Pemiscot County Memorial Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Hayti, Missouri.
- Location
- 946 E Reed Street, Hayti, Missouri 63851
- CMS Provider Number
- 26A469
- Inspections on file
- 13
- Latest survey
- February 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pemiscot County Memorial Hospital during CMS and state inspections, most recent first.
The facility did not maintain a surety bond at the required level to secure residents' personal funds. The policy did not address the need for a bond one and one-half times the average monthly balance of residents' funds. The approved bond was $35,000.00, while the required amount was at least $46,500.00. The Revenue Cycle Director was unaware of this requirement, and the Administrator acknowledged the expectation for compliance.
The facility failed to maintain 24-hour licensed nursing coverage, affecting all residents. The policy required sufficient nursing staff to meet residents' needs, but the Payroll Based Journal (PBJ) Staffing Report showed inadequate coverage for an entire quarter. The Chief Nurse Officer and Administrator were informed of the issue in November 2024, with staff turnover contributing to the deficiency.
The facility failed to provide RN coverage for eight consecutive hours per day, seven days a week, as required by policy. The deficiency was identified through record reviews and interviews, revealing no RN coverage for 90 out of 92 days in the fourth quarter of 2024. The issue was attributed to staff turnover, and the facility's leadership was unaware of the extent of the coverage gaps until November 2024.
The facility failed to obtain physician's orders for code status for several residents, impacting their rights to request or refuse treatment. Despite having forms indicating Full Code or DNR status, these were not signed or dated by the physician or resident. Interviews with staff confirmed the absence of required orders, highlighting a lapse in following state and federal regulations.
The facility failed to issue the required SNF ABN and NOMNC forms to residents and their legal representatives, as mandated by regulations. Specifically, the facility did not provide these notices at least two calendar days before the end of skilled Medicare services for three residents. The Chief Nursing Officer confirmed that the staff was unaware of these forms or the related regulations, leading to the oversight.
The facility failed to maintain a safe, clean, and homelike environment, with observations of stained ceiling tiles, unswept and unmopped floors, and untidy resident rooms. Residents reported longstanding issues with leaks and inadequate housekeeping services. The administration acknowledged dissatisfaction with the contracted housekeeping vendor and was seeking a replacement.
A facility failed to accurately code the MDS for a resident, marking an antidepressant as an antipsychotic. The resident, diagnosed with dementia and other conditions, was prescribed Remeron for visual hallucinations, but no antipsychotic was ordered. The MDS Coordinator mistakenly identified Remeron as an antipsychotic, leading to the error.
The facility failed to follow physician orders for blood glucose monitoring times for two residents, leading to a deficiency in care. A resident with diabetes had their blood glucose checked after meals instead of before, and the required insulin was not administered as ordered. The Chief Nursing Officer confirmed that blood glucose should be checked before meals, and insulin should be administered 15-30 minutes prior, highlighting a systemic issue with adherence to physician orders.
A resident at risk for pressure ulcers was left in a Geri chair without a pressure-reducing device for extended periods, contrary to their care plan and physician's orders. This led to the development and progression of a pressure ulcer from Stage 2 to Stage 3. The resident, with severe cognitive impairment and multiple diagnoses, required substantial assistance for transfers. Facility staff, including the DON and CNO, were unaware of the prolonged chair use, and the physician was not informed of the situation.
A resident with severe cognitive impairment and requiring substantial assistance was transferred without a gait belt, contrary to facility policy. An LPN and CNA conducted the transfer by holding the resident under the arms and pulling on the pants, which was not compliant with safe transfer guidelines. Staff interviews revealed the LPN forgot to apply the gait belt, and the CNA acknowledged the oversight.
The facility failed to ensure an appropriate diagnosis for a psychotropic medication for a resident and did not monitor the drug regimen or follow up on a GDR recommendation for another resident. One resident was prescribed Haldol for insomnia without an appropriate diagnosis, while another had no documented rationale or physician response for GDR recommendations on multiple medications.
The facility failed to maintain and close dumpsters properly, leaving trash exposed and lids open, with furniture obstructing closure. Staff interviews confirmed expectations for proper closure, but no policy was provided.
