Parkwood Skilled Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Maryland Heights, Missouri.
- Location
- 3201 Parkwood Lane, Maryland Heights, Missouri 63043
- CMS Provider Number
- 265523
- Inspections on file
- 21
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Parkwood Skilled Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to follow physician orders for weekly weight monitoring for several cognitively intact residents receiving dialysis, all of whom had significant cardiac and renal diagnoses such as CHF, ESRD, prior MI, and TIA. Although policies required accurate transcription and completion of physician orders and coordination with dialysis staff, EMR review showed multiple missed weekly weights over consecutive months, with only sporadic entries despite active weekly weight orders. Staff, including an LPN and a CMT, stated that any nurse could obtain and document weights and that dialysis communication forms with post-dialysis weights should be transcribed into the EMR. Facility leadership, including the DON and ADON, acknowledged that the prior DON had been receiving dialysis communication forms but had not uploaded or transcribed most post-dialysis weights, resulting in incomplete weight documentation for these residents.
Staff left a topical gel and inhaler at a resident's bedside without completing the required assessment or obtaining a physician order for self-administration, despite facility policy mandating these steps. The resident, who was alert but legally blind and had multiple diagnoses, used the medications independently without authorization. Staff interviews confirmed that no residents were approved for self-administration at the time, and the medications were only removed after the deficiency was identified.
Staff did not follow physician orders for wound care for a resident with multiple chronic conditions. Required steps such as daily dressing changes, wound soaks, application of silver wound gel and mepitel, and use of ace wraps were omitted or substituted with other products. The resident reported inconsistent dressing changes, and staff confirmed the correct wound care supplies were not available.
A resident with cognitive impairment and multiple skin issues developed a pressure wound that worsened, and was prescribed new psychotropic medications. The responsible party was not notified of the wound changes or new medication orders, despite facility policy and staff expectations requiring such communication and documentation.
A resident at risk for pressure wounds did not receive a head-to-toe skin assessment or Braden Score on admission, and weekly wound assessments were inconsistently documented. Staff failed to accurately record the progression of a heel pressure ulcer, and the Wound Nurse was not promptly notified of changes. This resulted in inadequate monitoring and documentation of the resident's pressure wound.
A resident dependent on staff for daily care reported that a CNA verbally abused them, used profanities, threw a bed remote at them, and made threatening remarks. Although the incident was reported internally to the charge nurse and administrator, the administrator did not notify regulatory authorities as required by policy and regulations, resulting in a failure to report the abuse allegation.
The facility did not accurately transcribe or document wound care orders and treatments for several residents, resulting in incomplete medical records. For example, a resident with multiple amputations and complex wounds did not have updated treatment orders entered after a hospital readmission, and there was no documentation explaining missed or held treatments. Two other residents with pressure ulcers had multiple undocumented or unrecorded wound treatments, with no explanations for missed care or refusals. Staff interviews revealed confusion about documentation responsibilities and inconsistent practices, leading to gaps in the residents' clinical records.
The facility failed to maintain resident dignity and respect, with incidents of staff speaking disrespectfully, not providing necessary care, and entering rooms without knocking. A resident with Alzheimer's was left in an unhygienic state, another post-surgery resident was not assisted with grooming or feeding, and a third resident experienced staff entering without knocking. Staff often did not wear name badges, violating facility policies on privacy and dignity.
The facility failed to honor resident requests for personal funds as per regulations, limiting withdrawals to $20.00 and not holding excess funds in interest-bearing accounts. The BOM was unaware of the requirement to honor requests up to $49.00 for Medicaid residents within 24 hours, and the facility held excessive petty cash instead of managing funds properly.
The facility failed to maintain a clean and homelike environment, with observations of unclean rooms, medical equipment, and common areas. Residents reported issues such as running toilets and lack of hot water, which were not addressed promptly. Housekeeping staff were shorthanded, and their working hours did not cover evenings, leading to unsanitary conditions. The facility's cleaning schedule was not effectively implemented, resulting in an environment that was not safe or comfortable for residents.
The facility's policy on background checks for new hires was insufficient, failing to specify necessary checks and omitting the requirement to check the NA Registry for all staff. This led to three employees, including a Dietary Aide, an LPN, and a Housekeeping Aide, not having their NA Registry checks completed. The HR/Staffing Coordinator was unaware of the need to check all staff for federal indicators.
The facility failed to provide necessary ADL assistance and hygiene care for several residents, leading to deficiencies in personal hygiene and grooming. A resident with Alzheimer's was left with soiled hands and saturated briefs, while another with dementia had severely matted hair due to inadequate washing. Additional residents experienced neglect in grooming and feeding assistance, highlighting a failure to adhere to facility policies.
The facility failed to provide individualized activities for three residents, each with specific preferences and needs. One resident with dementia and depression was not offered any activities despite a strong interest in music and group activities. Another resident with Alzheimer's disease had only one documented one-on-one activity, and a third resident with a history of stroke was observed without engagement in activities. The Activity Director acknowledged the lack of a structured schedule for one-on-one activities.
The facility failed to employ a qualified Activity Director, as the current director lacked necessary training and certification. Despite the facility's assessment tool indicating the need for a qualified professional, the Activity Director had no prior training or certification in activities. Initial training was provided by the DON, and although there were discussions about certification, no steps had been taken to enroll the director in relevant classes.
The facility failed to maintain accurate narcotic count records, affecting three medication carts. Observations showed missing narcotic count sheets for the Garden Unit, and the Terrace Unit's count sheets had discrepancies, including missing package totals and staff initials. Interviews confirmed that narcotic counts were not consistently completed by both on-coming and off-going staff, as required by facility policy.
The facility failed to maintain a temperature log for a medication room refrigerator containing insulin and left a medication cart unlocked and unattended in the Garden Unit. Staff confirmed that temperature logs were missing and that the cart should be locked when unattended to ensure resident safety.
