Pleasant View Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Rock Port, Missouri.
- Location
- 470 Rainbow Drive,, Rock Port, Missouri 64482
- CMS Provider Number
- 265744
- Inspections on file
- 13
- Latest survey
- May 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pleasant View Nursing Home during CMS and state inspections, most recent first.
The facility failed to treat residents with dignity during meal service by standing while feeding residents and not serving all residents at the same table simultaneously. This caused frustration and discomfort among the residents, as confirmed by observations and interviews with staff and residents.
The facility failed to maintain a clean and homelike environment, with issues such as missing trim, damaged drywall, a broken medication cart, dusty medical equipment, and peeling drywall. These deficiencies were confirmed through staff interviews and affected residents with specific medical needs.
The facility failed to check the CNA Registry and conduct required background checks for five of six sampled staff members, including an RN, a cook, a nurse aide, a maintenance supervisor, and a care partner. The Business Office Manager admitted to not checking the CNA Registry for non-nursing employees, and the Director of Nursing and the Administrator were unaware of the requirement to check the CNA Registry for all employees.
The facility failed to provide written notice of transfer or discharge to residents or their responsible parties, including the reasons for the transfer, in a language they understood. This affected three residents, who were transferred to the hospital or emergency room without the necessary documentation. Staff interviews revealed inconsistencies in filling out transfer forms and notifying the Ombudsman.
The facility failed to complete a Level I PASARR for two residents with mental disorders, including Alzheimer's Disease, schizoaffective disorder, dementia, depression, and schizophrenia. The required documentation was missing from their medical records, despite confirmation from the DON and Administrator that PASARRs should be completed upon admission.
The facility failed to develop and implement comprehensive care plans for five residents, neglecting to address hospice care, pressure ulcers, oxygen and CPAP usage, and the use of cane rails. These deficiencies were identified through observations, interviews, and record reviews.
The facility failed to follow professional standards of care for four residents by not obtaining necessary physician's orders for blood sugar monitoring and CPAP machine use, and by not adhering to timing guidelines for blood sugar checks before meals.
The facility staff failed to ensure dependent residents received necessary services to maintain good personal hygiene. One resident had unaddressed chin whiskers and partially removed fingernail polish, while another had uncombed hair and facial hair. Staff interviews revealed inconsistencies in shaving and nail care practices, with reliance on Hospice for these services. The facility's policies were found to be inadequate in specifying the frequency of these activities or addressing resident preferences.
The facility failed to assess residents for entrapment risk and ensure bed dimensions were appropriate before installing bed rails. Two residents had bed rails installed without proper assessments or physician's orders, and staff interviews revealed a lack of understanding and adherence to procedures. Observations confirmed the improper installation of bed rails, putting residents at risk.
The facility had a 20% medication error rate, affecting four residents. Errors included improper administration of eye drops, incorrect handling of Lidocaine patches, crushing a non-crushable medication, and failing to instruct a resident to swish and spit after using an inhaler.
The facility failed to store medications securely, leaving them unattended on dining tables for residents without proper supervision or orders for self-administration. Additionally, opened vials and insulin pens were not properly dated, violating facility policies.
The facility failed to ensure that food and drink served to residents were palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that hot and cold foods were not served at appropriate temperatures, and pureed foods were not made to the proper consistency. These issues affected three residents, who reported dissatisfaction with the food temperature and consistency.
The facility failed to store, prepare, and serve food according to professional standards, with multiple areas of the kitchen not cleaned properly, expired and undated food items, and inadequate hand hygiene and sanitation practices among dietary staff. Observations and interviews revealed inconsistent cleaning routines, improper food labeling, and a lack of adherence to hand hygiene protocols.
The facility failed to assist a resident in maintaining hydration status by not providing water in the resident's room, despite the care plan indicating the need for a water jug at all times. Observations and interviews revealed that the resident often felt extremely thirsty and had dry, scaly skin and chapped lips. Staff confirmed the resident was not on fluid restriction, but water was not consistently available.
The facility failed to ensure the Dietary Manager had the appropriate competencies and skills, as the DM lacked certification and completed training. The facility relied on a consulting dietician who visited monthly and regional support quarterly, leading to a deficiency in managing dietary services with qualified personnel.