The facility failed to implement Enhanced Barrier Precautions during wound care for a resident, as an LPN did not wear an isolation gown. Additionally, proper glove changing and hand hygiene practices were not followed during blood glucose monitoring for another resident. The facility also lacked a Legionella risk management process and did not have a policy for infection control in laundry services.
The facility failed to provide the required twelve hours of annual in-service training for two CNAs, as there was no documentation of attendance or time durations for the sessions. The facility lacked a policy for nurse aide in-service training, and the Facility Assessment did not address the mandatory training requirements, including Dementia Care and Resident Abuse Prevention. Interviews with the DON and CNO confirmed the necessity of these trainings.
The facility failed to post daily nurse staffing information in a prominent location accessible to residents and visitors for four days. The staffing information was incorrectly placed by the time clock on the hospital side, contrary to the facility's policy. Interviews with the DON and CNO revealed a lack of awareness about the requirement to post the information in the nursing home area.
A resident dependent on a gastrostomy tube for nutrition and hydration experienced severe weight loss due to the facility's failure to administer prescribed tube feedings and water flushes. Numerous missed opportunities for care were documented, and the resident's condition was not reported to the physician in a timely manner. Staff interviews revealed issues with scheduling and documentation, contributing to the deficiency.
The facility failed to follow physician orders for three residents, resulting in missed medication doses and incomplete lab tests. A resident with a UTI and sepsis had multiple missed antibiotic doses, while another resident with seizures missed several doses of Keppra. Interviews revealed a lack of documentation and awareness among staff, with the DON not auditing charts effectively.
The facility failed to provide sufficient nursing staff, resulting in missed administration of tube feedings, medications, and wound treatments for a resident. The absence of licensed nurse coverage on specific shifts led to incomplete care and documentation, as revealed by interviews with the DON and CNO. The facility relied on hospital staff to cover shifts, lacking a policy for staffing licensed nurses.
The facility did not ensure an RN was on duty for eight consecutive hours daily, as required. Review of schedules and assignment sheets showed no RN coverage on specific dates, despite the facility's assessment tool indicating a need for two RNs. The CNO believed hospital staff were part of the LTC staff, leading to inconsistent RN scheduling.
A resident with severe cognitive impairment and multiple health conditions, including paraplegia, experienced inadequate pressure ulcer care at a facility. The facility failed to consistently perform and document wound assessments and treatments, with numerous missed opportunities for care. Staff interviews revealed lapses in following the facility's wound management policy, leading to insufficient monitoring and documentation of the resident's pressure ulcer.
A resident with an indwelling urinary catheter experienced improper catheter care and documentation deficiencies. Observations showed the catheter bag was often positioned incorrectly, and there were numerous missed opportunities for documenting catheter care. Despite staff awareness and reporting to the DON, the issues persisted.
Failure to Maintain Adequate Surety Bond for Residents' Personal Funds
Penalty
Summary
The facility failed to maintain a surety bond for the security of residents' personal funds at the required level. The facility's policy, titled 'Notice of Rights and Rules' and revised in May 2019, did not address the requirement for a surety bond to be at least one and one-half times the average monthly balance of the residents' personal funds for the last 12 consecutive months. The facility's approved bond amount was $35,000.00, while the average monthly balance of the residents' personal funds was $30,696.22. This average, when rounded to the nearest thousand, equaled $31,000.00, requiring a bond amount of at least $46,500.00. During interviews, the Revenue Cycle Director was unaware of the requirement for the surety bond to be one and one-half times greater than the average balance, and the Administrator acknowledged the expectation for the bond to meet this requirement.
