Parkway Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Missouri.
- Location
- 2323 Swope Parkway, Kansas City, Missouri 64130
- CMS Provider Number
- 265532
- Inspections on file
- 34
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Parkway Health Care Center during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, bipolar disorder, vascular dementia, anxiety, impulse disorder, severe memory impairment, and documented exit-seeking and wandering behaviors was admitted to a secured dementia unit. The resident expressed a desire to leave, packed belongings, pressed emergency exit doors, and wandered into other residents’ rooms. After the unit’s magnetic door locks failed, the resident first exited the building and was returned by staff. The administrator instructed an LPN to keep the resident in line of sight while the doors remained unsecured, but the LPN later went to the restroom without arranging coverage while a CMT had left and a CNA was occupied with smoke-break preparations. During this brief period without direct supervision, the resident eloped again and was later found off-site on public transit, with the facility’s investigation citing both the door-lock failure and non-adherence to policies and procedures as directly contributing to the elopement.
Multiple residents did not receive their prescribed medications as ordered, including treatments for chronic and acute conditions. Missed doses were attributed to staff shortages and medications being on order, with residents reporting they did not refuse their medications. Documentation was often incomplete, and staff, including the DON and nurse practitioner, were unaware of the extent of missed doses or lack of proper notification, contrary to facility policy.
The facility did not maintain adequate nursing staff with the necessary competencies to meet resident needs, resulting in missed medication administration and insufficient supervision, especially on the memory care and Transitional Units. On multiple occasions, only one nurse was assigned to cover both units, leading to residents not receiving scheduled medications and staff being unable to provide required checks and supervision.
A resident with complex behavioral health needs, including schizophrenia and traumatic brain injury, experienced repeated behavioral incidents such as aggression, disrobing, and falls. The facility did not develop an individualized care plan identifying behavioral triggers or de-escalation strategies, and staff lacked consistent training and access to resident-specific behavioral information. Care plans were not updated after significant events or medication changes, resulting in inadequate management of the resident's behavioral health needs.
The facility did not complete or properly document required interdisciplinary assessments for capacity to consent to sexual activity for two residents with psychiatric diagnoses and legal guardianship. Despite policy requirements, forms were incomplete or missing, signatures were lacking, and there was no evidence of proper coordination with health professionals or guardians. Staff interviews confirmed that assessments were not consistently performed.
A broken window in a locked behavioral and mental health unit, caused by a resident with a history of aggression and cognitive impairment, was left unrepaired with glass shards accessible to all residents for over three weeks. Facility staff were aware of the hazard but did not ensure timely communication or action to secure the area or remove the glass, contrary to facility policy.
The facility failed to maintain residents' dignity and personal possessions, as several residents were observed wearing ill-fitting or incorrect clothing. Issues included outdated inventories, lack of proper labeling, and residents wearing clothes that did not fit or belong to them. Staff acknowledged the problem but did not adequately address it, despite residents having funds available for clothing.
The facility failed to accurately complete MDS assessments for several residents, resulting in deficiencies in care planning. A resident's activities and cognitive assessments were incomplete, while another's care plan lacked necessary assistance details. Additionally, a resident's dental issues were not documented, and cognitive patterns were missed for a resident in a Memory Care Unit. The MDS Coordinator and other staff acknowledged these oversights.
The facility failed to notify residents or their representatives about care plan meetings, affecting seven residents. Despite policies emphasizing person-centered care, there were no instructions for inviting residents to meetings. Interviews revealed that residents and their representatives were unaware of or not invited to meetings, and staff showed confusion about the invitation process.
The facility failed to maintain adequate dietary staffing to meet food and nutrition service requirements, affecting all individuals consuming food from the kitchen. Observations showed the Dietary Manager often working alone or with reduced staff, leading to the use of disposable dining ware due to the absence of a dishwasher. The deficiency was attributed to staffing cuts related to a low resident census.
The facility did not follow pre-prepared menus, failing to meet residents' nutritional needs as required by regulations. Observations showed a lack of basic food items and no alternate menus posted. The Dietary Manager revealed issues with food ordering and substitutions, leading to meals not matching the scheduled menu, potentially affecting all who ate from the kitchen.
The facility failed to maintain proper food safety and sanitation standards, with issues such as unclean floors, lack of operable thermometers, and improper food storage. Observations included dented and rusted cans, blood puddling in a refrigerator, and unrefrigerated open jugs of sauces. Additionally, kitchen utensils and equipment were not maintained in good condition, with paper residue on a can opener, chipped spatulas, and a flaking cutting board, potentially affecting all who consumed food from the kitchen.
The facility lacked a clear policy for handling and storing food brought in by visitors, as observed during a kitchen inspection. The Dietary Manager was unaware of any existing policy, despite the Dietary Resident Rights Policy indicating that such food should be considered personal property and stored safely. This oversight could impact all residents consuming outside food.
The facility failed to maintain a comprehensive infection prevention program, lacking specific Legionella management and incomplete infection tracking. TB testing for residents and staff was inadequate, with missing documentation and incomplete tests. Enhanced Barrier Precautions were not properly implemented, with insufficient PPE use and lack of staff education. Hygiene supplies were missing, and cleanliness issues were observed.
The facility did not designate a qualified Infection Preventionist (IP) for its Infection Prevention and Control Program. The DON, acting as the IP, had not passed the IP certification test and did not spend the required 20 hours per week on infection control duties due to other responsibilities. A policy for the IP was not provided during the survey.
The facility failed to maintain essential kitchen equipment, including a stove, chemical dishwasher, and convection oven, in proper working condition. The stove required early activation to be warm enough for use, the dishwasher's thermometer was broken, and the convection oven operated poorly. The Dietary Manager and Administrator confirmed these issues, with the latter noting the need for a complete kitchen renovation.
The facility's locked dementia unit was found lacking in hygiene supplies and maintenance, with several rooms missing toilet paper, paper towels, and soap. Observations revealed broken fixtures and unsanitary conditions, including mold-like substances and feces. Staff interviews indicated a lack of consistent hygiene practices, with concerns about residents misusing supplies. The DON and Administrator acknowledged the issues, noting plans for repairs and emphasizing the need for hygiene supplies and assistance.
The facility failed to provide written notification of hospital transfers for three residents, as required by policy. Despite being responsible for sending transfer notices, the nursing staff did not issue them for the affected residents, who were cognitively impaired and discharged to hospitals multiple times without proper documentation.
The facility failed to provide bed hold notifications to three residents upon hospital transfer, as required by their policy. Despite the policy stating that residents or their representatives should receive a copy of the bed hold policy during such transfers, documentation was missing for these instances. Interviews with the DON and LPNs confirmed the oversight, with nurses responsible for the notifications unsure why they were not given.
The facility failed to develop comprehensive care plans for three residents, leading to unmet needs. One resident's care plan lacked activity preferences, another's did not address a broken tooth, and a third's failed to address language barriers. Staff were unaware of these issues, indicating lapses in communication and care planning.
The facility failed to assist three residents with oral care, despite their inability to perform these activities independently. One resident, who was severely cognitively impaired, did not receive necessary assistance, and staff were unaware of who was responsible for oral care. Another resident, needing substantial help, lacked a toothbrush and toothpaste, and staff had not provided assistance. A third resident, requiring supervision, also lacked access to oral care supplies, which were locked away. Observations showed that most residents on the locked unit did not have oral care supplies, and staff were unsure of their location or documentation.
The facility failed to provide an ongoing activities program for residents, resulting in minimal participation and engagement. Several residents, including those with cognitive impairments, were not involved in activities due to the absence of an activities director and a lack of scheduled events. Staff interviews revealed confusion about responsibilities, and communication barriers further hindered resident engagement.
The facility failed to maintain a safe environment by allowing tripping hazards and inadequate supervision, particularly in the dining room where a resident was left unattended in a broken wheelchair. The resident, with cognitive impairments, attempted to stand, risking a fall. Additionally, improper transfer techniques were used to lift the resident from the floor, contrary to the care plan requirements.
The facility failed to post staffing information correctly at the beginning of each shift, as required. Observations and staff interviews confirmed the absence of posted staffing sheets at the entrance reception desk, nurse's stations, and designated halls. The Director of Nursing acknowledged the deficiency, noting that staffing sheets should be visible to residents and visitors.
The facility failed to ensure proper narcotic count procedures, leading to discrepancies in narcotic count sheets and potential medication errors. Nursing staff did not consistently count narcotics together at shift changes, resulting in blank slots on count sheets. Specific instances of non-compliance were noted, including missing signatures and incorrect medication administration for residents. Staff interviews revealed a lack of awareness and training regarding proper procedures.
The facility failed to implement gradual dose reductions (GDR) for two residents on psychotropic medications and did not conduct necessary lab tests for another resident. A resident with severe cognitive impairment did not receive a GDR despite pharmacist recommendations, and another resident's lithium levels were not monitored as required. Additionally, a third resident on multiple psychotropic medications had no documented physician response to GDR recommendations. The Director of Nursing acknowledged the lack of documentation and follow-up on these issues.
