Pin Oaks Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mexico, Missouri.
- Location
- 1525 West Monroe, Mexico, Missouri 65265
- CMS Provider Number
- 265481
- Inspections on file
- 22
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Pin Oaks Living Center during CMS and state inspections, most recent first.
A resident with a history of stroke and mobility issues experienced a fall resulting in injury, but staff did not complete required assessments, documentation, or obtain physician orders for treatment. The responsible party was not notified, and the incident was not properly recorded until after the resident was discharged, with staff interviews confirming that standard procedures were not followed.
The facility failed to ensure the DON served full-time in their role and did not act as a charge nurse despite having over 60 residents. The DON was observed working as a floor nurse, which interfered with her administrative duties. She also served as the Infection Preventionist, working dual roles due to staffing shortages. The Administrator confirmed the extensive working hours and mentioned contacting the corporate office for agency nurse support.
The facility failed to monitor residents on psychotropic medications, affecting five residents. Policies required staff to document and report medication effectiveness, but this was not done. Residents lacked behavior and side effect monitoring, and care plans did not address psychotropic medication use. The DON confirmed expectations for monitoring, but it was not implemented.
The facility failed to secure medications properly, with an unlocked medication cart and an unattended open medication room. Controlled medications were left unsecured on a counter, contrary to policy. An LPN and CMT confirmed these lapses, and the Administrator acknowledged the need for secure storage.
The facility failed to maintain infection control during medication administration, nebulizer equipment handling, and wound care. An LPN administered medication by pouring a tablet into her bare hand, contrary to expected practices. A resident's nebulizer mask was not cleaned or bagged after use, and oxygen tubing was not changed weekly as required. Additionally, the DON/IP did not sanitize hands between glove changes during wound care, violating the facility's infection control policy.
A facility failed to assess and obtain a physician's order for a resident to self-administer medications, as required by policy. Over-the-counter medications were found in the resident's room without proper authorization. A CMT also failed to observe the resident taking prescribed medications. Staff interviews confirmed the oversight, highlighting a lapse in following medication administration guidelines.
The facility failed to properly document and honor the code status of two residents, leading to potential non-compliance with their advance directives. One resident's DNR form lacked a physician's signature, and another resident's code status was inconsistently documented, causing confusion among staff about their resuscitation preferences.
The facility failed to notify two residents of potential non-coverage and financial liability for services not covered by Medicare. Notices of Medicare Non-Coverage were issued, but no Advanced Beneficiary Notices were provided when coverage ended, and the residents continued to receive skilled nursing care. The Administrator admitted to using the wrong form for beneficiary notices.
A resident with severe cognitive impairment was verbally abused by another resident who was cognitively intact. The incident was documented by an LPN but was not investigated or reported as required by the facility's policy. Interviews with the DON and Administrator revealed awareness of the incident, but no clear actions were taken to address the potential abuse.
The facility failed to report abuse allegations involving three residents. A cognitively intact resident reported staff-to-resident abuse, which was not reported to authorities. Another incident involved a cognitively impaired resident verbally abused by another resident, also not reported. The Administrator was unaware of reporting requirements during a survey.
The facility did not investigate an incident of verbal abuse between two residents, one severely cognitively impaired and the other cognitively intact. Despite documentation by an LPN, interviews with the DON and Administrator confirmed the lack of investigation, contrary to facility policy.
The facility failed to provide comprehensive care plans for three residents, leading to potential gaps in care. One resident with COPD did not have a care plan for oxygen use, another lacked plans for mental health conditions and medication administration, and a third did not have updated interventions after a coffee burn incident. Staff confirmed these deficiencies.
A facility failed to complete a discharge summary for a resident who was transferred to another facility. The resident, admitted with multiple diagnoses including sepsis and multiple myeloma, was discharged without a completed discharge summary, as required by the facility's policy. This was confirmed by the Social Services Director during an interview.
The facility failed to implement scheduled activities programs, impacting residents' participation and documentation. A resident with moderate cognitive impairment was not engaged in activities despite documented preferences, and no alternative activities were offered. The Activities Director's absence led to a lack of routine group activities, confirmed by staff interviews.