Insufficient Licensed Nursing Coverage
Penalty
Summary
The facility failed to ensure licensed nursing coverage for 24 hours a day, which was necessary to adequately provide resident care and meet resident needs. This deficiency had the potential to affect all residents residing at the facility, which had a census of 18. The facility's policy, revised in May 2019, required sufficient nursing staff with appropriate competencies and skills to provide nursing and related services to meet residents' needs safely. However, the facility's Payroll Based Journal (PBJ) Staffing Report for Quarter 4, from July 1, 2024, to September 30, 2024, showed insufficient licensed nursing coverage for every day of the quarter. During interviews, the Chief Nurse Officer (CNO) and the Administrator acknowledged the staffing issues. The CNO was informed of the concern in November 2024 when the facility was cited, but was unaware of the extent of the insufficient coverage throughout the quarter. The Administrator also became aware of the staffing concern at the same time. The report indicates that there was significant staff turnover, which contributed to the deficiency in maintaining adequate licensed nursing coverage.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, as required by their policy. This deficiency was identified through interviews and record reviews, revealing that there was no RN coverage for 90 out of 92 days during the fourth quarter of 2024. The facility's policy, revised in May 2019, mandates sufficient nursing staff to meet residents' needs and requires the use of an RN for at least eight hours a day, seven days a week, unless waived. However, the Payroll Based Journal (PBJ) Staffing Report showed a lack of RN coverage from July 1, 2024, to September 30, 2024. Interviews with the Chief Nurse Officer (CNO) and the Administrator indicated that the issue of RN coverage was brought to their attention in November 2024. The CNO was unaware of the extent of the RN coverage gaps during the submitted quarter, attributing the deficiency to significant staff turnover. The Administrator confirmed that a designated Director of Nursing (DON) and a weekend RN were hired to address the staffing requirements, but these actions were taken after the deficiency period.
Failure to Obtain Physician's Order for Code Status
Penalty
Summary
The facility failed to obtain a physician's order for code status for several residents, which is a critical aspect of honoring residents' rights to request, refuse, or discontinue treatment. Specifically, the facility did not have signed or dated code status forms for three residents within the sample and five residents outside the sample. These forms, which indicate whether a resident is Full Code or Do Not Resuscitate (DNR), were either missing or incomplete, lacking necessary signatures from both the physician and the resident or their representative. This deficiency was identified through interviews and record reviews, revealing that the facility's policy on Do Not Resuscitate Orders was not being followed as required by state and federal regulations. The residents involved had various medical conditions, including diabetes, heart disease, dementia, and mental health disorders, which necessitate clear directives regarding their code status. Despite the presence of green and red forms in the residents' charts indicating Full Code and DNR status, respectively, these forms were not properly executed. Interviews with facility staff, including an LPN, the Chief Nursing Officer, and the Director of Nursing, confirmed that there should be a physician's order for each resident's code status, which was not present in these cases. This oversight in documentation and adherence to policy could potentially impact the care and treatment decisions made for these residents in emergency situations.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to issue the required Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) forms to residents and their legal representatives, as mandated by regulations. Specifically, the facility did not provide these notices at least two calendar days before the end of skilled Medicare services for three residents. This deficiency was identified through interviews and record reviews, revealing that the facility staff was unaware of the requirement to complete these forms. For Resident #9, there was no documentation indicating that the SNF ABN or NOMNC was provided before the end of skilled Medicare services, and the resident remained in the facility. Similarly, Resident #20 was discharged home without receiving the NOMNC, and Resident #69, who also remained in the facility, did not receive the SNF ABN or NOMNC. The Chief Nursing Officer confirmed during an interview that the staff was not aware of these forms or the related regulations, leading to the oversight.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment, as evidenced by multiple observations of unsanitary and unsafe conditions. Ceiling tiles with large brown stains were noted in several areas, indicating potential water damage or leaks. Residents reported that these stains had been present for an extended period, and in some cases, were due to rain seeping in through windows. Additionally, electrical devices were improperly plugged into power adapters, and dirty towels were left on window sills, further contributing to the unsanitary conditions. Housekeeping services were inadequate, with observations of unswept and unmopped floors in resident hallways and rooms. The facility's contracted housekeeping staff was reportedly short-staffed, and there was no daily checklist to ensure cleanliness standards were met. Interviews with staff revealed that housekeeping duties were inconsistently performed, with some areas being neglected due to staff being redirected to other parts of the building. The lack of a maintenance log for repairs and environmental concerns further exacerbated the issue, as staff relied on an online system to report problems, which may not have been addressed promptly. Additional observations included untidy resident rooms with trash on the floor, unmade beds, and foul odors. In one instance, a family member was observed cleaning a room in preparation for a new resident's admission, highlighting the inadequacy of housekeeping services. The facility's administration acknowledged dissatisfaction with the contracted housekeeping services and was in the process of seeking a new vendor. However, the current state of the facility posed a potential risk to the health and safety of all residents due to the unsanitary and unsafe environment.