The facility failed to lock medication carts when not in direct observation, with carts left unattended in hallways as residents passed by. Additionally, medication carts contained unrelated items like applesauce, hand sanitizer, and bleach wipes, and had loose pills in drawers. Staff interviews confirmed these practices violated facility policy.
The facility failed to maintain an effective antibiotic stewardship program, with significant gaps in documentation and tracking of infections and antibiotic usage over a year. Several residents were prescribed antibiotics, but these were not included in the stewardship program. The DON acknowledged the lack of tracking and mentioned efforts to start monitoring antibiotic usage in the electronic medical record.
The facility failed to provide education and document consent or declination for influenza and pneumococcal vaccines for four residents. The policy requires education upon admission, but records lacked documentation for these residents, indicating a process failure.
The facility failed to document COVID-19 vaccine education for a resident and two staff members. The resident's medical record lacked documentation of vaccine education, administration, or declination since admission. Similarly, two staff members' records were missing documentation of vaccine education or declination. The DON stated that such documentation should be included in resident progress notes and employee files upon hire, but this was not done.
The facility failed to provide the required 12 hours of annual in-service training for CNAs, with insufficient in-person sessions and online training. Additionally, no competency reviews were conducted for CNAs over the past year, and the DON did not track in-service hours for nursing staff.
A resident with limited English proficiency was not provided with adequate translation support, hindering their evaluation and participation in activities. The facility lacked documentation of the resident's language needs, and staff were unaware of the resident's primary language. Attempts to use phone translators were unsuccessful, and there was no translation phone line or picture gram available. The resident's care plan and assessments were incomplete, highlighting a significant gap in accommodating language barriers.
The facility failed to provide the required NOMNC and SNF ABN to two residents discharged from Medicare Part A benefits. This deficiency occurred due to a lack of proper communication and responsibility assignment, as the Social Services Director was unaware of their duty to issue these notices. Consequently, the residents or their representatives were not informed about the end of Medicare coverage and potential liability for non-covered services.
A resident with severe cognitive impairment was allegedly touched inappropriately by another resident. The guardian reported the incident, but the facility failed to notify the state agency within the required timeframe due to inconclusive information and lack of harm evidence. The report was delayed by a week, violating the facility's policy.
A facility failed to accurately complete the MDS for a resident, omitting the BIMS assessment and cognition score. The resident had anxiety and depression, which could affect cognition. The temporary MDS Coordinator and DON acknowledged the oversight, noting the MDS should be completed on admission, annually, and with significant changes.
A facility failed to complete a significant change assessment within 14 days for a resident placed on hospice care. The resident's care plan did not include hospice services, and the MDS Coordinator and DON acknowledged the oversight.
The facility failed to ensure that residents with mental disorders and intellectual disabilities had the necessary PASRR screenings and did not integrate PASRR recommendations into care plans. One resident with a complex psychiatric history did not have all relevant diagnoses reflected in their care plan, and another resident's PASRR was missed entirely. Staff interviews revealed a lack of awareness and communication regarding residents' mental health needs.
A facility failed to follow up on a request for monitoring after a resident's chemotherapy and radiation treatment for cancer. The resident's responsible party raised concerns about oncologist visits and prostate exams, but these were not addressed. The facility lacked a policy for this care area, and there was no diagnosis of cancer in the resident's records, despite a history of liver cancer. Communication issues and a lack of follow-up contributed to the deficiency.
The facility failed to provide necessary vision services to two residents. One resident was observed without glasses despite needing them, and there was no documentation of their vision needs. Another resident reported needing new glasses but had not been assessed or seen by an eye doctor. Staff interviews confirmed the lack of action in addressing these residents' vision needs.
The facility failed to ensure that the Medication Regimen Review (MRR) by the pharmacist was reviewed and responded to by the physician(s), and did not monitor for side effects of antipsychotic medications for two residents. One resident was not monitored for side effects of psychotropic medications, and the pharmacist's recommendations for a Comprehensive Metabolic Panel (CMP) were not followed. Another resident's pharmacy review notes included instructions for a lipid panel and assessment of medication risks, but there was no documented response. Both residents received antipsychotic medications without proper monitoring or response to pharmacist recommendations.
The facility failed to provide necessary dental care for two residents, resulting in deficiencies. One resident had a broken tooth upon admission and did not receive timely dental services despite repeated requests. Another resident experienced discomfort with ill-fitting dentures, affecting their ability to eat, and had not been seen by a dentist despite a consult order. Interviews revealed a lack of communication and responsibility among staff for scheduling dental appointments.
A resident with severe cognitive impairment experienced a significant decline in condition, but the facility staff failed to notify the family in a timely manner. The LPN asked the Social Work Coordinator to contact the family, but this was delayed, and the family was not informed about the resident's condition and potential need for hospice care until late in the afternoon. Interviews revealed an expectation for immediate family notification, which was not met, leading to the deficiency.
A resident with severe cognitive impairment drank an unknown liquid from an unmarked spray bottle found in an unlocked cabinet under a sink in the dining area. The resident's care plan did not address their behavior of picking up and consuming non-food items, and the cabinet was not locked as required by facility policy. Staff interviews revealed that the resident was not visible from the nurse's station due to a blind spot, and it was unclear how the spray bottle ended up under the sink.
A resident was financially exploited by a housekeeper who borrowed $50 under emotional duress, promising repayment. Despite facility policies against such actions, the housekeeper, aware of these rules, accepted the money, claiming it was offered by the resident. The resident, feeling deceived after learning the housekeeper repaid others, reported the incident. Interviews confirmed the housekeeper's acknowledgment of wrongdoing, highlighting a breach of the facility's abuse and exploitation policies.
A cognitively intact resident loaned $50 to a housekeeper, who requested the money to repair a phone and promised repayment. The resident felt obligated to lend the money after the housekeeper cried. The housekeeper admitted to taking the money, violating facility policies, and was terminated. The facility failed to report the incident to law enforcement, as required by the Elder Justice Act, resulting in a deficiency.
A resident with severe cognitive impairment was physically abused by a staff member who threw a meal tray, causing injury. Additionally, the facility failed to protect residents from aggression by another resident with a history of aggressive behavior, resulting in physical altercations and injuries. These incidents highlight the facility's inability to manage resident-to-resident aggression and staff responses effectively.
A resident with severe cognitive impairment and a history of elopement managed to leave a locked memory care unit unsupervised. The resident exited the facility after a housekeeper left a door ajar, and a visitor held the main entrance open. The resident wandered outside for six minutes before being noticed by another resident, who alerted staff. Interviews revealed staff inattention and failure to follow the facility's elopement protocol.
The facility failed to prevent an abuse incident where a resident punched another resident in the face on the smoke porch, resulting in a facial hematoma. Both residents had no prior history of physical aggression towards each other, and there were no staff witnesses to the incident.
A resident with paranoid schizophrenia and psychotic disorder eloped from the facility through an unsecured smoke porch door. The resident discovered the door was not locked, placed toilet paper in the locking mechanism, and exited the facility. The resident was found down the street and returned without health issues. Staff were unaware of the resident's actions due to a missed smoke break and an unlocked inner door.
Failure to Supervise Exit-Seeking Resident After Door Lock Failure Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a known elopement-risk resident received adequate supervision and protection from accident hazards when the secured unit’s magnetic door locks and alarms were not functioning. The resident had multiple mental health and cognitive diagnoses, including schizoaffective disorder bipolar type, bipolar disorder, vascular dementia, anxiety disorder, impulse disorder, severe memory impairment, and was only oriented to self. A quarterly MDS indicated the resident had a history of wandering throughout the unit, entering other residents’ rooms, and exit-seeking behaviors. The resident’s care plan identified risk for wandering and elopement and directed staff to engage the resident in purposeful activity, identify times when wandering/elopement was more prevalent, and schedule regular walks. On the day of the incident, a repeat BIMS documented that the resident was not cognitively intact. Later that day, nursing notes showed the resident verbally expressed a desire to leave the facility, continued to pack belongings, pressed emergency exit doors, and wandered into other residents’ rooms. Staff initiated frequent visual checks in response to these behaviors. Around 6:00 P.M., the magnetic locks on the main floor dementia unit lost power, and the resident exited the unit via a stairwell and reached the sidewalk before being quickly returned to the unit by staff. The Administrator was notified of the malfunction and arrived on-site, attempted to restore the locks, and contacted the repair company. The Administrator instructed the LPN to ensure the resident remained within line of sight at all times until the magnetic locks were repaired, and the LPN and CMT monitored the doors and the resident from the unit dining room. Despite these instructions and the known door-lock failure, the resident was left unsupervised. After the first elopement, staff, including the LPN, CMT, and CNA, reported they tried to keep the resident in constant view and checked on the resident every few minutes. However, the CMT left shortly after the end of the shift, and the CNA was occupied preparing for the next smoke break. The LPN, who had been assigned to maintain visual oversight of the resident and the unsecured doors, went to the restroom for approximately two minutes without arranging coverage, even though the Administrator remained in the building and the CNA was present on another hall. When the LPN returned, the resident was no longer in the dining room, and a search revealed the resident had eloped a second time. The resident remained unaccounted for until the following afternoon, when the resident was found on a public transit system in a major metropolitan area and later evaluated at a hospital with no injuries identified. The facility’s internal investigation concluded there was a failure in the magnetic door locking system and in adherence to established policies and procedures, and that the facility was aware of ongoing door lock issues and the resident’s exit-seeking behaviors but failed to provide appropriate protective oversight, which directly contributed to the resident’s elopement. The Administrator later stated that nursing staff had documentation from the previous facility indicating the resident was an elopement risk since the morning of admission, several hours before the resident arrived. The Administrator indicated there were only 15 residents on the unit with an LPN, CMT, and CNA assigned, and expressed that the LPN should have had time to review the admission information and communicate with the sending facility. The Nurse Practitioner reported an expectation that staff would have been aware of the resident’s exit-seeking behaviors and would have provided intensive monitoring after the first elopement, particularly given the resident’s need for a locked environment and the failure of the magnetic locks. The Administrator also stated that the event was preventable because the resident had two elopements within an hour, staff knew the magnetic locks were not working properly, and the LPN had been specifically instructed to keep the resident in line of sight until the locks were verified as working.