A resident at risk for pressure ulcers developed a stage 2 ulcer due to inadequate care. The resident's Broda chair lacked a pressure-reducing cushion, contrary to care plan requirements. Facility staff were misinformed about cushion use in Broda chairs, and wound care orders were incomplete.
A resident with chronic obstructive pulmonary disease, using continuous oxygen therapy, was taken to a smoking patio with the oxygen tank still attached to their wheelchair, posing a fire hazard. The staff responsible for supervision had not received formal training on managing smokers with oxygen use, leading to the potential risk. Interviews revealed that staff were only instructed to turn off the oxygen but not to remove the tanks from the smoking area.
A resident with ESRD receiving hemodialysis lacked physician orders for the care and maintenance of their dialysis catheter, leading to potential inconsistent care. Despite facility policy requiring such orders, none were found in the resident's records. The resident's care plan noted frequent attempts to dislodge the catheter, with most care provided by a community dialysis center.
The facility failed to assess and obtain informed consent for bed rail use for two residents, R9 and R53, leading to potential injury risks. R9, with moderate cognitive impairment, had bed rails without documentation of assessment or consent. Similarly, R53 had bed rails without a current assessment or consent, despite an outdated order. The facility's policy requires these steps, which were not followed.
The facility failed to ensure the safety of bed rails for two residents, both moderately cognitively impaired, as their bed rails were found to be loose. Despite the facility's policy for regular inspections, the loose rails were not documented or addressed in the maintenance log. The Maintenance Director confirmed the absence of a formal monitoring process, and the DON stated that bed rails should be maintained and safe.
A resident's medications, including oxycodone/acetaminophen and gabapentin, were found missing in a facility. The medications were brought from home and counted by staff upon admission. However, discrepancies in medication counts and documentation were discovered, and staff interviews revealed that narcotic counts were not consistently conducted at shift changes. The facility could not determine if the medications were miscounted or misappropriated.
A facility failed to properly handle and document medications for a resident, including not completing required narcotic counts at shift changes and not verifying medications brought from home with a pharmacist or physician. This led to discrepancies in medication records and missing medications. Staff interviews revealed a lack of awareness and adherence to facility policies.
The facility failed to ensure staff treated three residents with dignity and respect. A CNA made derogatory comments, ignored call lights, and used inappropriate language, causing emotional distress to the residents. Interviews confirmed the CNA's behavior, and the Interim DON and Administrator were unaware of these incidents.
Failure to Assess, Document, and Notify After Resident Fall with Injury
Penalty
Summary
Facility staff failed to follow professional standards of practice by not completing an assessment, documentation, or obtaining physician orders for treatment after a resident experienced a fall with injury. The facility's policy requires staff to observe, record, and report any change in a resident's condition, including after a fall, and to notify the physician and responsible party, complete incident reports, and document all assessments and interventions. In this case, there was no documentation of the fall event, no nursing progress notes regarding the fall or treatment of injuries, and no evidence of physician or responsible party notification on the date of the incident. The resident involved had a history of hemiplegia and hemiparesis following a stroke, was confused, verbally communicative, and had unsteady/unsafe independent transfers. The resident's responsible party reported that the resident fell while attempting to use the bathroom independently, sustained a bruise and skin tears, and was treated with butterfly bandages. However, the responsible party was not notified of the fall or injuries, and the facility's records did not reflect any assessment or treatment orders related to the incident at the time it occurred. Interviews with staff revealed that neurological checks were initiated, but the required documentation, notifications, and incident reporting were not completed. Staff members acknowledged that standard procedure was not followed, with each assuming that the necessary steps would be completed by others. The fall event was only documented retroactively after the resident had been discharged and the incident was brought to the attention of facility leadership.