Inaccurate MDS Coding for Antipsychotic Medication
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, which is a federally mandated assessment instrument. The deficiency was identified through observation, interview, and record review. The facility's policy on the Resident Assessment Instrument (RAI) requires comprehensive and accurate documentation to ensure proper care planning. However, the MDS for one resident was incorrectly coded, indicating the resident received a scheduled antipsychotic medication, which was not the case. The resident in question had diagnoses of dementia, hypertension, visual hallucinations, and insomnia. The resident's Physician Order Sheet did not include any orders for antipsychotic medications but did include an order for Remeron, an antidepressant, for visual hallucinations. During an interview, the MDS Coordinator admitted to mistakenly marking Remeron as an antipsychotic on the MDS, leading to the inaccurate assessment. This error highlights a lapse in the facility's adherence to its own policy for accurate MDS documentation.
Failure to Follow Blood Glucose Monitoring Orders
Penalty
Summary
The facility failed to adhere to physician orders for blood glucose monitoring times for two residents, leading to a deficiency in the quality of care provided. Resident #2, who was admitted with diagnoses including type 2 diabetes mellitus, hypertension, heart disease, and heart failure, had an order for blood glucose monitoring before meals and at bedtime. However, on the observed date, the resident's blood glucose was checked after lunch, and the required sliding scale insulin was not administered as per the physician's order. LPN E incorrectly stated that the resident required a different dose and delayed the administration of insulin. Similarly, Resident #7, who was admitted with hypertension and diabetes mellitus, also had an order for blood glucose monitoring before meals and at bedtime. The resident's blood glucose was checked after lunch, contrary to the physician's order. The Chief Nursing Officer confirmed that blood glucose should not be obtained directly after a meal and that sliding scale insulin should be administered 15-30 minutes before a meal. LPN E admitted that blood sugars were checked at specific times, but the sliding scale dose was usually given right after the blood sugar was taken, indicating a systemic issue with following physician orders for blood glucose monitoring and insulin administration.
Failure to Transfer Resident Leads to Pressure Ulcer Development
Penalty
Summary
The facility staff failed to appropriately transfer a resident, identified as at risk for pressure ulcers, from a Geri chair to a bed during sleep, leading to the development of a facility-acquired pressure ulcer. The resident, who was severely cognitively impaired and dependent on staff for various activities, was observed sitting in a Geri chair without a pressure-reducing device for extended periods over several days. Despite having an order to be in bed while sleeping, the resident was left in the chair, which contributed to the development of a Stage 2 pressure ulcer that progressed to Stage 3. The resident's medical history included Alzheimer's disease, anxiety disorder, insomnia, and vascular dementia, with impairments in both lower extremities. The resident was frequently incontinent and required substantial assistance for transfers. The care plan indicated the resident was at risk for pressure ulcers, with interventions to reposition and provide incontinence care. However, observations showed the resident remained in the Geri chair for long periods, even while asleep, contrary to the care plan and physician's orders. Interviews with facility staff, including the Director of Nursing and Chief Nursing Officer, revealed a lack of awareness and adherence to the resident's care plan. The physician was also unaware that the resident was kept in the chair for extended periods, which was detrimental to the resident's wound. The failure to transfer the resident to a bed during sleep and the lack of a pressure-reducing device in the Geri chair were significant factors in the development and progression of the pressure ulcer.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to provide a safe transfer for a resident, identified as Resident #69, who was severely cognitively impaired and required substantial to maximal assistance for transfers. The resident's care plan indicated the need for two staff members to assist with transfers and highlighted the resident's risk for falls. During an observation, it was noted that the resident was transferred from a Geri chair to a toilet without the use of a gait belt, contrary to the facility's policy. The transfer was conducted by an LPN and a CNA who held the resident under the arms and pulled on the top of the pants, which was not in compliance with the established guidelines for safe transfers. Interviews with the staff involved revealed that the LPN forgot to apply the gait belt before the transfer, and the CNA acknowledged that a gait belt should have been used. The CNO mentioned that the resident was probably a Hoyer lift transfer, but this method could not be used for toileting. The failure to use a gait belt during the transfer process was a deviation from the facility's policy and posed a potential risk to the resident's safety.