Removal Plan
- Educate all staff on intensive monitoring of residents, when to notify management, abuse and neglect, and elopement.
- Complete elopement evaluations on all residents to ensure no other residents are at risk.
- Repair the magnetic locks.
- Suspend and terminate Licensed Practical Nurse (LPN) A.
Failure to Administer Medications as Prescribed and Incomplete Documentation
Penalty
Summary
The facility failed to ensure that multiple residents received their prescribed medications as ordered by their physicians, as evidenced by interviews and record reviews. Six sampled residents did not receive various medications, including critical treatments for conditions such as schizoaffective disorder, diabetes, hyperlipidemia, anxiety, depression, and infections. Missed doses were documented across several medication types, including oral tablets, injectables, and topical treatments, with some residents missing multiple consecutive doses. In some cases, entire courses of antibiotics or essential daily medications for chronic conditions were not administered as prescribed. Residents reported that they did not consistently receive their medications, attributing missed doses to staff shortages or medications being on order. Some residents specifically denied refusing their medications, indicating that the missed doses were not due to resident choice. Documentation on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) was often incomplete, with missing notes regarding the reason for non-administration or lack of notification to the physician or nurse practitioner when medications were not given, even when required by facility policy. Interviews with staff, including Certified Medication Technicians (CMTs), LPNs, the Director of Nursing (DON), and the Administrator in Training (AIT), revealed a lack of awareness regarding the extent of missed medication doses. Staff confirmed that medications are to be administered as ordered and that refusals or missed doses should be documented and reported to the appropriate medical provider. However, both the DON and the nurse practitioner stated they were not aware of the missed medications or lack of documentation, indicating a breakdown in communication and adherence to established medication administration protocols.
Failure to Provide Sufficient Nursing Staff Resulting in Missed Medications and Inadequate Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet the needs of all residents, particularly on the locked memory care and Transitional Units. On multiple occasions, only one nurse was assigned to cover both units simultaneously, with only one other staff member present on each unit. This staffing pattern resulted in missed medication administration for a group of residents on the Transitional Unit across numerous shifts, as documented in the facility's daily staffing sheets and confirmed by staff and resident interviews. The facility's own policy required adequate staffing based on census, acuity, and resident diagnoses, and mandated a licensed nurse to serve as charge nurse on each shift. However, review of staffing records over several weeks showed repeated instances where only one RN or LPN and two or three CNAs were present for up to 49 residents, with some shifts having even fewer staff. As a result, scheduled medications at various times (including 8:00 P.M., 9:00 P.M., 5:00 A.M., and others) were not administered to at least 13 residents on the Transitional Unit. Staff interviews corroborated that there were times when no nurse or CMT was present on the unit, and CNAs were left alone or had to leave their assigned unit to assist elsewhere, leaving residents unattended. Resident and staff interviews further confirmed the impact of insufficient staffing. One resident reported not receiving medications due to the absence of a nurse, and several CNAs described being the only staff on the unit or having to cover both units, resulting in residents not being checked as required. The DON and AIT acknowledged awareness of missed medication passes and insufficient staff to manage resident behaviors and ensure safety. The facility's failure to maintain adequate staffing directly led to unmet resident needs, including missed medication administration and lack of supervision.
Failure to Develop and Implement Individualized Behavioral Health Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized care plan that identified behavioral triggers and de-escalation needs for a resident with complex behavioral health diagnoses, including paranoid schizophrenia, traumatic brain injury, and polysubstance dependence. Despite documented incidents of aggression, disrobing, entering other residents' rooms, and multiple falls, the care plan lacked specific interventions, triggers, or instructions for staff on how to redirect or manage these behaviors. The resident experienced repeated behavioral episodes, including physical altercations, inappropriate undressing, and property damage, which were not adequately addressed in the care planning process. Staff interviews revealed a lack of consistent behavior management training and limited access to resident-specific behavioral information. Direct care staff, such as CNAs, reported relying on nurses for guidance, as they did not have access to care plans or written instructions regarding behavioral interventions. Some staff indicated that behavior management training was outdated or unavailable, and information about resident behaviors was often communicated verbally rather than documented or accessible in written form. Additionally, there was confusion among staff regarding where to find information about resident triggers and interventions, and some staff reported being told to "stay in their lane" when inquiring about behavioral management. The resident's behavioral health needs were further complicated by medication changes, hospitalizations for behavioral disturbances, and a lack of timely updates to the care plan following significant events such as hospital admissions and returns. Despite recommendations from hospital psychiatry and evidence of acute decompensation related to medication adjustments, the facility did not update the care plan to reflect new interventions or strategies. The absence of a comprehensive, individualized behavioral care plan and insufficient staff training contributed to ongoing behavioral incidents and inadequate management of the resident's physical, mental, and psychosocial well-being.
Failure to Complete Required Capacity to Consent Assessments for Sexual Activity
Penalty
Summary
The facility failed to thoroughly complete assessments for capacity to consent to sexual activity as required by its own policy for at least one resident. Specifically, the policy mandates that residents wishing to engage in sexual activity must be assessed for their ability to consent, especially if they have a guardian or cognitive impairment. The assessment is to be completed by the interdisciplinary team with input from the resident’s physician or psychiatrist, and should include evaluation of the resident’s awareness of the relationship, ability to avoid exploitation, and understanding of potential risks. However, for two residents known to engage in sexual activity, these assessments were either incomplete, missing, or not properly documented. One resident, who had a legal guardian and diagnoses including schizoaffective disorder, anxiety, and depression, was found to have engaged in sexual activity with another resident. Although the resident was assessed as cognitively intact on the MDS, the care plan and capacity to consent forms were incomplete or lacked required signatures from the resident, guardian, evaluator, or administrator. The legal guardian had communicated that the resident did not have the legal capacity to consent to sexual activity, and the facility’s documentation did not reflect a thorough interdisciplinary assessment as required by policy. Additionally, the resident was not moved to a secured same-sex unit as requested by the guardian after the initial incident. For the second resident, who also had significant psychiatric diagnoses and was adjudicated as incapacitated and disabled by the courts, there was no capacity to consent form completed at the time of the incident. The legal guardian explicitly stated that the resident did not have the legal capacity to consent to sex and requested increased supervision and a transfer to a same-sex unit. Despite this, the facility’s documentation and investigation did not show that the required interdisciplinary assessment was completed, nor was there evidence of proper coordination with health professionals or the guardian as outlined in the facility’s policy. Interviews with staff and health professionals confirmed that assessments for capacity to consent were not consistently performed or documented.
Failure to Remove Broken Glass Hazard in Behavioral Health Unit
Penalty
Summary
A deficiency occurred when a broken window in a locked behavioral and mental health unit was not promptly repaired or cleaned up, leaving glass shards accessible to all residents on the unit for an extended period. The window was broken by a resident with a history of aggressive behavior, traumatic brain injury, paranoid schizophrenia, and multiple comorbidities. The incident was observed by staff, and the broken glass remained on the windowsill for over three weeks, during which time the area was not secured or made safe for residents. Facility staff, including the Administrator in Training (AIT), were aware of the broken window but did not ensure timely communication or action to address the hazard. The AIT noticed the broken window approximately two weeks before the survey and began an investigation but did not complete it. The maintenance department was not informed of the issue until much later, and there was no documentation or communication in the maintenance thread regarding the broken window. The window was only repaired and the glass cleaned up after the Regional Maintenance Director became aware of the situation during the survey. Interviews with staff and residents confirmed that the broken window was known to facility leadership, but no immediate interventions were implemented to secure the area or remove the hazard. The facility's own policy required prompt reporting, investigation, and corrective action for incidents and accidents, but these procedures were not followed. The failure to address the broken window and remove the glass shards left all residents on the unit at risk of harm.