Failure to Ensure Full-Time Director of Nursing Role
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) served full-time in their role and did not act as a charge nurse when the facility had an average daily occupancy of over 60 residents. This deficiency was identified through observations, interviews, and a review of the DON's job description. The job description required the DON to be present in the facility or engaged in work-related activities for a minimum of eight hours per day, Monday through Friday, and to conduct routine inspections during second and third shifts and weekends. However, during the survey period, the DON was observed working as a floor nurse/charge nurse on Unit 1, which interfered with her ability to fulfill her administrative duties. Interviews with the DON revealed that she was unable to perform daily antibiotic reviews due to her responsibilities as both the interim DON and a floor nurse. She worked on the floor three days a week, performing tasks such as passing medications, providing wound measurements, and handling admissions and discharges. The DON also served as the Infection Preventionist (IP) for 30 hours a week. The dual roles had been ongoing for three and a half months due to staffing shortages, with two day-shift and two night-shift nurses having left. The Administrator confirmed the DON's extensive working hours and mentioned that they had contacted the corporate office regarding the use of agency nurses to supplement staff, but were still awaiting feedback.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper monitoring of residents who were administered psychotropic medications, affecting five out of six residents reviewed for unnecessary medications. The facility's policy on antipsychotic medication required staff to observe, document, and report the effectiveness of interventions, including medications, but this was not adhered to. The facility lacked a specific policy for monitoring antidepressant or psychotropic agents, leading to inadequate documentation and monitoring of residents' behaviors and side effects. For Resident 23, there was no routine documentation related to behavior monitoring or side effect monitoring despite being on antidepressant and antipsychotic medications. The Licensed Practical Nurse/Unit Manager confirmed the absence of orders or documentation for monitoring behaviors and side effects. Similarly, Resident 49's care plan did not specify behaviors to be monitored, and there was no evidence of behavior or side effect monitoring in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). Resident 56's care plan did not address behaviors or the administration of psychotropic medications, and there was no tracking of specific behaviors or side effects. The Director of Nursing confirmed the expectation for a care plan and tracking of side effects, but this was not implemented. Resident 57 and Resident 48 also lacked evidence of monitoring for behaviors, efficacy, or side effects related to their psychotropic medications, with the Director of Nursing acknowledging the expectation for monitoring and reporting unresolved issues to ensure residents' quality of life.
Medication Security Lapses in Facility
Penalty
Summary
The facility failed to ensure proper security measures for medications, as observed in several instances. One medication cart out of five was left unlocked and unattended on Hall 500, South II Wing. An LPN returned to the cart after one minute and realized it was unlocked, despite believing it had been secured. Additionally, a medication room on Hall 100, North Wing, was found with its door wide open and unattended, with no staff present to monitor the area. A CMT returned to the room two to three minutes later and confirmed the door was open, as well as the cabinet containing controlled medications. Further observations revealed that 18 cards of controlled medications were left unsecured on a counter in the medication room. These included medications such as clonazepam, pregabalin, lorazepam, lacosamide, oxycodone, hydrocodone, and tramadol. The LPN/UM confirmed that these narcotic medications were not locked in the cabinet as required. The facility's policy mandates that all medications must be stored securely, and medication carts and rooms should be locked when unattended. The Administrator acknowledged the expectation for medication security and confirmed that controlled medications should be maintained in a double lock manner.
Infection Control Deficiencies in Medication Administration and Equipment Handling
Penalty
Summary
The facility failed to maintain proper infection control during medication administration, as observed when an LPN poured a ferrous sulfate tablet directly into her bare hand before administering it to a resident. The LPN admitted to not recalling any training regarding touching pills with bare hands, and the facility lacked a specific policy addressing this practice. The administrator expected medications to be dispensed directly into a medicine cup without being touched by hands, highlighting a gap in infection control practices. Another deficiency was noted in the handling of nebulizer equipment for a resident with COPD. The resident reported that the nebulizer mask was not cleaned or bagged after use, and observations confirmed the mask was left hanging on the bedrail without being dated or bagged. A CMT confirmed the mask should be bagged and the equipment cleaned after each use, as per the facility's infection control policy. The DON/IP acknowledged the expectation for staff to follow these procedures to prevent respiratory infections. Additionally, the facility failed to ensure proper hand hygiene during wound care. The DON/IP did not sanitize her hands between glove changes while treating a resident's wounds, despite the facility's policy requiring hand washing between glove changes. The DON/IP admitted to being nervous and forgetting to sanitize her hands during the procedure. Furthermore, the facility did not change oxygen tubing weekly as required, with observations showing tubing dated three weeks prior. Both a CNA and LPN confirmed the tubing should be changed weekly, and the DON stated this was the expectation for infection prevention.