Failure to Ensure Appropriate Diagnosis and Monitor Drug Regimen
Penalty
Summary
The facility failed to ensure an appropriate diagnosis for the use of a psychotropic medication for one resident and did not monitor the drug regimen or follow up on a gradual dose reduction (GDR) recommendation for another resident. Resident #9 had diagnoses including type 2 diabetes mellitus, bipolar disorder, depression, and anxiety, and was prescribed trazodone, Remeron, and melatonin. A GDR was recommended for these medications, but there was no documentation of a rationale or physician response, and the facility did not follow up with the physician for a rationale. Resident #69, who was admitted with diagnoses of Alzheimer's disease, anxiety disorder, insomnia, and vascular dementia, was prescribed Haldol for insomnia. The facility did not provide an appropriate diagnosis for the use of Haldol, and the Chief Nursing Officer acknowledged that insomnia was not a suitable diagnosis for this medication. The physician also recognized that insomnia was not a good diagnosis for Haldol, although the resident had vascular dementia with some psychosis.
Improper Disposal and Maintenance of Dumpsters
Penalty
Summary
The facility failed to ensure that the dumpsters were properly closed and maintained to prevent pest entry and contain garbage. Observations over several days revealed that the lids of dumpsters one, two, and three were left open, with various trash bags and debris exposed. Dumpster two was obstructed by furniture and shelving, preventing its closure, while a desk chair was consistently found against dumpster three. Additionally, a large opened bag of trash was repeatedly observed on the ground beside dumpster three. Interviews with facility staff, including the Maintenance Director, Housekeeping Supervisor, and Administrator, confirmed that the expectation was for staff to close the dumpster lids after discarding trash. They also stated that there should be no trash or debris on the ground around the dumpsters. Despite these expectations, the facility did not provide a policy regarding the proper maintenance and closure of dumpsters, contributing to the observed deficiencies.
Infection Control Deficiencies in Wound Care, Blood Glucose Monitoring, and Legionella Management
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for a resident, as observed when an LPN did not wear an isolation gown while performing wound care. The LPN was unaware of the need for a gown until after the procedure, and the facility had not educated staff on EBP. The CNO confirmed that the facility had not practiced EBP, and a CNA mentioned that staff should wear gowns and gloves when caring for residents with wounds. Additionally, the facility did not adhere to proper glove changing and hand hygiene practices during point-of-care blood glucose monitoring for another resident. An LPN failed to perform hand hygiene before putting on gloves, did not change gloves between tasks, and did not perform hand hygiene after removing gloves. The LPN acknowledged the need for hand hygiene and glove changes, and the IP and CNO confirmed the correct procedures that should have been followed. The facility also lacked an infection control program and risk management process specific to Legionella disease. The Maintenance Supervisor and IP were unaware of measures to prevent Legionella growth, and the facility had pulled the Legionella policy, deeming it inapplicable. Furthermore, the facility did not have a policy for infection control practices in laundry services, and the IP and CNO were unaware of proper procedures for handling dirty and clean laundry.