The facility failed to serve food at safe and palatable temperatures for two residents and those on the Veranda hall. A resident with manic depression and schizophrenia reported cold food, while another with major depressive disorder and Alzheimer's disease also expressed dissatisfaction. Observations showed breakfast and lunch trays served below required temperatures, and staff interviews confirmed expectations for proper food temperatures.
The facility failed to maintain kitchen sanitation and ensure staff compliance with hair restraint policies. Observations showed unclean kitchen equipment and improper use of hairnets by staff, including a Maintenance Aide and Dietary Aide. Interviews confirmed expectations for cleanliness and proper hair restraint use, which were not met.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with medical devices and wounds, as required by CMS and CDC guidelines. Observations revealed no EBP signs or gowns available for staff, and improper infection control practices during medication administration were noted. Additionally, newly hired employees did not have their PPD tests read within the required timeframe. Staff interviews indicated a lack of awareness and training on EBP, with the DON and Unit Manager not believing the requirements applied to their facility.
The facility failed to conduct routine inspections of bed rails, leading to potential safety risks for residents. Several residents with medical conditions such as seizures, stroke, Parkinson's disease, and dementia were observed with unsecured or uninspected side rails. The facility's policy lacked guidance for routine inspections, and interviews with staff revealed no system in place for such inspections, despite expectations for maintenance staff to ensure safety.
The facility's pest control program was ineffective, leading to a severe roach infestation affecting multiple residents. Observations showed live and dead roaches in residents' rooms, and staff interviews confirmed the widespread issue. Despite bi-weekly treatments by a pest control company, there were no documented recommendations or effective measures to address the infestation, causing distress among residents.
A resident was found with unattended medication at their bedside without a physician's order for self-administration. The facility's policy requires staff to remain with residents until medications are taken, but this was not followed. Interviews with staff confirmed that no residents had orders for self-administration or for medications to be left at the bedside.
A facility failed to accurately code a resident's life expectancy in the MDS assessment, despite the resident being on hospice care. The MDS Coordinator misunderstood the requirement, believing that a life expectancy of less than six months should only be marked if the resident was actively dying, not realizing that hospice admission includes a certification of terminal illness with such a life expectancy.
The facility failed to coordinate a required Level II PASARR screening for a resident with serious mental illness, as indicated by their Level I screening. The resident, who was cognitively intact and diagnosed with dementia, manic depression, and recurring major depressive disorder, was receiving antipsychotic and antidepressant medications. Despite the need for a Level II screening, no documentation was found to confirm its completion.
The facility failed to provide complete and individualized care plans for three residents, leading to deficiencies in addressing specific needs. A resident with Alzheimer's was not care planned for playing in stool, resulting in inadequate perineal care. Another resident, with major depressive disorder and anxiety, was not care planned for room cleaning refusal and food storage, leading to a bug infestation. A third resident, with heart and renal failure, had no care plan for leg edema and cellulitis, despite requiring Tubi grips. The DON and Administrator acknowledged these oversights.
The facility failed to follow physician orders for two residents, resulting in inadequate care. One resident with chronic edema and cellulitis did not receive a Tubi grip as ordered, and another resident with a g-tube did not have a dressing applied to the site, leading to redness and drainage. Staff were unaware of the orders, and the DON expected compliance with physician directives.
A resident at high risk for pressure ulcers developed a new ulcer on the coccyx due to the facility's failure to routinely turn and reposition them. Despite a care plan requiring frequent repositioning and skin assessments, the resident was often left on their back without support, and staff failed to report the new ulcer to the nurse. The lack of communication and documentation led to a delay in addressing the resident's skin condition.
A resident with dysphagia, heart failure, and dementia did not receive tube feeding as per physician orders, compromising nutritional intake. Observations showed the tube feeding was turned off early without documentation or physician notification. Staff interviews revealed a lack of adherence to orders and absence of a specific policy on tube feeding care.
The facility failed to properly assess and document the use of side rails for several residents, lacking physician orders and informed consent. Residents with conditions such as Parkinson's, stroke, and renal disease had side rails installed without proper evaluation, leading to inconsistencies in care plans. Staff interviews revealed a lack of clarity and adherence to the facility's policy on side rail use.
The facility failed to provide prescribed diets to two residents. One resident with dysphagia received regular liquids instead of nectar-thickened liquids, while another resident continued to receive a pureed diet despite an upgrade to a mechanical-soft diet. Staff interviews revealed communication and documentation lapses regarding dietary changes.
The facility failed to provide residents and visitors with easy access to the most recent survey results and plans of correction, as required by the Resident's Rights document. The survey binder, which should have contained these documents, was not readily accessible and lacked the necessary information from recent surveys. Residents were unaware of the binder's location, and the Administrator admitted that these documents should be available without request.
The facility failed to perform and document neuro checks per policy for a resident who fell. Despite the resident's high fall risk and multiple diagnoses, no neuro checks were recorded after the fall, contrary to the facility's guidelines. Staff interviews confirmed the importance of neuro checks, but the facility did not adhere to its own procedures.