Failure to Assess and Order Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R375, had an assessment and a physician's order for self-administration of medications. This deficiency was identified during an observation where over-the-counter medications were found on R375's dresser and bedside table, visible from the hallway, while the resident was not present in the room. The medications included melatonin, low dose aspirin, Miralax, Imodium, lubricant eye drops, and Osteo Bi-Flex. The facility's policy requires an assessment and a physician's order for residents to self-administer medications, which was not completed for R375. Additionally, a Certified Medication Technician (CMT) was observed providing medications to R375 without ensuring the resident took them, as the CMT walked away after placing the medications on the table. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing/Infection Preventionist (DON/IP), confirmed that the medications should not have been at the resident's bedside without proper assessment and order. The DON/IP stated that the admitting nurse should have checked the resident's belongings upon admission to prevent such occurrences.
Failure to Document and Honor Residents' Code Status
Penalty
Summary
The facility failed to ensure that the code status and advance directives of residents were properly documented and honored, leading to a deficiency in the care provided. For Resident R375, the facility did not obtain a physician's signature on the Do-Not-Resuscitate (DNR) form, despite the resident having signed it and expressed her wishes not to be resuscitated. The Social Services Director (SSD) acknowledged that the form was faxed to the physician, who was on vacation, and no verbal DNR order was obtained. Consequently, the nursing staff, including Registered Nurse (RN)1, indicated they would perform full resuscitation on R375 due to the lack of a signed DNR form, despite the resident's clear wishes. Similarly, for Resident R48, there was a discrepancy in the documented code status. Although the resident was initially documented as DNR, the electronic medical record (EMR) showed an order for Full Code status. The SSD and RN1 identified that the necessary Out of Hospital DNR form, which should have been signed by both the resident and the physician, was missing from the resident's hard chart. The resident had expressed his preference not to be resuscitated if his heart stopped, but the conflicting documentation and lack of a signed DNR form led to confusion about his code status. Interviews with facility staff, including the SSD, RN1, and the Director of Nursing/Infection Preventionist (DON/IP), revealed that there were expectations for obtaining and documenting code status changes immediately, with appropriate signatures from both the resident and the physician. However, these procedures were not followed, resulting in the potential for residents' advance directive wishes not being honored. The facility's policies on CPR and advance directives were also found to be lacking in clarity regarding the handling of code status and CPR provision.
Failure to Notify Residents of Non-Coverage and Financial Liability
Penalty
Summary
The facility failed to properly notify residents of potential non-coverage and beneficiary financial liability, affecting two of three residents reviewed for beneficiary notification. Resident 225 was admitted and discharged on unspecified dates, and a Notice of Medicare Non-Coverage (NOMNC) dated 09/03/24 indicated a coverage end date of 09/14/24. However, there was no Advanced Beneficiary Notice (ABN) provided when Resident 225's coverage for skilled nursing was due to end, and the resident continued to receive care after the coverage end date. Similarly, Resident 227 was admitted and discharged on unspecified dates, with a NOMNC dated 08/23/24 indicating a coverage end date of 08/25/24. No ABN was provided for Resident 227, who also continued to receive skilled nursing care after the coverage end date. During an interview, the Administrator acknowledged using the wrong form for beneficiary notices for both residents. The facility did not provide a policy related to ABN, which contributed to the oversight in notifying residents of their potential financial liability for services not covered by Medicare.
Failure to Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R25, from verbal abuse by another resident, R49. R25, who was severely cognitively impaired with a BIMS score of two out of 15, was verbally abused by R49, who was cognitively intact with a BIMS score of 15 out of 15. The incident occurred when R49 yelled expletives at R25 and staff, which was documented in a progress note by LPN1/UM. Despite the incident being recorded, there was no evidence of an investigation into the verbal abuse, and it was not included in the facility's reportable incident documentation. Interviews with facility staff, including LPN1/UM, the DON, and the Administrator, revealed that the incident was known to them, but there was uncertainty about whether it constituted verbal abuse. The DON could not recall if the incident was reported to her, and the Administrator acknowledged the incident was discussed in a daily nursing meeting. However, there was no clear action taken to address the potential abuse, and the facility's policy to ensure residents remain free from abuse was not upheld in this case.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse involving three residents. One resident, who was cognitively intact, reported an allegation of staff-to-resident abuse, stating that a Certified Medication Tech was verbally abusive and physically hurt her during care. This incident was not reported to the State Agency, Ombudsman, or local law enforcement in a timely manner. The facility's Administrator was unaware of the requirement to report such incidents during a recertification survey, mistakenly believing that surveyors would handle the reporting. Another incident involved a cognitively impaired resident who was verbally abused by another resident. The incident was documented in a progress note, but there was no evidence that it was reported to the appropriate authorities. The Director of Nursing could not recall if the incident was reported to her and confirmed that it was not reported externally. The Administrator acknowledged awareness of the incident but was unsure of the reporting requirements for resident-to-resident abuse.