Failure to Maintain Residents' Dignity and Personal Possessions
Penalty
Summary
The facility failed to ensure that residents' personal possessions were maintained and that residents' dignity was respected, as evidenced by multiple instances of residents wearing ill-fitting or damaged clothing. Several residents were observed wearing clothes that were too large, lacked proper fastenings, or belonged to other residents. For example, one resident was seen wearing sweatpants that were too large, causing them to fall below the waist, while another resident was observed wearing pajama pants that were too big. Additionally, a resident was found wearing a trash bag tied to their belt loops to keep their pants up, which was acknowledged by the DON as an inappropriate intervention. The facility's failure to maintain accurate and updated inventories of residents' personal effects contributed to the issue. Many residents' inventories were outdated or incomplete, leading to confusion and the use of other residents' clothing. In some cases, residents' closets were found empty, and their clothing was not properly labeled, making it difficult for staff to ensure that residents wore their own clothes. The lack of proper inventory management and labeling resulted in residents frequently wearing clothes that did not fit or belong to them, compromising their dignity and comfort. Interviews with staff revealed that the issue of residents wearing ill-fitting or incorrect clothing was known but not adequately addressed. Staff members, including LPNs and CNAs, acknowledged the problem and indicated that residents often went "shopping" in each other's closets. Despite having funds available in their trust accounts, residents were not provided with adequate clothing, and staff did not consistently report or address the issue. The facility's Social Service Director and DON recognized the dignity issue but admitted to challenges in maintaining residents' clothing and belongings, highlighting a systemic problem in managing residents' personal possessions.
Inaccurate MDS Assessments Lead to Deficiencies in Care Planning
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for several residents, leading to deficiencies in care planning. For Resident #10, the activities section was left blank, and the cognitive assessment was not completed, despite the resident being able to engage in conversation and participate in activities. The MDS Coordinator, who took over the position in June 2024, acknowledged that the Activity Director should have completed the activities section, and the MDS Coordinator was responsible for the cognition assessment. Resident #16's care plan did not specify the assistance required for care activities, and the quarterly MDS lacked assessments for cognition and functional abilities. Similarly, Resident #43's quarterly MDS did not assess speech, understanding, cognition, or functional abilities. The MDS Coordinator admitted that all sections should have been completed and accurate. Resident #45's MDS indicated clear speech and understanding, yet the cognitive assessment was not completed due to communication difficulties. Resident #9's admission MDS was incomplete, with a blank activities section and an inaccurate dental assessment, as the resident had a broken tooth upon admission. The MDS Coordinator, who was temporarily covering the role, expected these issues to be documented. Resident #41's quarterly MDS did not include a cognitive patterns assessment, despite residing in a locked Memory Care Unit. The Social Services Director and DON acknowledged that the MDS should have been completed upon admission and updated quarterly, but Resident #41 was missed.
Failure to Notify Residents of Care Plan Meetings
Penalty
Summary
The facility failed to notify residents or their representatives about care plan meetings, which are essential for developing, reviewing, and revising individualized care plans. This deficiency was identified for seven out of thirteen sampled residents, despite the facility's policy emphasizing the importance of person-centered care planning. The policy did not include instructions for inviting residents or their representatives to these meetings, leading to a lack of participation from the residents or their guardians. Interviews with residents and their representatives revealed that they were not aware of or invited to care plan meetings. For instance, a resident who was cognitively intact reported not being invited to any care plan meetings, and their electronic health record showed no evidence of such invitations. Similarly, a guardian of a severely cognitively impaired resident was unsure about the timing of the last care plan meeting and noted that the care plan was overdue. Staff interviews indicated confusion and inconsistency regarding the process of inviting residents and their representatives to care plan meetings. Some staff members believed that residents were invited, while others were unsure of the process. The Social Services Director and MDS Coordinator were responsible for inviting family members, but there was no clear documentation or communication to ensure that invitations were sent out. This lack of coordination and documentation resulted in residents and their representatives not being informed or involved in care plan meetings.
Inadequate Dietary Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to hire an adequate number of dietary staff to safely and effectively carry out the functions of the food and nutrition services, as required by State of Missouri rules and regulations, national guidelines, and professional standards. This deficiency potentially affected all individuals consuming food from the kitchen, including residents, visitors, volunteers, and staff. At the time of the survey, the facility had a census of 50 residents, with a licensed capacity for 97 residents. On 10/15/24, an observation between 2:04 P.M. and 2:52 P.M. revealed that the Dietary Manager (DM) was the only staff member present in the kitchen. During an interview, the DM stated that the dietary staff consisted of one morning cook and aide and one afternoon cook and aide, and that staffing was insufficient due to the low resident census. The DM also mentioned filling in staffing gaps as needed. On 10/18/24, an observation between 12:03 P.M. and 12:11 P.M. showed the DM with two other staff members in the kitchen. The DM explained that they had resorted to using Styrofoam plates and cups and plastic utensils because, although they normally had a cook and two aides, one of whom was a dishwasher, the staff was reduced due to the low census, leaving them without a dishwasher.
Failure to Follow Pre-Prepared Menus and Ensure Nutritional Adequacy
Penalty
Summary
The facility failed to adhere to pre-prepared menus that were designed to meet the nutritional needs of residents, as required by state regulations and professional standards. Observations and interviews revealed that the facility did not have basic food items in stock as per their main menus, and there were no alternate or always available food menus posted in the dining rooms. This deficiency was noted during a survey when a test plate served did not match the scheduled menu items, indicating a lack of compliance with the planned dietary provisions. The Dietary Manager (DM) disclosed that the menus were sourced from DiningRD.com and not from their food vendor, U.S. Foods. The DM also mentioned that the Regional Dietary Manager (RDM) was responsible for ordering foodstuffs but sometimes failed to check the menus for necessary items, leading to substitutions like Sloppy Joes instead of the scheduled roast beef. The DM attempted to provide alternatives with similar caloric and nutritional value when residents did not prefer the scheduled meals, but the lack of proper menu adherence and food availability potentially affected all individuals consuming meals from the facility's kitchen.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards in the kitchen and Dry Storage (DS) room, as observed during inspections. The deficiencies included unclean floors, lack of operable thermometers in refrigerators and freezers, and improper storage of foodstuffs. Specifically, heavily dented and rusted cans were found in the DS room, and blood was observed puddling in the bottom of a refrigerator labeled as a Meat Freezer, with temperature discrepancies noted. Open jugs of teriyaki and soy sauce were not refrigerated as required by their labels, and various debris, including cardboard and onion peels, were found under food racks. Additionally, the facility failed to maintain kitchen utensils and equipment in good condition, which could lead to cross-contamination. Observations included paper residue on a manual can opener, chipped spatulas, and a cutting board that was excessively scored with plastic bits flaking off. These practices were not in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety, potentially affecting all residents, visitors, volunteers, and staff consuming food from the kitchen.
Deficiency in Policy for Outside Food Handling
Penalty
Summary
The facility failed to maintain a well-known, on-site policy regarding the acceptance, usage, and storage of foods brought into the facility for residents by food delivery services, family, and/or other visitors. This deficiency was identified during an observation on 10/15/24, where a reach-in refrigerator and freezer were noted in specific areas outside the kitchen. The Dietary Resident Rights Policy, last reviewed on 11/6/23, stated that food brought in by family or friends would be considered personal property of the patient, and staff would assist in its safe and sanitary storage. However, during an interview on 10/23/24, the Dietary Manager (DM) admitted to not knowing if there was a policy about outside food brought in for residents and mentioned that residents would need to eat it in the lobby rather than taking it back to their rooms. This lack of awareness and implementation of a policy had the potential to affect all residents consuming food brought in by visitors, with the facility having a census of 50 residents and a licensed capacity of 97.
Inadequate Infection Control and TB Testing in LTC Facility
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program, specifically for preventing the development and transmission of Legionella and other water-borne pathogens. The facility's existing Legionella management documentation was inadequate, lacking a facility-specific risk management plan and documentation of maintenance activities such as cleanings and inspections. The facility's Infection Control Surveillance program was incomplete, with missing documentation for several months and inconsistencies in tracking infections, particularly those not treated with antibiotics. The facility also failed to ensure proper tuberculosis (TB) testing for residents and employees. Several residents and employees did not receive the required two-step TB skin tests upon admission or hire, and there were instances where TB test results were not properly documented. Additionally, the facility did not ensure that staff wore gloves when cleaning up bodily fluids, and there were inadequate supplies for hand hygiene, such as soap and towels, in resident bathrooms. Enhanced Barrier Precautions (EBP) were not properly implemented for residents with wounds or indwelling medical devices. There was a lack of signage and isolation carts with personal protective equipment (PPE) outside resident rooms, and staff were not consistently using gowns and gloves during high-contact care activities. Observations revealed that some staff were unaware of when to use PPE, and there was a lack of education on EBP. Furthermore, the facility had issues with cleanliness and maintenance, such as unclean dining areas and missing hygiene supplies in resident bathrooms.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) responsible for the Infection Prevention and Control Program. The Director of Nursing (DON) was acting as the IP but had not passed the required IP certification test, despite completing the infection control training modules. The DON had been attending IP program classes but did not dedicate the minimum required 20 hours per week to the Infection Control Program due to also fulfilling DON duties. The facility did not provide a policy for the Infection Preventionist upon request during the survey, and the facility had a census of 50 residents.