Failure to Follow Physician Orders for Weekly Weights in Dialysis Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure physician orders for weight monitoring were followed for multiple residents receiving dialysis. Facility policies on physician orders and dialysis required that orders be transcribed and followed as prescribed, with all obtained weights documented in the electronic medical record (EMR), and that there be ongoing communication and coordination with dialysis staff. Despite these policies, four of five residents identified as receiving dialysis services had missing or inconsistent weight documentation in the EMR, even though they had active orders for weekly weights. One resident with congestive heart failure, a history of thrombotic pulmonary emboli, and iron deficiency anemia had multiple overlapping weekly weight orders with specified start and stop dates, but no weights recorded in the EMR for October 2025, January 2026, or February 2026, and only two weights documented in November and December 2025. The most recent dialysis communication sheet for this resident showed a post-dialysis weight in mid-December 2025, but this information was not reflected as ongoing weight entries in the EMR. Another cognitively intact resident with ESRD, a history of TIA, and a prior MI had an active order for weekly Sunday weights, yet had no recorded weights in November 2025 or January 2026, and only sporadic weights documented in December 2025, late February 2026, and early March 2026. A third cognitively intact resident with ESRD, a history of TIA, unspecified heart failure, and coronary artery disease had weekly weight orders, including an active order for Monday day-shift weights, but had no recorded weights in December 2025 or January 2026 and only two weights documented in February and March 2026. A fourth cognitively intact resident with ESRD, essential hypertension, iron deficiency anemia, and insomnia had an active weekly weight order, but only three weights were documented over a roughly six-week period. Staff interviews with an LPN, a CMT, and facility leadership confirmed that residents on dialysis typically have weekly weight orders, that any nursing staff member can obtain and record weights in the EMR, and that dialysis communication forms are supposed to be collected and transcribed. The DON, ADON, and an LPN reported that the previous DON had been receiving dialysis communication forms but had failed to upload or transcribe most of the post-dialysis weights into the EMR, contributing to the incomplete weight records identified by surveyors.
Failure to Follow Policy for Self-Administration of Medications
Penalty
Summary
Staff failed to follow acceptable nursing practice by leaving a resident's topical gel and inhaler in the resident's room without proper assessment or authorization for self-administration. The resident, who was alert and oriented but legally blind and diagnosed with diabetes and end stage renal disease, did not have a care plan or physician order permitting self-administration or bedside storage of medications. Facility policy requires an interdisciplinary team assessment and a prescriber's order before a resident can self-administer medications or keep them at bedside, but no such assessment or order was present in the resident's medical record. Observations showed that both the diclofenac sodium topical gel and Breztri inhaler remained on the resident's over bed tables for several hours. Interviews with the resident confirmed self-use of these medications as needed, and interviews with multiple LPNs revealed that the required assessment and physician order for self-administration had not been completed. Staff acknowledged that the resident did not have authorization to self-administer medications, and the medications were subsequently removed from the room after this was discovered.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
Staff failed to follow physician orders for wound care for one resident with diagnoses including high blood pressure, diabetes, and heart failure. The physician's order required daily cleansing of both lower extremities with Vashe wound cleanser, a 3-5 minute soak, application of silver wound gel to the wound bed, covering with mepitel, an ABD pad, and wrapping with kerlix and ace wrap. Observations revealed that the resident's dressings were not changed daily as ordered, and ace wraps were not consistently applied. The resident reported that dressings were changed only three to four times in the previous week and that ace wraps had only been applied once during a hospital stay. Direct observation of wound care by an LPN showed that the wounds were cleaned with Vashe, but no soak was performed, silver wound gel and mepitel were not applied, and ace wraps were omitted. Instead, silver sulfadiazine cream was used, which is not the same as silver wound gel per staff interview. The treatment cart did not contain silver wound gel. The Administrator confirmed that staff are expected to follow physician orders and facility policies.
Failure to Notify Responsible Party of Wound Changes and New Medications
Penalty
Summary
The facility failed to notify a resident's responsible party regarding the development and deterioration of a pressure wound, as well as the initiation of new psychotropic medications. The resident, who was cognitively impaired and at risk for pressure wounds, was admitted with multiple skin issues, including dermatitis and a pressure ulcer. Documentation showed that the resident developed a dark, soft area on the right heel, which later opened and worsened, but there was no record of the responsible party being informed about these changes. Additionally, the resident was prescribed several new medications for depression, mood disorder, and agitation, including doxepin, Depakote Sprinkles, and hydroxyzine. Despite facility policy requiring notification and documentation of such changes to the responsible party, there was no evidence in the progress notes or physician documentation that the responsible party was informed about the new medication orders. Interviews with nursing staff and facility leadership confirmed that the expectation was for the responsible party to be notified of any new wounds, changes in wound condition, and new medication orders, with such communication documented in the resident's record. However, the review of records and staff statements indicated that these notifications did not occur as required, resulting in a deficiency related to failure to communicate significant changes in the resident's condition and treatment.
Failure to Perform and Document Required Pressure Ulcer Assessments
Penalty
Summary
The facility failed to ensure that a resident with a pressure wound received proper assessment and monitoring, as required by facility policy. Upon admission, the resident, who was cognitively intact and at risk for developing pressure wounds, was not given a head-to-toe skin assessment or a Braden Score evaluation. The resident was admitted with dermatitis, an open area on the right inner thigh, and a pressure ulcer on the right heel. Despite physician orders and facility policy mandating weekly skin assessments and documentation, there was no admission skin assessment or Braden Score completed, and documentation of weekly wound assessments was inconsistent and incomplete. Progress notes and treatment records revealed that the resident developed a dark, soft area on the right heel, which was initially not open but later progressed to an open wound with slough and eschar. The wound was treated according to orders, but there was a lack of accurate and timely documentation regarding the wound's progression. The skin assessment data form completed on one occasion was inaccurate, failing to note the heel wound, and there were no further completed skin assessment forms or detailed documentation of the wound's condition after it opened. Interviews with facility staff, including the LPN, Nurse Manager, Wound Nurse, and Director of Nursing, confirmed that required assessments and documentation were not performed as expected. Staff acknowledged that weekly skin assessments, progress notes, and accurate documentation of wound condition were not consistently completed. The Wound Nurse was not aware of the heel wound until notified by staff days after admission, and the resident was not seen by the Wound Nurse Practitioner until several days after the wound opened. The lack of proper assessment and documentation led to a failure in providing appropriate pressure ulcer care and prevention for the resident.