Failure to Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an incident of resident-to-resident verbal abuse involving two residents. One resident, who was severely cognitively impaired with a BIMS score of two, was verbally abused by another resident who was cognitively intact with a BIMS score of 15. The incident was documented in a progress note by an LPN, but there was no evidence that the incident was investigated as required by the facility's policy on abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. Interviews with facility staff, including the LPN who documented the incident, the DON, and the Administrator, revealed that the incident was not investigated. The DON acknowledged that it was the responsibility of the management team to investigate such incidents, but she was unsure if it had been done. The Administrator confirmed awareness of the incident but stated that it had not been interpreted as abuse and was unsure of the investigation procedures for resident-to-resident abuse.
Lack of Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were in place for three residents, leading to potential gaps in care. One resident, who was moderately cognitively impaired and diagnosed with chronic obstructive pulmonary disease (COPD), was receiving oxygen therapy but did not have a care plan addressing the use of oxygen. This was confirmed by multiple staff members, including the Licensed Practical Nurse/Unit Manager and the Director of Nursing, who acknowledged the absence of a care plan for the resident's oxygen use. Another resident, diagnosed with COPD, depressive disorder, and anxiety, did not have a care plan addressing his mental health conditions or the administration of psychotropic medications. This oversight was confirmed by the Registered Nurse and the Director of Nursing/Infection Preventionist. Additionally, a third resident, who had experienced a coffee burn, did not have an updated care plan with interventions to prevent further incidents, despite a lid being added to her coffee cup. The Director of Nursing was unsure if this intervention had been documented in the care plan.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a final discharge summary for a resident at the time of discharge, which is a requirement according to the facility's Resident Discharge/Transfer Policy. The policy mandates that a discharge summary and post-discharge plan of care form be completed and signed by the resident or their representative, with the original placed in the record. However, for one resident, who was admitted with multiple diagnoses including sepsis, palliative care, and multiple myeloma, and later discharged to another facility, the discharge summary was left entirely blank. This oversight was confirmed during an interview with the Social Services Director, who acknowledged that the electronic discharge summary was not completed for the resident who transferred to be closer to family.
Failure to Implement Scheduled Activities Programs
Penalty
Summary
The facility failed to implement its scheduled activities programs for residents, as evidenced by the lack of execution of planned activities and inadequate documentation of resident participation. The activity calendars for November showed a variety of activities scheduled, but during the survey period, only a few of these activities were actually conducted. The Activities Director was absent for personal reasons, and it was assumed that other staff members would conduct the activities, but this did not occur. The Activities Director also failed to document activity participation in resident logs for several weeks. One resident, identified as R9, was particularly affected by this deficiency. R9 was moderately cognitively impaired and had specific activity preferences documented in her care plan, including a preference for afternoon activities and interests in group activities, reading, and religious activities. Despite these preferences, R9 was not observed participating in any activities during the survey period, even when activities she was interested in, such as BINGO and a music program, were offered. There was no documentation of her participation in activities from late September to mid-November, and no alternative or one-on-one activities were provided to her during the survey. Interviews with facility staff, including the Activities Director and a Licensed Practical Nurse/Unit Manager, confirmed that group activities were not routinely offered during the Activities Director's absence. The Administrator acknowledged that activities should be provided based on individual assessments and preferences, and participation should be documented. This failure to provide and document activities created the potential for residents, including R9, to experience isolation due to a lack of participation in facility activities.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide adequate care and treatment to prevent skin breakdown for a resident who was at risk for developing pressure ulcers. The resident, who had dementia and type 2 diabetes, was moderately cognitively impaired and was using a Broda chair without a pressure-reducing cushion, despite having a pressure-reducing mattress on their bed. The resident developed a stage 2 pressure ulcer on the coccyx, and the care plan indicated that a pressure-reducing cushion should be applied to the Broda chair, but this was not done. Observations confirmed that the resident's Broda chair did not have a pressure-reducing cushion, and the Licensed Practical Nurse/Unit Manager and Director of Nursing both stated that previous administration had informed them that such cushions could not be used with Broda chairs. However, the manufacturer's instructions did not prohibit the use of pressure-reducing cushions. Additionally, the wound care orders were incomplete, lacking specific instructions for the dressing application, which the LPN/UM acknowledged and intended to update.