Deficient Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential kitchen equipment in a safe and proper operating condition, which could potentially affect the nutritional needs of all residents, visitors, volunteers, and staff consuming food from the kitchen. During an inspection, it was observed that the stove required early activation to be warm enough for lunchtime use, indicating it was not functioning properly. The chemical dishwasher's thermometer was broken, preventing verification of adequate cleaning temperatures, and no steam was observed when the machine was opened after use. Additionally, the convection oven was reported to be operating poorly. The Dietary Manager confirmed these issues during the inspection, and the Administrator acknowledged ongoing problems with the dishwashing machine and expressed the need for a complete kitchen renovation.
Deficiencies in Hygiene and Maintenance in Dementia Unit
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for residents, particularly in the locked dementia unit. Observations revealed that several resident rooms lacked essential hygiene supplies such as toilet paper, paper towels, and soap. Additionally, many rooms had broken fixtures, including toilet paper holders, baseboards, and drywall, and were found to be dirty with feces and mold-like substances on the floors and walls. These deficiencies were noted in multiple rooms, affecting the living conditions of the residents. Interviews with staff, including housekeepers, certified medication technicians, and licensed practical nurses, revealed a lack of consistent hygiene practices. Staff reported that they did not stock paper towels or soap in the resident bathrooms due to concerns that residents might eat the soap or flush paper towels down the toilet. Despite these concerns, there was an expectation that toilet paper should be available, although it often was not. Staff also expressed uncertainty about how or when residents cleaned their hands, indicating a gap in hygiene management. The Director of Nursing and the Administrator acknowledged the deficiencies, with the DON stating that there should be hygiene supplies in each bathroom and that staff should assist residents with hand hygiene. The Administrator mentioned plans to address the physical disrepair in the facility, such as fixing broken baseboards and doors. However, the report highlights the immediate need for improvements in maintaining a sanitary and comfortable environment for residents, particularly those in the locked dementia unit.
Failure to Notify Residents of Hospital Transfers
Penalty
Summary
The facility failed to notify residents and/or their representatives of transfers to a hospital, including the reasons for the transfer in writing, for three residents out of a sample of 13. Resident #14, who was moderately cognitively impaired, was discharged to a hospital on two occasions, but no discharge notices were found in the medical records for these dates. Similarly, Resident #60, who was cognitively impaired, was discharged to a hospital twice, with no discharge notices documented for these transfers. Resident #10 was also discharged to an acute hospital twice, with no transfer/discharge notices available in the medical records for these dates. Interviews with the Director of Nursing (DON) and Licensed Practical Nurses (LPNs) revealed that the nurses were responsible for sending transfer notices when residents were discharged to the hospital. However, the DON acknowledged that notices were not given to Resident #14 and was unsure about Resident #60's transfer notices. The LPNs confirmed that the nurses were supposed to send the notices, but they were not provided for the residents in question. The facility's policy required notification of changes, including transfers, but this was not adhered to in these cases.
Failure to Provide Bed Hold Notifications
Penalty
Summary
The facility failed to provide bed hold notifications to residents or their representatives upon transfer or discharge to a hospital for three residents out of a sample of thirteen. This deficiency was identified through interviews and record reviews, revealing that the facility did not adhere to its own Bed Hold Policy. The policy required that a copy of the bed hold policy be provided to residents or their representatives when they were discharged to a hospital or went on therapeutic leave. However, for Resident #14, Resident #60, and Resident #10, there was no documentation of bed hold notifications in their medical records during their respective hospital transfers. Resident #14 was discharged to the emergency room on two occasions, and Resident #60 was also discharged to the emergency room, yet neither received the required bed hold notice. Similarly, Resident #10 was discharged to an acute hospital twice, with no bed hold documentation found in the medical records for either instance. Interviews with the Director of Nursing and Licensed Practical Nurses revealed that the nurses were responsible for providing the bed hold notices, but they were unsure why the notifications were not given. The facility's failure to provide these notifications was a clear deviation from their established policy.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for three residents, leading to deficiencies in addressing their needs. Resident #14's care plan, initiated in March 2024, lacked documentation of activity preferences despite the resident expressing interest in various activities such as reading, music, and social events. The MDS Coordinator and Social Services Director were unaware of these omissions, indicating a lapse in transferring information from assessments to care plans. Resident #9's care plan did not address a broken tooth, a concern noted upon admission in May 2024. Despite a dental referral being ordered, it was never completed, and the issue was not reflected in the resident's care plan. Interviews with the resident and staff revealed a lack of awareness and follow-through on the dental issue, highlighting a failure in communication and care planning. Resident #41's care plan failed to address language and communication needs, as the resident, residing in a Memory Care Unit, did not have a completed BIMS assessment. The care plan lacked details on the resident's language, and there were no tools available to facilitate communication. Interviews with staff and the resident's guardian revealed a lack of knowledge about the resident's background and language, resulting in communication barriers that were not addressed in the care plan.
Failure to Assist Residents with Oral Care
Penalty
Summary
The facility failed to provide necessary assistance for oral care to three residents who were unable to perform these activities independently. Resident #5, who was severely cognitively impaired and dependent on staff for oral care, did not receive the required assistance. During an interview, an LPN admitted to not knowing who was responsible for ensuring oral care was performed, where supplies were kept, or where the care was documented. Similarly, Resident #41, who needed substantial help with oral care, was found without a toothbrush or toothpaste in their room. Staff members were unsure of the location of the resident's oral care supplies and had not assisted the resident with oral hygiene. Resident #43, who required supervision and assistance for oral hygiene, also lacked access to a toothbrush and toothpaste. An LPN stated that the resident could perform oral care if they had the necessary supplies, which were locked away. Observations revealed that most residents on the locked unit did not have access to oral care supplies, and staff were unaware of where these supplies were stored or how oral care was documented. The Director of Nursing confirmed that oral care should have been documented in the care plan and that residents should have had their own labeled toothbrushes in their bathrooms.
Lack of Activities Program for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests and well-being of several residents, as evidenced by the lack of scheduled activities and participation documentation. Resident #8, who was moderately cognitively impaired, participated in activities only a few days each month, with many days left blank on the participation log. The activities director had quit, and no one was conducting activities, leaving the resident to walk the halls without engagement. Interviews with staff revealed confusion about who was responsible for activities, and the Director of Nursing confirmed that activities had not been consistent since the departure of the activities director. Resident #14, also moderately cognitively impaired, showed no participation in activities for several months, with blank logs and missing activity calendars. Observations indicated the resident spent most of the time in bed, with no engagement in activities. Staff interviews highlighted a lack of awareness about the resident's participation and the absence of an activities director, leading to a lack of structured activities for the resident. Resident #9, who was cognitively intact, expressed dissatisfaction with the available activities, preferring to stay in the room playing video games. The resident's participation log showed minimal engagement, and staff interviews confirmed the absence of an activities director and a lack of scheduled activities. Resident #41, residing in a locked memory care unit, had no documented activity preferences or participation since early in the year. The resident faced communication barriers due to a language difference, and there were no tools like a communication board or translation services to facilitate engagement. Staff interviews revealed a lack of knowledge about the resident's language and interests, and the absence of an activities director contributed to the deficiency in providing appropriate activities.
Tripping Hazards and Inadequate Supervision in LTC Facility
Penalty
Summary
The facility failed to maintain a safe environment by allowing tripping hazards in multiple locations, including buckling laminate floor planks, ripped linoleum, and a dragging door. These hazards were observed in various resident rooms and the hallway, posing a risk to all individuals in the facility. The facility's Safe and Homelike Environment Policy mandates a safe and risk-free environment, which was not upheld as per the observations and the administrator's acknowledgment. Additionally, the facility did not provide adequate supervision in the dining room, where a resident was left unattended and attempted to stand up from a wheelchair, risking a fall. The resident, who had cognitive impairments and a history of falls, was observed in a regular wheelchair instead of a high-back wheelchair, which was broken. The staff was unaware of the broken wheelchair, and there was confusion about how to handle the situation safely, leading to inadequate supervision and potential risk of injury. The facility also failed to safely transfer the resident from the floor. The resident, who had a behavior of lying on the floor, was lifted without a gait belt by staff members who used improper techniques. The resident's care plan indicated the need for safe handling during transfers, but the staff did not follow the appropriate procedures. The DON acknowledged that the transfer method used was incorrect and that the resident's high-back wheelchair had been broken for over a month, with hospice notified but no resolution in place.
Failure to Post Staffing Information Correctly
Penalty
Summary
The facility failed to ensure that staffing information was posted correctly at the beginning of each shift in locations where residents and visitors could easily see it. Observations on multiple dates revealed that there were no posted staffing sheets at the entrance reception desk, the glass case near the door to the [NAME] hall, or on the [NAME] and Cherry halls. Interviews with staff, including a Certified Medication Technician (CMT), a Licensed Practical Nurse (LPN), and a Certified Nursing Assistant (CNA), confirmed the absence of posted staffing sheets at the nurse's stations and the entrance reception area. The Director of Nursing (DON) also confirmed that the staffing sheets were not posted in the required locations. The facility's staffing policy was requested but not received at the time of the survey exit. The facility assessment indicated the required daily nursing services, including specific numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Medication Technicians (CMTs), and Certified Nursing Assistants (CNAs). Despite this, the staffing sheets were not visible in the designated areas, as confirmed by the Staffing Coordinator and the DON. The DON acknowledged that staffing sheets should be posted at the front entrance and on each unit where they could be easily seen by residents and visitors.