Failure to Report Alleged Abuse as Required by Policy and Regulations
Penalty
Summary
The facility failed to follow its abuse reporting policy and regulatory requirements by not reporting an allegation of abuse involving one resident. The resident, who was dependent on staff for mobility, toileting, and nutrition, and had diagnoses including morbid obesity and generalized anxiety disorder, reported that a CNA entered the room without knocking or identifying themselves, turned on the lights without warning, and then verbally abused the resident using profanities and derogatory language. The resident also alleged that the CNA snatched the bed remote from their hands, threw it at them, and threatened further harm before leaving the room. The incident was reported to the charge nurse and the administrator by staff on the same day. Despite the facility's policy requiring immediate reporting of all alleged violations involving abuse to the administrator and state authorities, the administrator did not report the allegation to the regulatory authority. The administrator stated that since an internal investigation determined that abuse did not occur, they believed reporting was unnecessary. This failure to report the allegation as required constitutes a deficiency in following both facility policy and state/federal regulations.
Failure to Accurately Document and Transcribe Wound Care Orders
Penalty
Summary
The facility failed to properly transcribe and document treatment orders and wound care for multiple residents, resulting in incomplete and inaccurate medical records. For one resident with significant medical needs, including bilateral amputations and end-stage renal disease, the facility did not transcribe new wound care orders following a hospital readmission. The Treatment Administration Record (TAR) continued to reflect outdated orders, and there was no documentation explaining why treatments were held or not administered. Additionally, there was no record of the new wound vacuum therapy or barrier ointment orders from the hospital, and the progress notes lacked details about changes in treatment or the resident's transitions in and out of the facility. For two other residents with pressure ulcers and other wounds, the TAR contained multiple blank entries and notations indicating treatments were not administered, without any corresponding documentation in the progress notes to explain the omissions or refusals. The facility's policies required that all treatments and refusals be documented, and that physician orders be accurately transcribed and implemented. However, the records showed repeated failures to document whether treatments were completed, refused, or why they were not given. Staff interviews confirmed that blanks on the TAR meant treatments were either not done or not signed off, and that there was confusion about documentation responsibilities when residents left or returned to the facility. The deficiencies were further compounded by inconsistent documentation practices among nursing staff and a lack of clarity regarding who was responsible for entering and updating treatment orders. The facility's own policies emphasized the need for complete, accurate, and timely documentation of all clinical care, including wound treatments and resident refusals. Despite these policies, the survey found that essential information was missing from the medical records, and there was no evidence that physicians were notified when treatments were not administered as ordered.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by several incidents involving inappropriate staff behavior and inadequate care. One resident, diagnosed with Alzheimer's disease and requiring substantial assistance with toileting hygiene, was observed with a brown substance on their hands and a strong odor of bowel movement in their room. Despite this, a CNA addressed the resident in a disrespectful manner and failed to provide necessary perineal care, leaving the resident in an unhygienic state for an extended period. Another resident, admitted for therapy following neck surgery, reported not receiving assistance with grooming or feeding. The resident, who lacked full use of their arms, was left with disheveled hair and an untouched breakfast tray, leading to feelings of neglect and sadness. The resident also expressed discomfort due to improperly worn clothing and noted that staff often entered their room without knocking or introducing themselves, further diminishing their sense of dignity and respect. Additionally, a cognitively intact resident with a diagnosis of depression experienced staff entering their room without knocking or wearing name badges, which was a common occurrence according to the resident. The facility's policies on resident privacy and dignity were not adhered to, as staff frequently failed to announce themselves or wear identification, contributing to an environment where residents' rights to privacy and respect were compromised.
Failure to Honor Resident Financial Requests and Manage Funds Properly
Penalty
Summary
The facility failed to honor resident requests for personal funds in accordance with regulatory requirements. During a group interview, seven cognitively intact residents reported that their requests for personal funds were limited to $20.00, and if they wanted more, they had to wait. The Business Office Manager (BOM) confirmed that she typically only allowed $20.00 for cash withdrawals, based on outdated information that residents could only receive $20.00 per day unless they were leaving the facility. The BOM was unaware that requests for up to $49.00 should be honored within 24 hours for Medicaid residents. Additionally, the facility did not comply with regulations regarding the management of resident funds in excess of $100.00 for non-Medicaid residents and $50.00 for Medicaid residents. The BOM was unaware that excess funds needed to be held in an interest-bearing account. An observation revealed that the facility had $4,938.17 in petty cash, far exceeding the allowable cash on hand. The Administrator stated that the facility's policy was to provide up to $20.00 when residents requested personal funds and to inquire about purchases if more was requested, but he expected excess funds to be held in an interest-bearing account.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by multiple observations of unclean rooms, medical equipment, and common areas. Residents' rooms were found with debris, dirt, and dried spills, and some rooms had significant issues such as brown smears on walls, sticky floors, and dust accumulation on air conditioning units. In one instance, a resident was observed with a brown substance on their hands and under their nails, with a strong odor of bowel movement in the room, which was not adequately cleaned by the staff. The facility's housekeeping schedule was not effectively implemented, leading to these unsanitary conditions. Several residents reported issues with their living conditions, including a running toilet and lack of hot water, which affected their comfort and hygiene. Despite these complaints, the issues were not addressed in a timely manner, and staff interviews revealed that these problems had persisted for a long time. The maintenance director was unaware of these issues, indicating a lack of communication and follow-up on maintenance requests. The facility's administrator expected staff to report such issues, but the process for addressing them was not effectively managed. Housekeeping staff were reported to be shorthanded, and their working hours did not cover the evening shift, leaving a gap in cleaning services from 3:00 P.M. to 7:00 A.M. This lack of coverage contributed to the accumulation of dirt and debris in resident rooms and common areas. Interviews with staff revealed that there was no deep cleaning schedule, and the existing cleaning routine was insufficient to maintain a clean environment. The facility's failure to ensure adequate cleaning and maintenance resulted in an environment that was not safe, clean, or comfortable for the residents.