Deficiency in CNA In-Service Training
Penalty
Summary
The facility failed to conduct the required twelve hours of annual in-service training for two Certified Nurse Assistants (CNAs), identified as CNA C and CNA D, out of the two sampled. The facility's census was 18 residents. The facility did not have a policy in place for nurse aide in-service training. The Facility Assessment, revised on 02/04/25, did not address the mandatory 12-hour in-service training for nurse aides, which should include Dementia Care and Resident Abuse Prevention training. CNA C, hired on 12/09/14, attended a total of nine in-services from December 2023 to November 2024, but there was no documentation of individual times for each in-service or a total time for the annual in-service trainings. CNA D, hired on 11/11/21, had no documentation of in-service attendance from November 2023 to October 2024. Interviews with the Director of Nursing (DON) and the Chief Nurse Officer (CNO) confirmed that CNAs are required to have 12 hours of in-services annually, covering topics such as abuse, neglect, and dementia management, with documented time durations for each session.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility staff failed to post the required daily nurse staffing information in a prominent location readily accessible to residents and visitors for four consecutive days. The facility's policy, revised in November 2019, mandates that staffing information be made available in a readable format to residents and visitors at any given time, and that it should be posted daily at the beginning of each shift. However, observations on four different days revealed that the daily nurse staffing information was posted by the time clock located on the hospital side of the building, rather than in the nursing home facility area where it would be accessible to residents and visitors. Interviews with the Director of Nursing (DON) and the Chief Nurse Officer (CNO) confirmed the oversight. The DON acknowledged that the staffing sheet was posted on the hospital side and should have been placed inside the nursing home facility area. The CNO explained that the staffing sheet was placed by the time clock to ensure staff filled out their time worked, but was unaware that it needed to be posted in a prominent area on the nursing home side. This failure to comply with the facility's policy resulted in the deficiency noted by the surveyors.
Failure to Administer Tube Feeding and Water Flushes
Penalty
Summary
The facility failed to administer nutrition and water flushes for a resident who was dependent on a gastrostomy tube for nutrition and hydration. This failure resulted in a severe weight loss for the resident, which was not assessed or reported to the physician in a timely manner. The resident experienced a 9.6% weight loss in 30 days, a 9% weight loss in 90 days, and a 13.3% weight loss in 180 days. The facility's policy required that significant weight changes be reported to the physician, but this was not done until much later. The resident's Medication Administration Record (MAR) showed numerous missed opportunities for administering both the prescribed tube feeding and water flushes. Specifically, there were 32 missed feedings and 36 missed water flushes from 10/04/24 to 10/19/24, and additional missed opportunities were documented in the following weeks. The facility's Director of Nursing (DON) and other staff members were aware of the documentation issues but did not take effective action to ensure that the resident received the necessary care. Interviews with staff revealed that there was a lack of licensed nursing staff scheduled on weekends, and the facility relied on hospital staff to provide care when needed. However, there was no proper documentation or communication between the hospital and facility staff regarding the care provided. The Chief Nursing Officer (CNO) and the Administrator were unaware of the extent of the missed feedings and the resident's weight loss until it was too late. The physician was not informed of the resident's condition, and the care plan was not updated to address the significant weight loss.
Failure to Follow Physician Orders and Document Medication Administration
Penalty
Summary
The facility failed to follow physician's orders for three residents, leading to missed medication administrations and incomplete lab tests. Resident #1 was admitted to the hospital with a urinary tract infection (UTI) and sepsis, and upon return, had orders for Bactrim and amoxicillin. However, there were multiple missed doses of these antibiotics as documented in the Medication Administration Record (MAR). Additionally, a new order for amoxicillin was not fully administered, resulting in further missed doses. The resident was later sent to the emergency room for evaluation due to blood in the urine and pain, and a new antibiotic was prescribed. Resident #2, who was hospitalized for a UTI, had an order for Bactrim DS, but the MAR showed several missed doses. Similarly, Resident #3, diagnosed with seizures, had an order for Keppra, but there were numerous missed doses documented in the MAR. Furthermore, there was no documentation of a completed Keppra level test, as the order was not entered into the system, and the lab confirmed that no test had been conducted. Interviews with facility staff, including the Chief Nursing Officer (CNO), Licensed Practical Nurse (LPN), and Certified Medication Technician (CMT), revealed a lack of documentation and awareness of the missed medications. The Director of Nursing (DON) was expected to audit the charts, but she did not consider it her responsibility to ensure orders were completed. The facility lacked a system to verify that orders were followed, relying solely on the DON's audits, which were not effectively conducted.