The facility failed to follow infection control standards for catheter care when a resident's urinary catheter drainage bag was observed touching the floor and hooked on a trash can. Staff interviews confirmed that the drainage bag should not be in contact with the floor or contaminated surfaces.
Failure to Treat Residents with Dignity During Meal Service
Penalty
Summary
The facility failed to treat residents with dignity and respect during meal service. Specifically, staff members were observed standing while feeding residents who required assistance, which is against the facility's policy of treating residents with dignity. This was observed with two residents who required substantial assistance with eating due to their medical conditions, including Guillain-Barre syndrome and stroke. The Administrator and Activity Director were both seen standing while feeding these residents, which they later acknowledged was inappropriate behavior. Additionally, the facility did not serve meals to all residents at the same table simultaneously, causing frustration and discomfort among the residents. Multiple residents expressed dissatisfaction with the meal service process, noting that it was uncomfortable to watch their tablemates eat while they waited for their own meals. Observations confirmed that residents at the same table were served at different times, sometimes with significant delays between servings. Interviews with staff members, including the Dietary Aide and Dietary Manager, revealed inconsistencies in the meal service process. The Dietary Aide admitted to not serving all residents at one table at the same time and tried to make it fair by serving those who had been in the dining room the longest. The Dietary Manager acknowledged that residents at the same table should be served together but cited challenges in monitoring when residents arrived in the dining room. The Administrator and Director of Nursing also confirmed that they would expect all residents at the same table to receive their meals simultaneously.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and comfortable homelike environment, as evidenced by several observations and interviews. The nurses' station had missing trim and damaged drywall, and the medication cart was in disrepair with black duct tape holding it together. Additionally, a pillar near the dining room entrance had significant paint gouges, and the chair at the nurses' station was heavily worn with missing leather. Resident #22's oxygen concentrator and CPAP machine were found to be dusty, and Resident #200's room had a peeling drywall seam on the ceiling. Room [ROOM NUMBER] A had scuff marks and gouges on the wall with missing paint and exposed plaster. These deficiencies were confirmed through staff interviews, where it was acknowledged that the medication cart and chair were in poor condition and that the walls and ceiling should not have been in disrepair. Resident #22, who had moderate intact cognition and was on oxygen therapy for sleep apnea, was directly affected by the unclean oxygen concentrator and CPAP machine. Resident #200, who had multiple diagnoses including Guillain-Barre Syndrome, strokes, and cognitive communication deficit, was admitted to the facility recently and was found to have a peeling drywall seam in their room. The facility's policy on maintaining a homelike environment was not adhered to, as evidenced by the various areas of disrepair and lack of cleanliness observed during the survey.
Failure to Conduct Required Background Checks and CNA Registry Verification
Penalty
Summary
The facility staff failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator, which is a marker given by the federal government to individuals who have committed abuse or neglect. This deficiency affected five of six sampled staff members, including an RN, a cook, a nurse aide, a maintenance supervisor, and a care partner. The facility's policy, dated January 2017, mandates that the CNA Registry and other background checks be conducted prior to hiring any staff. However, the review of employee files showed that these checks were not performed for the sampled staff members, and the Business Office Manager admitted to not checking the CNA Registry for non-nursing employees. Additionally, the Director of Nursing and the Administrator were unaware of the requirement to check the CNA Registry for all employees, not just nursing staff. During interviews, the Business Office Manager mentioned that the facility no longer maintained hard copy personnel files on-site and that all documents were uploaded into an online system. This system may have overwritten some records, leading to missing background checks for some employees. The Administrator confirmed that background checks should be completed before hiring but was unsure if the CNA Registry should be checked for all employees. This lack of adherence to the facility's policy and the failure to conduct necessary background checks resulted in the deficiency noted by the surveyors.