Failure to Ensure Safe Smoking Practices for Resident on Oxygen
Penalty
Summary
The facility failed to ensure a safe environment for a resident using oxygen therapy during smoking activities, which posed a potential fire hazard. The resident, who had chronic obstructive pulmonary disease and was receiving continuous oxygen therapy, was observed being assisted to a smoking patio with an oxygen tank still attached to their wheelchair. The Floor Tech, responsible for supervising the resident, had not received formal training on managing smokers with oxygen use and was only verbally instructed to turn off the oxygen. However, the oxygen tank was not removed from the smoking area, and another resident was already smoking nearby. Interviews with various staff members, including the Director of Nursing, Maintenance Director, and Housekeeping staff, revealed a lack of formal training regarding the supervision of residents who smoke while using oxygen. The staff were only instructed to turn off the oxygen but not to remove the tanks from the smoking area. The Administrator confirmed the absence of training related to smokers and oxygen use, acknowledging that oxygen tanks should not be present in the smoking area. This oversight in training and policy implementation led to the potential risk of fire hazards in the facility.
Failure to Provide Comprehensive Dialysis Care
Penalty
Summary
The facility failed to ensure comprehensive dialysis services were provided for a resident with End Stage Renal Disease (ESRD) who required hemodialysis. The resident, who was cognitively intact, had a dialysis catheter in place and was receiving dialysis three times per week at a community dialysis center. However, there were no physician orders in place for the care and maintenance of the resident's intravenous dialysis catheter, as confirmed by both the Licensed Practical Nurse/Unit Manager and the Director of Nursing. This lack of orders created the potential for incomplete and inconsistent care of the resident's dialysis catheter. The facility's policy on the care of a resident receiving dialysis required treatment for cleaning as ordered by the physician and for nurses to maintain the dressing at the access site at all times. Despite this, a review of the resident's records, including the Medication Administration Record and Treatment Administration Record, revealed no documentation indicating routine care and maintenance of the dialysis catheter. The resident's care plan noted that most catheter care would be provided by the dialysis center, but also indicated that the resident frequently attempted to dislodge the catheter or remove the dressing, necessitating reminders not to interfere with the catheter.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to appropriately assess and obtain informed consent for the use of bed rails for two residents, R9 and R53, out of a total of nine residents reviewed for accidents. The facility's policy requires a comprehensive assessment and informed consent before the use of bed rails, but these steps were not followed for the two residents. This oversight created a potential risk for injury due to the unnecessary use of side rails. Resident R9, who was moderately cognitively impaired and required assistance for mobility, was observed with bed rails in use despite no documentation of an assessment, physician's order, or care plan for their use. The resident's electronic medical record (EMR) lacked evidence of a recent assessment or informed consent for the bed rails, and the Licensed Practical Nurse/Unit Manager confirmed these omissions during a review of the EMR. Similarly, Resident R53, also moderately cognitively impaired, was observed with bed rails in use without a current assessment or informed consent. Although there was an order for assist rails dated nearly two years prior, there was no recent assessment or care plan reflecting the use of side rails. The Director of Nursing confirmed that the facility's expectations for bed rail use, including a current assessment and informed consent, were not met for these residents.