Narcotic Count and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper narcotic count procedures were followed, leading to discrepancies in narcotic count sheets and potential medication errors. Observations revealed that nursing staff did not consistently count narcotics together at shift changes, and there were numerous instances of pre-signing narcotic count sheets. This resulted in blank slots on the narcotic count sheets, indicating that the required dual verification process was not adhered to. Additionally, the facility's policy on controlled substance administration and accountability was not followed, as evidenced by the lack of accurate documentation and unresolved discrepancies in narcotic counts. Specific instances of non-compliance were noted across multiple medication carts and shifts. For example, on several occasions, narcotic count sheets were missing signatures from both oncoming and off-going nurses, and there were periods where no narcotic count sheets were available for review. Interviews with staff members, including LPNs and CMTs, revealed a lack of awareness and training regarding the proper procedures for narcotic counts, with some staff admitting to pre-signing sheets due to habitual practices or the tardiness of incoming staff. The deficiencies also extended to the administration of medications for specific residents. For instance, Resident #24 had multiple instances where Clonazepam doses were not signed out on the MAR, and discrepancies were noted in the narcotic count sheet. Similarly, Resident #2's Lorazepam doses were inconsistently documented, with incorrect dosages administered and discrepancies in the narcotic count. Resident #11's narcotic record showed an incorrect ending count for Tylenol with codeine, indicating potential unaccounted medication. The DON acknowledged the issues, stating that there should not have been any blanks on the narcotic count sheets and that discrepancies should have been reported immediately.
Failure to Implement GDR and Conduct Lab Monitoring
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) of psychotropic medications for two residents and did not conduct necessary lab tests for another resident. Resident #41, who was severely cognitively impaired, was prescribed Depakote and Quetiapine Fumarate for dementia, anxiety, and psychotic disturbance. Despite the pharmacist's requests for a GDR in August and September, there was no documented physician response or action taken. The Director of Nursing (DON) acknowledged that GDRs should be completed quarterly and documented in the progress notes, but there was no such documentation for Resident #41. Resident #14, who was moderately cognitively impaired and diagnosed with schizoaffective disorder, was prescribed Lithium Carbonate. The resident's care plan lacked antipsychotic medication monitoring, and the required lithium level labs were not drawn every three months as ordered. The resident's medical record showed only one lithium level documented in the past 12 months, despite the need for four. The DON admitted that the lab order was not placed in the lab database, which led to the oversight, and there was no documentation of resident refusals or follow-up actions. Resident #51, diagnosed with dementia, depression, psychotic disorder, and insomnia, was prescribed multiple psychotropic medications, including Fluoxetine, Trazodone, Valproic acid, and Quetiapine. The pharmacist recommended assessing the risk versus benefit of these medications and considering a GDR, but there was no documented response from the physician. The DON confirmed that the pharmacist's recommendations were not followed up in the progress notes, indicating a lack of physician response. The facility's failure to act on the pharmacist's recommendations and ensure proper medication management and monitoring contributed to the deficiencies identified.
Medication Cart Security and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medication carts were locked when nursing staff was not in direct observation, leading to potential safety risks. On multiple occasions, Certified Medication Technicians (CMTs) left medication carts unlocked and unattended in hallways, allowing residents to pass by closely. For instance, a CMT left a cart unlocked for five minutes while attending to a resident in a room, during which time several residents passed by the cart. Another CMT left a cart unlocked while administering medications in a dining room, with residents walking by the cart multiple times. Additionally, the facility did not maintain proper storage conditions for medications. Observations revealed that medication carts contained extra objects such as an opened cup of applesauce, hand sanitizer, and bleach wipes mixed with residents' prescribed medications. There were also loose pills found in the drawers of the medication carts. Interviews with staff, including CMTs, an LPN, and the Director of Nursing, confirmed that these practices were against the facility's policy, which mandates that medication carts be locked when not in use and free of unrelated items.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish a comprehensive infection prevention and control program, specifically lacking an effective antibiotic stewardship program. The program was supposed to include protocols for antibiotic use and a system to monitor antibiotic usage. However, the facility's records showed significant gaps in documentation and tracking of infections and antibiotic usage over a 12-month period. For several months, there was no documentation of infections or antibiotic usage, and when infections were noted, there was no accompanying documentation of lab results, signs or symptoms, or whether antibiotics were administered. Additionally, the review of specific residents' records revealed that antibiotics prescribed to them were not included in the Antibiotic Stewardship program. For instance, residents were prescribed antibiotics like Doxycycline and Cephalexin for various infections, but these were not tracked as part of the stewardship program. The Director of Nursing acknowledged the lack of tracking by the previous DON and mentioned efforts to start monitoring antibiotic usage in the facility's electronic medical record. However, the deficiency in the program was evident as the necessary documentation and tracking were not consistently maintained.
Failure to Provide Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure that residents were provided with education to accept or decline the influenza and pneumococcal vaccines, as required by their policy. This deficiency was identified for four residents out of a sample of 13, with a total facility census of 50 residents. The facility's policy, dated 5/14/24, mandates that residents or their legal representatives receive education on the benefits and potential side effects of these vaccines as part of the admission process. However, for Residents #43, #46, #41, and #33, there was no documentation in their medical records indicating that such education was provided, nor was there any record of vaccine administration or declination. During an interview, the Director of Nursing (DON) acknowledged that staff are supposed to discuss immunization education during resident council meetings and that the pharmacy provides education during vaccine clinics. The DON also stated that residents should be educated and either sign a declination form or receive the vaccines upon admission, with influenza vaccines offered yearly. Despite these procedures, the records for the four residents in question lacked documentation of education, consent, or declination, indicating a failure in the facility's process to ensure compliance with their immunization policy.
Deficiency in COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure the provision and documentation of education regarding the COVID-19 vaccine for residents and staff. Specifically, for one resident, there was no documentation of education, administration, or declination of the COVID vaccine since their admission. Additionally, two staff members lacked proper documentation of COVID vaccine education, administration, or declination in their employment records. The Director of Nursing indicated that resident vaccine education should be documented in progress notes and that employee vaccine status and education should be recorded upon hire. However, these procedures were not followed, leading to the deficiency.
Deficiency in CNA Training and Competency Reviews
Penalty
Summary
The facility failed to provide the required annual 12 hours of in-service training for Certified Nursing Assistants (CNAs), as mandated by regulations. The facility's assessment indicated that staffing was adequate, but the review of in-service signature sheets revealed that only 11 in-person in-services were held over the past year, with several months lacking any in-service sessions. Additionally, the in-services did not cover essential topics such as behavior and resident rights. The Relias online training program was also insufficient, as three out of five CNAs did not receive the total 12 hours of training required. Furthermore, the facility did not conduct competency reviews for any of the CNAs over the previous 12 months. Interviews with staff, including CNAs and the Director of Nursing (DON), highlighted a lack of tracking for in-service hours and competency evaluations. The DON acknowledged that in-services were held monthly and more frequently if needed, but there was no system in place to ensure that each nursing staff member completed the required training hours.