Failure to Provide Written Notice of Transfer or Discharge
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to residents or their responsible parties, including the reasons for the transfer, in a language they understood. This deficiency affected three residents. For Resident #2, there was no documentation of a bed-hold letter or a letter explaining the reason for the transfer to the hospital for surgery. The resident had intact cognitive skills and required assistance with daily activities, with diagnoses including diabetes mellitus, breast cancer, depression, and an abscess of the left great toe. For Resident #39, the facility did not document a bed-hold letter or a letter explaining the reason for the transfer to the emergency room after the resident experienced facial burning, itching, and swelling. The resident had moderately impaired cognitive skills and was independent with toilet use, personal hygiene, and transfers, with diagnoses including dementia, anxiety, and depression. Interviews with staff revealed that transfer forms were not consistently filled out with the resident's appeal rights, and the Ombudsman was not notified of transfers and discharges. Resident #46, who was severely cognitively impaired and had diagnoses including weakness, Parkinson's disease, disorientation, dependence on renal dialysis, and diabetes, was sent to the emergency room without the necessary transfer paperwork. The LPN only sent a copy of the resident's medication list, diagnosis, allergies, and code status. The facility did not have a policy for transfers, discharges, or notifying the Ombudsman, and the Administrator was unaware of the requirement to notify the Ombudsman monthly of transfers and discharges.
Failure to Complete PASARR for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure staff completed a Level I Preadmission Screen and Resident Review (PASARR) for two residents, which is a federal requirement to evaluate individuals for possible mental disorders or intellectual disabilities. Resident #33, who was admitted on 8/17/22, had diagnoses including Alzheimer's Disease and schizoaffective disorder but did not have a Level I PASARR in their medical record. The resident's care plan indicated behaviors of paranoia and required reassurance, and the Quarterly Minimum Data Set (MDS) showed severe cognitive impairment. The Social Services Designee confirmed the absence of the PASARR in the resident's medical record during an interview on 4/8/24. Similarly, Resident #22, who had diagnoses including dementia, depression, and schizophrenia, also did not have a PASARR available in their medical record. The resident's care plan, dated 1/31/24, indicated mental health and behavioral needs, and the Quarterly MDS showed moderate intact cognition with hallucinations and delusions. The Director of Nursing (DON) and the Administrator both confirmed that PASARRs should be completed upon admission and available in all residents' medical records, but the required documentation was missing for these two residents.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for five of twelve sampled residents. Specifically, the care plans did not address hospice care for one resident, pressure ulcers for another, and the use of oxygen and a CPAP machine for a third resident. Additionally, the care plans did not include the use of cane rails for two residents. These deficiencies were identified through observations, interviews, and record reviews conducted by surveyors. Resident #3, who was admitted with hospice services, did not have hospice care addressed in their care plan. The resident confirmed that hospice provided showers and catheter changes, but this was not reflected in the care plan. Similarly, Resident #6, who had a pressure ulcer, did not have this condition addressed in their care plan despite physician orders for wound care and the resident's own acknowledgment of the sore. The MDS Coordinator and the Director of Nursing both confirmed that pressure ulcers should be included in the care plan. Resident #22, who required oxygen therapy and used a CPAP machine, did not have these needs addressed in their care plan. The resident confirmed the use of these devices, and observations corroborated their presence. Additionally, Residents #34 and #39, who used cane rails for mobility, did not have this equipment included in their care plans. The MDS Coordinator, Director of Nursing, and Administrator all acknowledged that these elements should have been included in the care plans.
Failure to Follow Professional Standards of Care
Penalty
Summary
The facility failed to ensure staff followed professional standards of care for four of 12 sampled residents. For Resident #46, the staff administered insulin without checking blood sugar levels due to the absence of a physician's order for blood sugar monitoring. The Licensed Practical Nurse (LPN) used nursing judgment to administer insulin, despite the resident having severe cognitive impairment and multiple diagnoses, including diabetes. The facility's Director of Nursing (DON) and Administrator acknowledged that an order for blood sugar checks should have been obtained when insulin was prescribed. For Resident #22, the facility did not have physician's orders for the use of a Continuous Positive Airway Pressure (CPAP) machine or for changing the oxygen tubing. The resident, who had intact cognition and was on oxygen therapy, reported that the oxygen tubing was changed monthly instead of weekly. The Administrator confirmed that physician's orders should include instructions for changing oxygen tubing and filters for CPAP machines. Residents #18 and #35 had orders for blood sugar checks before meals, but staff did not consistently follow the timing guidelines. Blood sugars were obtained too close to mealtime, contrary to the facility's policy that blood sugars should be checked 30 minutes to an hour before meals. The Administrator and DON confirmed that staff should adhere to the timing guidelines for blood sugar checks to ensure proper insulin administration and resident safety.