Insufficient Nursing Staff and Missed Care Documentation
Penalty
Summary
The facility failed to ensure sufficient nursing staff to provide necessary care and services to residents, as evidenced by the absence of licensed nurse coverage 24 hours a day. The review of nursing schedules and assignment sheets revealed multiple instances where no licensed nursing staff were scheduled or worked during both day and night shifts on specific dates. This lack of staffing led to a failure in administering prescribed tube feedings, medications, and wound treatments for residents, particularly affecting one resident who required specific medical interventions. The medical record of a resident showed several orders for tube feedings, water flushes, and antibiotics, as well as wound care treatments. However, there was no documentation of the administration of these treatments on multiple occasions, indicating that the resident did not receive the necessary care as ordered. The resident had been admitted to the hospital with a urinary tract infection and sepsis, and upon return, continued to have specific medical orders that were not consistently followed. Interviews with the Director of Nursing (DON) and Chief Nursing Officer (CNO) revealed that the facility relied on hospital staff to cover shifts when licensed nurses were not scheduled, particularly on weekends. The DON did not consider it her responsibility to audit resident charts to ensure orders were completed, and the CNO was unaware of the extent of missed documentation. The facility lacked a policy for staffing licensed nurses, contributing to the deficiency in care and documentation.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, as required. This deficiency was identified through interviews and record reviews, which revealed that the facility did not have an RN scheduled and working for the required hours on specific dates. The facility's Facility Assessment Tool indicated a requirement for two RNs, but the nursing schedules and assignment sheets showed no documentation of an RN working the necessary hours on 10/01/24, 11/10/24, and 11/17/24. During an interview, the Chief Nursing Officer mentioned a misunderstanding, believing that hospital staff were considered part of the long-term care staff, and RNs were not always scheduled, with staff calling for assistance from the hospital supervisor as needed.
Failure in Pressure Ulcer Management and Documentation
Penalty
Summary
The facility failed to provide ongoing skin assessments, perform and document treatments, and monitor the progression of a pressure ulcer for a resident. The resident, who was admitted with severe cognitive impairment and multiple health conditions including paraplegia, had an unstageable pressure ulcer on the coccyx. The facility's policy required initial wound exams and ongoing documentation, but there were significant lapses in following these protocols. The resident's treatment records showed inconsistencies and missed opportunities in wound care. Orders for daily wound care were not consistently followed, with 21 missed treatments in October and four in November. Weekly skin assessments were also not documented consistently, with a gap from July to September. When assessments were conducted, they often lacked necessary details such as wound measurements and descriptions. Interviews with facility staff revealed a lack of adherence to the facility's wound management policy. The charge nurse was responsible for dressing changes and documentation, but this was not consistently done. The Chief Nursing Officer expected weekly assessments and complete documentation, but audits to ensure compliance were not mentioned. The deficiency highlights a failure in the facility's processes to ensure proper wound care and documentation for the resident.
Improper Catheter Care and Documentation Deficiency
Penalty
Summary
The facility failed to maintain proper positioning and placement of an indwelling urinary catheter and drainage bags for a resident, leading to potential health risks. Observations revealed that the catheter bag was improperly positioned, either hanging from the bed frame with tubing touching the floor or placed in the resident's lap while in a wheelchair. During a transfer, the catheter bag was held above the resident's bladder, contrary to the facility's policy that requires the catheter to be below the bladder level. Interviews with CNAs indicated uncertainty about proper catheter handling during transfers. Additionally, there was a significant lack of documentation regarding catheter care. The Treatment Administration Records showed numerous missed opportunities for documenting catheter care across two months. Despite being aware of the documentation issues, the facility's staff, including LPNs and a CMT, reported the problem to the DON, but no improvements were noted. The Chief Nursing Officer acknowledged the expectation for staff to provide and document catheter care as ordered, but the documentation was not consistently completed.
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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