Deficiency in Background Check Policy for New Hires
Penalty
Summary
The facility failed to develop and implement a comprehensive policy for conducting background checks on all newly hired employees, which led to a deficiency. The policy, revised on 8/29/24, required background checks to be completed two days prior to an employee's start date and included annual Family Care Safety screening and quarterly Employee Disqualification List screening. However, the policy did not specify which background checks were necessary before hiring and failed to mandate checking the Nurse Aide (NA) Registry for all staff to ensure no federal indicators of abuse, neglect, or misappropriation of resident property. This oversight resulted in three out of five sampled newly hired employees, including a Dietary Aide, an LPN, and a Housekeeping Aide, not having their NA Registry checks completed. During an interview, the Human Resources/Staffing Coordinator acknowledged that the NA Registry was only checked for certain positions and was unaware of the requirement to check all staff for federal indicators.
Deficiencies in ADL Assistance and Hygiene in LTC Facility
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in personal hygiene and grooming. One resident, diagnosed with Alzheimer's disease and requiring substantial assistance with toileting hygiene, was observed with a brown substance on their hands and under their nails, indicating a lack of perineal care after a bowel movement. Despite the strong odor of bowel movement in the room, the resident was not cleaned promptly, and their brief was saturated through their pants. The staff failed to provide immediate care, and the resident was left in this condition for an extended period. Another resident, dependent on staff for personal hygiene due to dementia and Parkinson's disease, was found with severely matted hair and large chunks of white flakes throughout. The facility's shower schedule was not adhered to, and the resident's hair was not properly washed or maintained, leading to significant neglect in grooming. The staff did not report the condition of the resident's hair to the nurse, nor did they attempt to address the issue with appropriate interventions such as medicated shampoo or family involvement. Additional residents were also affected by the facility's failure to provide adequate ADL assistance. One resident, admitted for therapy and unable to use their arms fully, was not assisted with brushing their hair or feeding, leading to discomfort and distress. Another resident had untrimmed and dirty fingernails, indicating a lack of routine nail care. The facility's policies on ADL assistance and hygiene were not followed, resulting in multiple instances of neglect and inadequate care for the residents.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide individualized activities to meet the interests and psychosocial well-being of three residents, as required by their needs and preferences. Resident #32, who has dementia, Parkinson's disease, and depression, was found to have no documented activity assessments or care plans addressing their activity preferences. Despite expressing a strong interest in listening to music and participating in group activities, the resident was observed in bed throughout the survey period without any one-on-one or group activities being offered. Resident #9, diagnosed with Alzheimer's disease and moderately impaired cognition, had a care plan that lacked specific goals for activities. Although the resident expressed a preference for listening to music, being outdoors, and participating in group activities, there was only one documented one-on-one activity since admission. Observations showed the resident in bed or self-propelling in a wheelchair without any engagement in activities or mental stimulation beyond routine care. Resident #55, who has a history of stroke and hemiplegia, also lacked a care plan that identified specific activity needs and preferences. Despite showing interest in music, reading, and social visits, the resident was observed in bed without any one-on-one activities or participation in group activities. The Activity Director admitted to not having a specific schedule for one-on-one activities and acknowledged the need for better documentation and structure in providing activities to residents.
Unqualified Activity Director Leads to Deficiency
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional. The Activity Director, who began working in February 2024, lacked the necessary qualifications and training as a therapeutic recreation specialist or activities professional. The facility's Facility Assessment Tool, updated in November 2023, indicated the need for therapy services and a qualified Activity Director, but there was no documentation of training requirements for this position. During interviews, the Activity Director admitted to having no prior training in activities and not being licensed, registered, or certified in occupational therapy or activities. The Director of Nurses provided some initial training, and there were discussions about the Activity Director taking classes to become certified, but no action had been taken to enroll her in such classes. The Administrator acknowledged the expectation for employing a qualified Activity Director and mentioned plans for certification, which had not yet been implemented.
Failure to Maintain Accurate Narcotic Count Records
Penalty
Summary
The facility failed to establish a system of record for all controlled drugs with sufficient detail to enable accurate reconciliation, affecting three out of three medication carts reviewed. The facility's policy required narcotics to be counted by the nurse or Certified Medication Technician (CMT) at the change of shift, with both the on-coming and off-going staff members initialing the count sheet. However, observations revealed that the Garden Unit nurses' cart and the CMT cart lacked narcotic count sheets for August 2024. Interviews with staff, including the Director of Nursing (DON), confirmed that the narcotic sheets for the Garden Unit could not be located. Further review of the Terrace Unit's Controlled Substance Shift Change Count Check Sheet for August 2024 showed significant discrepancies. Out of 50 shifts, 26 did not have the total number of packages noted, eight shifts lacked staff initials for the shift change count, and 16 shifts had only one staff initial. Interviews with CMTs and LPNs indicated that the narcotic count should be completed with one on-coming and one off-going staff member every shift, with the number of packages counted written on the shift count sheet. The failure to adhere to these procedures compromised the facility's ability to accurately reconcile controlled substances.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and monitoring of drugs and biologicals in the medication room refrigerator, as there was no temperature log available for review. During an observation, it was noted that the refrigerator contained multiple insulin pens and vials, but the temperature logs were missing. Certified Medication Technician (CMT) M was unable to locate the logs, and the Director of Nurses (DON) and Licensed Practical Nurse (LPN) L/Unit Manager confirmed that the logs could not be found. It was expected that the nursing staff on the night shift would check and record the temperatures daily, but this was not done. Additionally, the facility did not secure a medication cart, which was left unlocked and unattended in the Garden Unit. Multiple residents, some of whom were confused, were observed moving past the unlocked cart. The nurse responsible for the cart was not present at the time, and it was only locked upon the nurse's return. Interviews with CMT T, LPN C, and the DON confirmed that the medication cart should be locked whenever unattended to ensure resident safety, but this protocol was not followed.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to provide food that is palatable and at a safe and appetizing temperature for two residents and those on the Veranda hall. Resident #24, who is cognitively intact and diagnosed with manic depression and schizophrenia, reported that the food served in their room is not good and usually too cold. Similarly, Resident #45, also cognitively intact and diagnosed with major depressive disorder, anxiety disorder, and Alzheimer's disease, expressed dissatisfaction with the food, stating it is sometimes cold. Observations on the Veranda hallway revealed that breakfast and lunch trays were served at temperatures below the facility's policy requirements. Pancakes and sausage were served at 105.2°F and 99.5°F, respectively, while lunch items like mashed potatoes, chicken fried steak, and cooked carrots were served at temperatures ranging from 95.7°F to 107.4°F. Interviews with the dietary aide, food service manager, DON, and administrator confirmed the expectation that food should be served at a safe and palatable temperature, highlighting a failure in meeting these standards.