Failure to Accommodate Language Needs of Resident
Penalty
Summary
The facility failed to provide adequate communication support for a resident with limited English proficiency, leading to a deficiency in accommodating the resident's needs and preferences. The resident, who was identified as having dementia and a cognitive communication deficit, was not provided with a means of translating into their language, which hindered their ability to be fully evaluated and participate in activities. The care plan included instructions for alternative communication methods, such as language cards or a translating system, but these were not effectively implemented. Interviews with staff revealed a lack of knowledge about the resident's primary language, and attempts to use phone translators in incorrect languages were unsuccessful. The resident's care plan and medical chart lacked documentation of their language needs, and there was no evidence of a Pre Admission Screening and Resident Review (PASRR) being completed. The resident's guardian and family were not involved in providing language information, and the facility did not have a translation phone line or picture gram available to assist with communication. The deficiency was further compounded by the absence of a Brief Interview for Mental Status (BIMS) and incomplete sections in the resident's Minimum Data Set (MDS). Staff interviews indicated that the resident's language information was not transferred from paper to electronic charts, and there was no process in place to communicate with the resident in their own language. The lack of communication tools and assessments prevented the resident from being adequately evaluated and participating in activities, highlighting a significant gap in the facility's ability to accommodate residents with language barriers.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide the required Notice of Medicare Provider Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two residents who were discharged from Medicare Part A benefits. These notices are essential to inform residents or their representatives about the end of Medicare coverage and potential liability for services not covered. The deficiency was identified for two residents who remained in the facility after their Medicare Part A benefits ended. The facility's policy mandates informing residents of available services and charges, including those not covered by Medicare, but this was not adhered to in these cases. The deficiency occurred due to a lack of proper communication and responsibility assignment within the facility. The Director of Nursing acknowledged that the Social Services Director was responsible for issuing these notices, but there was a period when the facility did not have a Social Services Director. The new Social Services Director, who had been in the position for six weeks, was unaware of their responsibility to send these notices. Consequently, the notices were not provided to the residents or their representatives in a timely manner, as required by the facility's policy and CMS guidelines.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident to the state agency within the required two-hour timeframe. The incident involved a resident who was severely cognitively impaired and diagnosed with dementia, anxiety, and a stroke. The resident's guardian reported that another resident had been touching the resident inappropriately. Despite the guardian's report, the facility did not notify the state agency promptly as required by their policy. The facility's Administrator and Director of Nursing (DON) did not report the incident to the state agency because the resident was unable to confirm the guardian's allegations, and conversations with the resident were vague. The DON conducted an investigation but found the information inconclusive and noted no indications of harm. As a result, the facility did not make a self-report to the state agency until a week later, which was a violation of the facility's abuse and neglect policy.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the comprehensive Minimum Data Set (MDS) for a resident, which is a federally mandated assessment tool used for care planning. Specifically, the Brief Interview for Mental Status (BIMS) was not assessed, and the summary score for the resident's level of cognition was not recorded. The resident had diagnoses of anxiety and depression, which are significant conditions that could impact their cognitive assessment. The temporary MDS Coordinator, who was responsible for completing the MDS, acknowledged that all sections requiring assessment should have been addressed. The Director of Nursing confirmed that the MDS should be completed on admission, annually, and when a significant change is identified, and that cognition should have been assessed in the comprehensive MDS.
Failure to Complete Significant Change Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change comprehensive assessment within 14 days after a resident was placed on hospice care. The resident, identified as having a terminal prognosis, was admitted to hospice on February 16, 2024. However, the facility did not update the resident's care plan to include hospice services or interventions. The Minimum Data Set (MDS) Coordinator, who assumed the position on June 6, 2024, acknowledged that a significant change MDS should have been conducted when the resident was placed on hospice. The Director of Nursing also confirmed that the significant change MDS should have been completed within the required 14-day period.
Failure to Integrate PASRR Recommendations into Care Plans
Penalty
Summary
The facility failed to ensure that residents with mental disorders and intellectual disabilities had the necessary DA-124 level I screen and PASRR level II screen, as required by federal regulations. This deficiency was identified for two residents out of a sample of 13, in a facility with a census of 50 residents. The facility's policy, updated in July 2021, mandates the use of PASRR assessments to develop a care plan that reflects continuity from previous behaviors and placements. However, the facility did not have the PASRR documentation for Resident #9 on site until requested by the surveyor, and the care plan did not include all relevant mental health diagnoses or interventions. Resident #9 had a complex psychiatric history, including antisocial personality disorder, depressive disorder, bipolar disorder, schizophrenia, mild intellectual disability, and multiple suicide attempts. Despite these diagnoses being documented in the PASRR, they were not reflected in the resident's MDS or care plan. The resident expressed a need for mental health therapy, which had not been provided since admission. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's mental health needs and the absence of a structured process to address these needs. Resident #41 was admitted with diagnoses of dementia and cognitive communication deficit, and it was noted that a PASRR should have been completed but was missed. The Social Services Director and the DON acknowledged their responsibility for ensuring PASRR completion but admitted to oversight in this case. The deficiency highlights a systemic issue in the facility's process for integrating PASRR recommendations into care planning and ensuring that residents receive appropriate mental health services.
Failure to Follow Up on Cancer Treatment Monitoring
Penalty
Summary
The facility failed to follow up on a request from a resident's responsible party for monitoring after chemotherapy and radiation treatment for cancer. The resident, who was admitted to the facility in January 2023, had a past medical history of liver cancer according to a hospital emergency department note. However, the facility's records did not include a diagnosis of cancer, and the resident's care plan did not address liver cancer, prostate cancer, or benign prostatic hyperplasia (BPH). The resident's responsible party expressed concerns about the resident's oncologist visits and prostate exam, but these concerns were not adequately addressed by the facility staff. The facility did not have a policy related to the care area in question, and there was a lack of communication and follow-up regarding the resident's cancer-related diagnoses and treatment. The Director of Nursing (DON) did not recall any details about the oncologist and prostate exam, and the facility's phone system issues were cited as a possible reason for the oversight. The Doctor of Nursing Practice (DNP) who recently began seeing patients at the facility noted that the resident had a diagnosis of BPH but could not find a diagnosis of prostate cancer. This lack of clarity and follow-up contributed to the deficiency identified in the report.
Failure to Provide Vision Services to Residents
Penalty
Summary
The facility failed to ensure that two residents received necessary vision services, as required by their policy. Resident #51's annual Minimum Data Set (MDS) indicated no vision impairment and no use of corrective lenses, yet observations over several days showed the resident was not wearing glasses, and there was no documentation regarding the resident's vision in their electronic health record. Interviews revealed that the Social Services Director was unaware of the resident's need for an eye exam and glasses, and the resident was not seen by the eye doctor during their visit to the facility. Resident #33's quarterly MDS showed adequate vision and no use of corrective lenses, but the resident reported wearing glasses all the time and expressed a need for new glasses. Despite this, there was no documentation of the resident having received an eye exam or vision assessment. Interviews with staff, including a CNA and LPN, confirmed the resident wore glasses, but there was no record of the resident's vision needs being addressed. The DON was unaware of any issues with the resident's glasses, and the resident had not seen an eye doctor, despite the vision company visiting the facility recently.
Failure to Respond to Pharmacist Recommendations and Monitor Antipsychotic Side Effects
Penalty
Summary
The facility failed to ensure that the Medication Regimen Review (MRR) completed by the pharmacist was reviewed and responded to by the facility physician(s). This deficiency was observed in the cases of two residents, Resident #47 and Resident #51, who were not adequately monitored for side effects of their prescribed antipsychotic medications. The facility's policies required that each resident's medication regimen be reviewed monthly by a licensed pharmacist, with any irregularities communicated to the facility physician, Director of Nursing (DON), or staff for urgent needs. However, the facility did not act upon the pharmacist's recommendations as required. Resident #47, who had diagnoses including anxiety, depression, and schizophrenia, was not monitored for side effects of psychotropic medications as indicated in the Medication Administration Record (MAR)/Treatment Administration Record (TAR) for several months. Despite the pharmacist's recommendations for a Comprehensive Metabolic Panel (CMP) to be conducted, the resident's blood was not drawn as advised. The resident's physician orders included monitoring for specific side effects of Risperdal and Hydroxyzine, but this monitoring was not documented in the MAR/TAR. Similarly, Resident #51's pharmacy review notes included instructions for a lipid panel and an assessment of the medical risk versus benefit for the resident's antipsychotic medication regimen. However, there was no documented response to these recommendations in the resident's electronic health record. The resident, who had diagnoses including dementia, depression, and psychotic disorder, received antipsychotic medications without a gradual dose reduction or documentation of clinical contraindication. The facility's failure to respond to the pharmacist's recommendations and to monitor the residents as required by physician orders contributed to the identified deficiencies.
Failure to Provide Routine and Emergency Dental Care
Penalty
Summary
The facility failed to provide routine and emergency dental care for two residents, leading to deficiencies in their care. Resident #9 was admitted with a broken tooth and requested dental services upon admission. Despite the resident's repeated requests and the facility's policy to assist residents in obtaining dental care, the referral for dental services was not completed. Interviews with staff revealed a lack of awareness and communication regarding the resident's dental needs, resulting in the resident experiencing pain and concern over potential infection. Resident #17, diagnosed with dysphagia, had issues with ill-fitting dentures that were not addressed in a timely manner. The resident's care plan indicated a need for a mechanical soft diet due to swallowing difficulties, and a dental consult was ordered for a nodule under the tongue caused by dentures. However, the resident had not been seen by a dentist since the order was placed, and the discomfort with the dentures persisted, affecting the resident's ability to eat comfortably. Interviews with facility staff, including the Social Services Director, MDS Coordinator, and DON, highlighted a lack of clarity and responsibility in scheduling dental appointments. The Social Services Director, who was new to the position, was unaware of the residents' dental issues and had not scheduled any dental visits. The DON had been making appointments when aware of the need, but there was no consistent process in place to ensure residents received necessary dental care, leading to the deficiencies identified in the report.
