Maintenance Director was not responsible for the CAT phones' maintenance, and the DON was unaware of the extent of the call light delays. The Regional Director expected call lights to be answered according to policy, but the system's deficiencies prevented this. The facility's failure to ensure a functioning call light system led to significant delays in responding to residents' needs, as evidenced by the survey findings.
Resident's Dignity Compromised by CNA's Actions
Penalty
Summary
The facility failed to maintain the dignity of a resident when a Certified Nursing Aide (CNA) pulled down the resident's pants, exposing their buttocks to bystanders. This incident occurred on 9/30/24 when the resident, who was cognitively intact and had a history of residual schizophrenia and repeated falls, attempted to leave the facility during an episode of aggression. The facility's dignity policy emphasizes treating residents with respect and maintaining their privacy, which was not upheld in this situation. The incident was captured on facility cameras, and it was confirmed that CNA B was responsible for pulling down the resident's pants. CNA C witnessed the event but failed to report it to supervisors. The Director of Nursing (DON) and the Regional Director were informed of the incident on 10/3/24, and an investigation was initiated. Interviews with the involved parties revealed that the resident felt uncomfortable and embarrassed by the incident, and CNA B was assigned to monitor the resident due to self-harming behaviors earlier that day. Despite CNA B's denial of intentional misconduct, the video evidence showed the resident's dignity was compromised.
Inadequate Weight Management for Residents with PEG Tubes
Penalty
Summary
The facility failed to ensure appropriate weight management for two residents with PEG tubes, leading to discrepancies in their weight records. Resident #8 experienced a significant weight loss of 21 pounds over 34 days, which was not addressed with a re-weighing or a change in care plan. The resident's care plan did not reflect the weight loss, and there was no order for more frequent weighing despite the facility's policy requiring re-weighing for significant weight changes. Interviews with staff revealed a lack of awareness regarding the resident's weight loss and the absence of a protocol for addressing such changes. Resident #10 also faced issues with weight management, as the resident was not weighed for two months, contrary to the facility's policy of monthly weighing. The resident's weight was only recorded after a significant gap, and there was no care plan focus or intervention related to weight management. Interviews indicated that staff were unaware of the resident's weight status, and the facility's RD had to remind staff multiple times about the need for weighing the resident. The facility's scale calibration issues further contributed to the inconsistency in weight records. Interviews with various staff members, including CNAs, LPNs, RNs, and the ADON, highlighted a lack of communication and responsibility regarding weight monitoring. The ADON acknowledged the weight loss in Resident #8 and the trial diet for Resident #10, which could have contributed to weight changes. The facility's RD and physician expressed concerns about the inconsistency in weight records and the need for re-weighing residents with significant weight changes. Despite these issues, there was no indication of corrective actions or changes in treatment plans for the residents involved.
Deficiency in Tube Feeding Management and Documentation
Penalty
Summary
The facility failed to ensure proper management and documentation of tube feeding for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. The resident, who had diagnoses including paraplegia, unspecified dementia, severe protein-calorie malnutrition, and dysphagia, was receiving Jevity 1.5 tube feeding at 55 ml per hour and required a flush of 150 ml of water every six hours. However, the facility did not obtain physician's orders to ensure the intake of tube feeding and fluids was completed, and there was no documentation on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) for February and March 2024 regarding the resident's tube feeding. Observations revealed that the tube feeding bag was not changed every 24 hours as required, with the same bottle observed on consecutive days. Additionally, the flush bag was not labeled, contrary to the facility's policy expectations. Interviews with nursing staff indicated a lack of clarity and consistency in documenting and managing the resident's tube feeding. The Licensed Practical Nurse (LPN) was unaware of the specific orders and did not expect the tube feeding administration to appear on the TAR, while the Registered Nurse (RN) acknowledged that the administration should be documented on the MAR/TAR and that the feeding bottle needed to be changed daily. The Assistant Director of Nursing (ADON) confirmed that tube feeding bottles should be hung for a maximum of 24 hours and expected staff to date and label both the tube feeding bottle and flush bag. The ADON also noted that there should be an order for the resident to receive tube feeding and a place on the TAR for documentation, but was unsure why this was not the case. The ADON speculated that a recent diet change might have caused the tube feeding order to drop from the resident's original Physician Order Sheet (POS), leading to the lack of documentation and scheduling on the TAR.
Failure to Ensure Accessible Call Light System for Bedbound Resident
Penalty
Summary
The facility failed to ensure that the call light system was operable and within reach for a resident who was bedbound and required total assistance from staff. The resident, who had multiple medical conditions including quadriplegia, stroke, and morbid obesity, was observed without a call light within reach. The resident reported that the call light was often on the floor and not accessible, and instead relied on a virtual assistant to call the facility for help, which was not always effective. During observations and interviews, it was noted that the resident's call light was unplugged and not available for use. Staff members, including a Certified Medication Technician and a Certified Nursing Assistant, acknowledged the absence of the call light and the resident's reliance on the virtual assistant. The facility's call light system required staff to check a monitor at the nursing station to see if a call light was activated, as there were no longer lights or sounds to alert staff directly at the resident's door. Interviews with the facility's staff, including a Registered Nurse, the Administrator, and the Assistant Director of Nursing, revealed that the resident's call light should have been plugged in and accessible. The facility was in the process of implementing a new call light system, but it was not fully operational at the time of the incident. Staff were expected to check on residents frequently and ensure call lights were available, but this was not consistently done for the resident in question.
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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