Failure to Maintain Kitchen Sanitation and Hair Restraint Compliance
Penalty
Summary
The facility failed to adhere to its food service policy, which mandates proper sanitation and food handling practices, including the use of hair restraints by dietary staff. Observations revealed that the deep fryer had sticky liquid streaks, the dry storage room contained food debris and trash wrappers, and the walk-in refrigerator had food debris and trash wrappers under the racks. Additionally, staff members, including a Maintenance Aide and Dietary Aide, were observed in the kitchen without proper hair restraints, with hairnets not fully covering their hair, and a beard not covered by a beard net. Interviews with staff, including a Dietary Aide, Food Service Manager, and the Administrator, confirmed the expectation that all kitchen staff should wear hair restraints correctly and maintain cleanliness in the kitchen and its equipment. The Food Service Manager emphasized that all kitchen staff are responsible for cleaning the floors, and the cook is responsible for cleaning the fryer. The Administrator also expressed the expectation for the kitchen and appliances to be clean and for staff to wear hair restraints properly.
Failure to Implement Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) as recommended by the CDC and required by CMS for residents with central lines, urinary catheters, wounds requiring treatment, and tube feedings. This deficiency was observed in nine residents who required EBP due to their medical conditions, such as having a gastrostomy tube, urinary catheter, or dialysis access site. During the survey, it was noted that there were no EBP signs posted on any resident doors, and no gowns were available to staff for use during high-contact resident care activities. Additionally, the facility did not adhere to proper infection control practices during medication administration. Staff were observed touching residents' medications and using their fingers to retrieve medications from stock bottles without wearing gloves. This practice was noted in the administration of medications to two residents, which is contrary to the facility's medication administration policy that requires medications to be dispensed without direct contact unless gloves are worn. The facility also failed to ensure that newly hired employees had their first step purified protein derivative (PPD) test read prior to starting work and within the required 24 to 48 hours after administration. Four out of five newly hired employees sampled did not have their PPD tests read within the specified timeframe. Interviews with staff revealed a lack of awareness and training regarding EBP, and the Director of Nursing (DON) and Unit Manager did not believe the EBP requirements applied to their facility, leading to non-implementation.
Failure to Conduct Routine Inspections of Bed Rails
Penalty
Summary
The facility failed to ensure routine inspections of bed/side rails were conducted as part of a regular maintenance program, leading to potential safety risks for four residents. The facility's policy on restraints and side rails did not provide guidance for routine inspections after installation, which is crucial to identify possible areas of entrapment. The FDA guidance suggests evaluating the dimensional limits of gaps in hospital beds to mitigate entrapment risks, especially for vulnerable populations such as elderly residents who are frail or have uncontrolled body movements. Resident #55, who has a history of seizures, stroke, and hemiplegia, was observed using a side rail that moved several inches when pulled, indicating a lack of secure attachment. The resident's care plan did not document the use of side rails, and there was no record of maintenance inspections for gap measurements. Similarly, Resident #32, diagnosed with Parkinson's disease and dementia, was observed with U-shaped rails raised on both sides of the bed, but there was no documentation related to the use of side rails or inspections for safety. Residents #47 and #50 also had beds with enabler rails, but their medical records lacked documentation of side rail inspections to identify entrapment areas. Interviews with facility staff, including the Maintenance Director and Administrator, revealed that there was no system in place for routine side rail inspections, and the responsibility for installation and inspection was assigned to the maintenance staff. The Administrator expected routine inspections to reduce the risk of entrapment, but this was not being implemented effectively.
Facility Fails to Control Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant infestation of roaches affecting eight residents. The pest control logs indicated that treatments were conducted bi-weekly, but there were no documented recommendations from the pest control company for facility staff, nor were there any entries by staff for areas needing attention. Observations revealed numerous live and dead roaches in residents' rooms, including on personal items and in food storage areas, indicating a severe infestation problem. Residents reported seeing roaches in their rooms and expressed distress over the situation. One resident mentioned that housekeeping had not cleaned their room for at least six months, and they often ate meals in their room, which could contribute to the pest problem. Another resident's family member was observed sweeping the room to manage the roach problem, highlighting the inadequacy of the facility's pest control measures. Staff interviews confirmed the widespread presence of roaches, with some staff members resorting to personal measures like buying their own bug spray to combat the issue. The facility's Director of Nursing and Administrator acknowledged the pest problem, with the Administrator noting that the pest control company had been contracted since 2018. However, there was a lack of communication and follow-up from the pest control company, as they did not provide written recommendations or invoices. The Maintenance Director also noted that despite efforts to deep clean and spray affected areas, the roaches returned, indicating that the current pest control measures were insufficient to address the infestation.
Medication Administration Policy Violation
Penalty
Summary
The facility failed to adhere to its medication administration policy by leaving medication unattended in a resident's room without a physician's order for self-administration or for medications to be left at the bedside. The resident, who was cognitively intact but required maximum assistance for various activities of daily living, was found with multiple pills in a clear medication cup on the bedside table. The resident did not have a care plan or physician order permitting self-administration of medications or for medications to be left at the bedside. Interviews with facility staff, including a Certified Medication Technician, a Licensed Practical Nurse, and the Director of Nursing, confirmed that no residents in the facility had orders to self-administer medications or to have medications left at the bedside. Staff are expected to remain with residents until medications are taken, and if a resident refuses, it should be documented, or an attempt should be made later. The incident with the resident indicated a deviation from these established procedures.