Failure to Timely Notify Family of Resident's Condition Change
Penalty
Summary
The facility staff failed to notify the next of kin in a timely manner regarding a significant change in the condition of a resident who was severely cognitively impaired and had multiple diagnoses, including dementia, dysphagia, heart disease, and stroke. The resident was found cold and unresponsive with a low pulse rate, prompting the physician to be notified and a hospice evaluation to be ordered. However, the family was not informed of the resident's condition and potential need for hospice services until late in the afternoon, despite the resident's condition not improving throughout the day. The Licensed Practical Nurse (LPN) involved was informed of the resident's decline in the morning but did not directly contact the family. Instead, the LPN asked the Social Work Coordinator to notify the family, which was not done until much later. The Social Work Coordinator was not aware of the need to discuss hospice services with the family and only informed them of the resident's poor condition and the need to choose a hospital for transfer. The family representative received a message about the resident's condition around 4:00 P.M., but was not aware of the situation until later. Interviews with facility staff, including the Acting Director of Nursing (DON) and the facility Administrator, revealed that there was an expectation for immediate family notification in such situations. The LPN was expected to follow up with the Social Work Coordinator to ensure the family was contacted, which did not occur. This lack of timely communication and follow-up led to the deficiency in notifying the resident's family about the significant change in condition and potential need for hospice care.
Resident Drinks Unknown Substance Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure resident safety when a resident with severe cognitive impairment drank an unknown liquid substance from an unmarked spray bottle. The resident, diagnosed with vascular dementia, chronic kidney disease, and end-stage heart failure, was found seated on the floor with the under-the-sink cabinet door open, drinking from a clear plastic spray bottle. The incident occurred in the dining room area close to the nurse's station, where the resident was not adequately supervised. The facility's policies on accidents and supervision, as well as chemical storage and labeling, were not adhered to, leading to this incident. The resident's care plan did not address the resident's behavior of wandering or picking up and consuming items not belonging to them, despite the resident being known to engage in such behaviors. The cabinet under the sink, where the spray bottle was found, was not locked, contrary to the facility's policy that required chemicals to be stored securely. Interviews with staff revealed that the resident was not visible from the nurse's station due to a blind spot, and the cabinet was not locked at the time of the incident. The spray bottle was unmarked, and it was unclear how it ended up under the sink. The staff involved were not aware of the presence of the bottle, and it was not part of the housekeeping supplies that should have been locked away. The facility's failure to secure hazardous materials and provide adequate supervision contributed to the resident's access to the chemical.
Resident Financial Exploitation by Housekeeper
Penalty
Summary
The facility failed to protect a resident from financial exploitation when a housekeeper, referred to as Housekeeper A, received $50 from the resident for personal use. The resident, who was cognitively intact, reported that Housekeeper A asked for the money to repair a phone and promised to repay it in two weeks. The resident felt obligated to lend the money due to Housekeeper A's emotional display, which included crying profusely. Despite the promise, Housekeeper A did not repay the resident, leading to the resident feeling deceived, especially after learning that Housekeeper A had borrowed and repaid money to other staff members. Housekeeper A admitted to taking the money from the resident, acknowledging that it was wrong and against the facility's policies on abuse, neglect, and exploitation. The housekeeper claimed that the resident had previously offered help if needed and denied any personal relationship beyond friendship. Despite receiving training on the facility's policies, Housekeeper A stated that they did not think it was wrong to accept money from a resident. The facility's policies clearly forbid solicitation or acceptance of money from residents, and Housekeeper A had signed acknowledgment of understanding these policies. Interviews with other staff, including the Housekeeping Supervisor and Human Resources Director, confirmed that Housekeeper A had accepted the money and was aware of the policies against such actions. The Administrator initially did not consider the incident as misappropriation, viewing it as a loan rather than a crime. However, the resident's account and the facility's policies indicate that the housekeeper's actions constituted financial exploitation, as the resident was manipulated into providing money under emotional duress.
Failure to Report Financial Exploitation Incident
Penalty
Summary
The facility failed to report an incident of financial exploitation involving a resident to local law enforcement, as required by state statute and facility policy. The incident involved a cognitively intact resident who reported loaning $50 to a housekeeper, who had asked for the money to repair a phone and promised to repay it in two weeks. The resident felt obligated to lend the money after the housekeeper cried profusely in the resident's room. The housekeeper admitted to taking the money, acknowledging awareness of the facility's abuse, neglect, and exploitation policies, and was subsequently terminated for violating these policies. The facility's Regional Director of Operations expected the Administrator to ensure a police report was filed, as the incident constituted a suspicion of a crime under the Elder Justice Act. However, the Administrator initially believed that the resident's active participation in giving the money did not constitute a crime. Upon further reflection, the Administrator recognized that local law enforcement should have been contacted to report the financial exploitation. This oversight resulted in a deficiency for failing to report the incident as required.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when a staff member, identified as CNA A, threw a plastic meal tray at the resident, resulting in a laceration that required eight stitches. The incident occurred after the resident, who was diagnosed with vascular dementia and severe cognitive impairment, threw a glass of water at CNA A. The staff member, startled by the action, responded by throwing the tray, which struck the resident on the upper lip. This action was determined to be an inappropriate response and was classified as abuse. Additionally, the facility did not protect three residents from abuse by another resident. One resident, diagnosed with early-onset Alzheimer's disease and schizophrenia, exhibited aggressive behavior towards two other residents. In one instance, the aggressive resident struck another resident in the face, causing a nosebleed. In another incident, the same resident used a racial slur and physically attacked another resident, leading to a physical altercation that resulted in injuries to both parties. These incidents highlight the facility's failure to manage resident-to-resident aggression effectively. The facility's policy on abuse and neglect defines abuse as the willful infliction of injury or punishment resulting in harm. Despite this policy, the facility did not adequately prevent or address the aggressive behaviors exhibited by the residents involved. The incidents were not appropriately managed, leading to physical harm and distress among the residents.
Resident Elopes from Memory Care Unit Due to Staff Inattention
Penalty
Summary
The facility failed to prevent a resident from eloping from a locked memory care unit, resulting in the resident exiting the facility unsupervised. The resident, who had a history of elopement and was at risk due to severe cognitive impairment and multiple diagnoses including Alzheimer's disease, traumatic brain injury, schizophrenia, anxiety disorder, and dementia, managed to leave the unit when a housekeeper inadvertently left a door ajar. The resident followed the housekeeper out and subsequently exited the facility through the main entrance, aided by a visitor who held the door open. The incident was captured on security video, showing the resident wandering outside the facility for approximately six minutes, focused on eating a pudding cup and not appearing to be aware of their surroundings. During this time, the resident was seen walking through the parking lot and approaching a busy street, although they did not venture onto the street itself. The resident was eventually noticed by another resident on the smoking porch, who alerted staff to the situation. Interviews with staff revealed a lack of awareness and vigilance, contributing to the resident's elopement. The receptionist at the front desk did not notice the resident leaving, and staff were not positioned to monitor the doors effectively. The facility's elopement protocol was not adequately followed, as the elopement book was not maintained at the front desk, and staff were not sufficiently alert to the resident's movements. The root cause of the incident was identified as staff becoming too comfortable and not paying attention to the residents' whereabouts.
Resident Abuse Incident on Smoke Porch
Penalty
Summary
The facility failed to ensure that Resident #2 was free from abuse when Resident #1 punched Resident #2 in the face, resulting in a facial hematoma. The incident occurred on the smoke porch, where Resident #1 approached Resident #2 and, after a verbal exchange, physically assaulted Resident #2. There were no staff witnesses to the incident, and the altercation ended after Resident #1 punched Resident #2 once in the face. Both residents were separated immediately after the incident, and Resident #2 was sent to the local hospital for evaluation, where a facial hematoma was diagnosed. Resident #2 had a history of Alzheimer's Disease, Schizophrenia, and Cognitive Communication Deficit. The resident's quarterly Minimum Data Set (MDS) indicated that the resident was rarely or never understood and had not exhibited any behavioral symptoms within the seven-day look-back period. Resident #1 had a history of Diffuse Traumatic Brain Injury, Major Depressive Disorder, and Paranoid Schizophrenia. The resident's quarterly MDS showed moderate cognitive impairment and delusions within the seven-day look-back period but no physical behaviors towards others. The facility's failure to provide adequate supervision and prevent the altercation between the two residents led to the abuse incident. The staff had no prior concerns about interactions between Resident #1 and Resident #2, and both residents had no history of physical aggression towards each other or other residents. The incident highlights a lapse in monitoring and intervention, as there were no staff present on the smoke porch at the time of the altercation, and the facility's abuse and neglect policy was not provided upon request.
Resident Elopement Due to Unsecured Door
Penalty
Summary
The facility failed to ensure the doors on the locked unit were secure, leading to the elopement of a resident diagnosed with paranoid schizophrenia and psychotic disorder. The resident, who was cognitively intact and not assessed as being at risk for elopement, left the facility through an unlocked smoke porch door. The resident discovered the door was not locked during a smoke break, returned to their room to get dressed, and then exited the facility through the same door. The resident was found down the street from the facility approximately 30 minutes later and was returned to the facility without any health issues. The investigation revealed that the door had been tampered with using toilet paper to prevent it from locking properly. The resident admitted to placing the toilet paper in the locking mechanism and planning their exit to visit family. Interviews with staff indicated that the resident missed the regularly scheduled smoke break and went out to smoke after the supervising staff had already returned inside. The facility had previously decided to leave the inner door to the smoke porch unlocked to allow more freedom for residents, which contributed to the staff being unaware of the resident's actions. Maintenance checks revealed that the door's magnetic lock malfunctioned, allowing the resident to exit the facility.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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