Failure to Maintain Bed Rail Safety for Residents
Penalty
Summary
The facility failed to ensure the physical safety of bed rails for two residents, R9 and R53, out of a total of nine residents reviewed for accidents. Observations revealed that the bed rails on both residents' beds were loose, which was confirmed by staff members. R9, who was moderately cognitively impaired and required assistance for mobility, was observed with a loose bed rail despite the assessment indicating that side rails were not in use. Similarly, R53, who was also moderately cognitively impaired and used the rails for mobility, had loose bed rails, although her assessment also indicated that side rails were not in use. The facility's policy required regular inspections of bed frames, mattresses, and bed rails to identify potential entrapment areas. However, the staff failed to document or address the loose bed rails in the maintenance log prior to the observations. The Maintenance Director confirmed the lack of a formal process for routine monitoring of bed safety, and the Director of Nursing expressed that bed rails should be maintained and safe for use. The failure to maintain the bed rails created the potential for injury to the residents.
Misappropriation of Resident Medications
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when 40 tablets of oxycodone/acetaminophen and five tablets of gabapentin were found missing. The medications were in the possession of facility staff, and the incident involved a resident who was admitted to the facility with chronic inflammatory demyelinating polyneuritis, polymyalgia rheumatica, and unspecified pain. The resident's family member brought medications from home to be used until the facility's pharmacy delivered the resident's prescriptions. Upon admission, the resident's medications were counted by RN A and CMT B, who reported 338 tablets of oxycodone/acetaminophen and two bottles of gabapentin with 186 and 85 tablets, respectively. However, the following day, it was discovered that 40 oxycodone/acetaminophen tablets and five gabapentin tablets were missing. The facility's investigation revealed that the narcotic count was not conducted at shift changes, and there were discrepancies in the documentation of medication administration and counts. Interviews with staff indicated that it was common practice not to count narcotics at shift changes, and there was confusion regarding the documentation of medication counts and administration. The DON expressed concerns about whether the initial medication count was accurate and noted that staff did not follow the facility's policies for medication count verification. The facility could not determine if the medications were miscounted upon admission or if they were misappropriated by staff.
Failure to Properly Handle and Document Medications
Penalty
Summary
The facility failed to ensure proper handling and documentation of narcotics and medications brought from home for a resident. Licensed staff did not complete the required narcotic counts at shift changes, which is necessary to detect any missing doses. This failure occurred across multiple shifts, as there was no evidence of verification of the controlled drug count between off-going and on-coming staff. Additionally, the facility did not follow its policy for accepting medications brought from home, as these medications were not examined and positively identified by a pharmacist or physician before use. Resident #1 was admitted to the facility with medications brought from home by a family member. These medications included oxycodone/acetaminophen and gabapentin, which were intended to be used until the resident's medications arrived from the pharmacy. However, the facility staff did not document the acceptance of these medications, including the name, strength, and quantity, nor did they verify them with a pharmacist or physician. This oversight led to discrepancies in the medication records, as the medications brought from home did not match the physician's orders. Interviews with staff revealed a lack of awareness and adherence to the facility's policies regarding medication verification and narcotic counts. It was common practice to use medications brought from home without proper verification, and staff often did not perform narcotic counts at shift changes. This resulted in missing medications, as evidenced by the discovery of unlabeled bags of gabapentin and missing tablets of oxycodone/acetaminophen. The Director of Nursing and the Administrator acknowledged these lapses and expressed expectations for staff to follow the facility's policies.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure staff treated three residents with dignity and respect. Resident #7 reported that a CNA called them a 'fatty' after a fall and threatened to leave them on the floor if they fell again. The CNA also made derogatory comments about the resident's urine odor and used inappropriate language in the resident's presence. Additionally, the CNA ignored the resident's call light and failed to return to provide assistance as promised, leaving the resident feeling disrespected and neglected. Resident #8 experienced similar disrespectful behavior from the same CNA, who made comments about the resident's room odor and cleanliness, despite the resident being bed-bound and unable to clean the room. The CNA's remarks about the resident's colostomy odor and the state of the room caused the resident significant emotional distress, leading them to ask staff to leave the room. The resident felt frustrated and angry due to the CNA's rude and condescending behavior. Resident #9 reported that the CNA refused to change their soiled incontinence brief, stating they had other people to take care of and leaving the resident in a dirty brief. The resident had to use the call light again to receive assistance from another staff member. Interviews with other CNAs and an LPN confirmed the inappropriate behavior of the CNA, including ignoring call lights, using derogatory language, and making residents feel disrespected. The Interim DON and Administrator were unaware of these incidents but emphasized the expectation for all staff to treat residents with dignity and respect.
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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