Inaccurate Coding of Life Expectancy for Hospice Resident
Penalty
Summary
The facility failed to ensure that the resident assessment was coded accurately to reflect a life expectancy of less than six months for a resident on hospice care. The medical record of a resident, who was admitted to hospice on May 10, 2024, indicated that the resident was receiving hospice care. However, the Minimum Data Set (MDS) assessment, dated May 21, 2024, incorrectly stated that the resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. During an interview, the MDS Coordinator revealed a misunderstanding of the requirements, stating that she only marked a life expectancy of less than six months if the resident was actively dying. She was unaware that admission to hospice inherently includes a certification of terminal illness with a life expectancy of less than six months.
Failure to Complete Required Level II PASARR Screening
Penalty
Summary
The facility failed to coordinate assessments for the Pre-Admission Screening and Resident Review (PASARR) program under Medicaid with the appropriate state-designated authority. This failure affected one of eight residents investigated for preadmission screening, specifically a resident who required a Level II screening due to serious mental illness. The resident's medical record indicated that they resided in a Medicaid-certified bed and had a DA-124c form dated 2/29/07, which showed a Level I screening criteria for serious mental illness. The form noted that the resident had serious problems in levels of functioning in the past six months, indicating the need for a Level II screening. However, there was no documentation of a Level II screening being completed. The resident's annual Minimum Data Set (MDS), dated 4/10/24, showed that the resident was cognitively intact and had diagnoses including dementia, manic depression, and recurring major depressive disorder. The resident was receiving antipsychotic and antidepressant medications and Medicaid benefits. An observation on 8/26/24 showed the resident in their room in a wheelchair, having just returned from dialysis, with no care concerns reported. During an interview, the Social Service Manager stated that she was not present when the Level I screen was conducted and could not find records of a Level II screening being requested or completed.
Deficiencies in Resident Care Plans
Penalty
Summary
The facility failed to ensure that residents had complete, accurate, and individualized care plans, as evidenced by deficiencies found in the care plans of three residents. Resident #9, diagnosed with Alzheimer's disease and moderately impaired cognition, required substantial assistance with toileting and was always incontinent of bowel and bladder. However, the care plan did not address the resident's behavior of playing in stool, which was observed during the survey. The resident was found with a brown substance on their hands and under their nails, and despite the presence of a strong odor of bowel movement, appropriate perineal care was not provided immediately. Resident #45, who was cognitively intact and diagnosed with major depressive disorder, anxiety disorder, and Alzheimer's disease, was not care planned for their refusal to allow staff to clean their room or for storing food in their room. This led to an infestation of bugs in the resident's room, with multiple bugs observed in the drawers and on the resident's pillow. The DON and Administrator acknowledged the resident's history of refusing room cleaning and storing food, and expected these issues to be addressed in the care plan. Resident #2, also cognitively intact, required maximum assistance for lower body dressing and had diagnoses including heart failure, renal failure, dementia, and depression. The care plan did not address the resident's leg edema, cellulitis, or the application of Tubi grips, which were ordered to reduce swelling. During the survey, the resident was observed with moderate edema and redness in the lower extremities, and CNA S was unaware of any special treatment for the resident's leg swelling. The DON confirmed that these issues should have been included in the care plan.
Failure to Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to provide care consistent with professional standards by not following physician orders for two residents. One resident, with a medical history of chronic edema and cellulitis, was not provided with a Tubi grip as ordered by the physician. Despite documentation indicating the treatment was completed, observations on multiple occasions revealed the resident was not wearing the Tubi grip. Interviews with staff, including a CNA and an LPN, indicated a lack of awareness of the Tubi grip order, and the LPN was unsure if the facility even had the necessary supplies. The Director of Nursing confirmed that staff are expected to follow physician orders and document treatments accurately. Another resident, with moderately impaired cognition and diagnoses of acute respiratory failure and dysphasia, did not have a dressing applied to their g-tube site as ordered by the physician. Observations showed the site was reddened and had darker red drainage, indicating a lack of proper care. Interviews with the Nurse Practitioner and the Wound Nurse confirmed the expectation for dressings to be applied per physician orders. The Director of Nursing stated that night shift nurses are responsible for g-tube dressing changes and expected the orders to be followed.
Failure to Prevent and Report Pressure Ulcer Development
Penalty
Summary
The facility failed to ensure that a resident, who was identified as dependent with mobility and at high risk for developing pressure ulcers, was routinely turned and repositioned by staff. This resulted in the development of a new pressure ulcer on the resident's coccyx. The facility's policy required weekly skin assessments by a registered or licensed practical nurse, and for any abnormalities to be reported to the physician, resident, or resident representative, and the Director of Nursing. However, the staff did not report the new pressure ulcer to the nurse as required. The resident's medical record indicated a high risk for pressure ulcers due to conditions such as Parkinson's disease, dementia, and depression. The care plan included interventions like applying barrier cream, frequent repositioning, and using pressure-relieving devices. Despite these measures, observations showed the resident was often left on their back without repositioning or the use of cushions and pillows, contributing to the development of the pressure ulcer. The resident was noted to be in bed most of the time and required total assistance from staff, yet there was no documentation of the resident's refusal to be repositioned or any resistance during care. Interviews with staff revealed a lack of communication and documentation regarding the resident's skin condition. A CNA noticed a small area on the resident's buttocks earlier in the week and reported it to a nurse, but this was not followed up or documented. The Wound Clinic Nurse and facility Wound Nurse were unaware of the new pressure ulcer until it was observed during a later assessment. The Director of Nursing was only informed of the new pressure ulcer after it had been identified by the Wound Clinic Nurse, indicating a breakdown in the facility's protocol for reporting and managing skin issues.
Failure to Follow Tube Feeding Orders
Penalty
Summary
The facility failed to ensure that a resident received tube feeding in accordance with physician orders, which compromised the resident's nutritional intake. The resident, who had diagnoses including dysphagia, heart failure, and dementia, was supposed to receive tube feeding from 8:00 P.M. to 8:00 A.M. However, observations on multiple days showed that the tube feeding was turned off early, with no documentation or notification to the physician. The resident's medical record lacked any notes regarding the early termination of tube feeding on these days. Interviews with staff revealed a lack of understanding and adherence to the physician's orders for tube feeding. An LPN mentioned that it was not necessary to document or notify the physician if the tube feeding was turned off early, comparing it to a resident refusing breakfast. The Director of Nursing and Unit Manager confirmed that the tube feeding should run the entire prescribed time, and any deviation should be documented and reported. The facility lacked a specific policy regarding tube feeding care, contributing to the deficiency.
Failure to Properly Assess and Document Side Rail Use
Penalty
Summary
The facility failed to ensure that side rails were accurately assessed as necessary devices before their installation and use for four residents. The facility did not obtain physician orders for the use of side rails and failed to document side rail use in the care plans of these residents. The facility's policy requires a careful evaluation and informed consent before using restraints, including side rails, but these steps were not followed. Resident #32, diagnosed with Parkinson's disease, dementia, and depression, had side rails installed without a physician's order or signed consent. The resident's evaluation indicated they could not independently get in and out of bed safely and did not use the side rails for positioning or support. Observations showed the resident with U-shaped rails raised, despite being unable to use their arms. Similarly, Resident #55, with a history of seizures and stroke, had side rails without a physician's order or consent. The resident was observed using the side rails to attempt to move and get out of bed, indicating a lack of proper assessment and documentation. Residents #47 and #50 also had side rails installed without physician orders. Interviews with staff, including the Wound Nurse, LPN, and DON, revealed inconsistencies in the assessment and documentation process for side rail use. The facility did not obtain consents for side rails, and there was a lack of clarity on the necessity and effectiveness of side rails for certain residents. The Administrator expected nurses to assess residents for side rail use and obtain physician orders, but these expectations were not met, leading to the deficiency.
Failure to Provide Prescribed Diets to Residents
Penalty
Summary
The facility failed to provide food and liquids in accordance with physician orders for two residents. Resident #269, who has acute respiratory failure and dysphagia, was observed receiving regular water and lemonade instead of the prescribed nectar-thickened liquids. This occurred despite the resident's care plan and physician's orders specifying the need for nectar-thickened liquids to manage their swallowing difficulties. Resident #32, diagnosed with dysphagia and dementia, was supposed to receive a mechanical-soft diet with thin liquids as per a recent upgrade by Speech Therapy. However, the resident continued to receive a pureed diet, as observed during multiple meal times. The care plan did not reflect the updated dietary needs, and the dietary slips used by staff still indicated a pureed diet, leading to the resident being fed incorrectly. Interviews with staff, including CNAs, LPNs, and the Director of Nurses, revealed a lack of communication and proper documentation regarding dietary changes. The staff relied on outdated dietary slips, and there was a failure to update the resident's dietary orders in the system and communicate these changes to the dietary department. The Food Service Manager and the Administrator both expressed expectations that residents should receive diets according to their physician orders, highlighting a gap between expectations and practice.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to make the most recent annual survey's plan of correction and statements of deficiencies, along with any abbreviated survey results completed since the most recent annual survey, readily available to residents and visitors. The facility's Resident's Rights document, provided to residents upon admission, guarantees the right to examine the results of the most recent survey conducted by Federal or State surveyors and any plan of correction in effect. However, the survey binder, which should contain these documents, was not accessible without requesting assistance from staff, as it was located behind the desk on an upper shelf at the front office. Observations revealed that the survey binder did not include the plan of correction for the annual survey completed on 4/21/23, nor did it contain the statements of deficiencies or plans of correction for the abbreviated surveys completed on 10/4/23 and 1/23/24. Interviews with residents representing the resident council indicated that they were unaware of the binder's location and believed it was at the front desk. The Administrator acknowledged that the most recent statements of deficiencies and plans of corrections should be available without requiring residents or visitors to request them.
Failure to Perform and Document Neuro Checks After Resident Fall
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice when staff did not perform neurological checks (neuro-checks) per the facility's policy for one of three residents sampled for falls. The facility's Fall Management Guidelines Policy required ongoing assessment and documentation, including neuro checks, following a resident's fall. However, the policy did not specify the frequency and duration of neuro checks. The computer-generated Neuro Check Sheet directed staff to perform neuro checks initially, then every 15 minutes times four, every 30 minutes times two, every 60 minutes times two, and then every shift times six. Despite this, no neuro checks were documented for Resident #3 after a fall on 8/19/23, as evidenced by the review of the electronic medical record and progress notes. Resident #3, who was alert and oriented, had multiple diagnoses including atrial fibrillation, heart failure, and chronic obstructive pulmonary disease. The resident required total assistance for bed mobility and transfers and was at high risk for falls. On 8/19/23, the resident was found on the floor by an aide, with no injuries noted. The incident was reported, and initial vital signs were taken, but there was no further documentation of neuro checks. Interviews with various staff members, including nurses and the Director of Nursing (DON), confirmed that neuro checks should have been performed and documented in the computer system following the fall. The DON and other staff members stated that neuro checks were important to monitor for changes in the resident's condition and should be documented in the computer. Despite this, the facility failed to follow its own policy and procedures, as no neuro checks were recorded for Resident #3 after the fall. The Administrator also confirmed that staff were expected to follow the facility's policies and procedures, indicating a lapse in adherence to professional standards of practice in this instance.
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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