Deficiency in Personal Hygiene Care for Residents
Penalty
Summary
The facility staff failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene. Specifically, staff did not ensure nail care was completed for one resident and shaving was completed for two residents. The facility's policies on nail care and shaving were found to be inadequate, as they did not specify the frequency of these activities or address specific resident preferences. Observations and interviews revealed that Resident #33 had 1/4 inch chin whiskers and partially removed fingernail polish, which the resident expressed dissatisfaction with. Despite the resident's requests, these issues were not addressed in a timely manner. Similarly, Resident #3 had uncombed hair and facial hair, and the resident could not recall the last time they were shaved. The resident expressed a desire to be shaved, but this was not done promptly. Interviews with staff indicated that shaving was typically done on shower days, and there was reliance on Hospice for nail care and shaving, which did not occur frequently enough to meet the residents' needs. The Administrator and Director of Nursing acknowledged that residents should be shaved if they do not like chin whiskers and that staff should talk to the family for non-alert and oriented residents. However, the facility's current practices and policies were insufficient to ensure consistent and timely personal hygiene care for the residents.
Failure to Assess and Install Bed Rails Properly
Penalty
Summary
The facility staff failed to assess residents for the risk of entrapment from bed rails prior to their installation and did not ensure that the bed's dimensions were appropriate for the residents' size and weight. Additionally, the staff did not complete quarterly assessments or obtain a physician's order before installing bed rails for two residents. The facility also lacked a policy on entrapment assessments, which contributed to these deficiencies. Resident #22 had bilateral assist bars installed without a physician's order, and the only bed rail assessment found was signed months after the resident's admission. Resident #39's care plan did not address the use of cane rails, and no entrapment assessment was completed for this resident either. The only bed rail assessment for Resident #39 was completed months after the resident's admission. Interviews with facility staff revealed a lack of understanding and adherence to proper procedures for bed rail assessments and installations. The Maintenance Supervisor admitted to not knowing what entrapment assessments were and did not measure the mattresses to bed frames or look for gaps. The Director of Nursing did not think physician's orders were needed for cane rails and expected entrapment assessments to be completed with changes in side rails, beds, or mattresses. The Administrator also acknowledged that residents with side rails should probably have a physician's order and that therapy should complete side rail assessments and measurements. Observations confirmed that both residents had cane rails installed on their beds without proper assessments or physician's orders. Resident #22 expressed that the rails were for positioning, while Resident #39 mentioned using the rails very little. The facility's failure to follow its own policies and procedures for bed rail use and entrapment assessments led to these deficiencies, putting residents at risk of harm from improper bed rail installations.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure staff administered medications with a medication error rate of less than five percent. Observations, interviews, and record reviews revealed that staff made five medication errors out of 25 opportunities, resulting in a 20% error rate. This affected four residents. Specific deficiencies included improper administration of eye drops without applying lacrimal pressure, incorrect handling and application of Lidocaine patches, and crushing a medication that should not be crushed, leading to incomplete ingestion by the resident. For Resident #21, the LPN administered eye drops without applying lacrimal pressure and failed to follow proper procedures for removing and applying Lidocaine patches. The patch was not removed the previous night, and the area was not cleaned before applying a new patch. For Resident #33, the LPN also failed to apply lacrimal pressure after administering eye drops for glaucoma. The LPN admitted to not knowing the correct duration for applying lacrimal pressure. For Resident #27, the LPN crushed Metoprolol Tartrate, which should not be crushed, and mixed it with a drink, resulting in the resident not consuming the entire dose. For Resident #43, the LPN did not instruct the resident to swish and spit out water after using a Dulera inhaler, leading the resident to swallow the water instead. The facility's policies and procedures were not followed, and the staff lacked knowledge about proper medication administration techniques.
Medication Management Deficiencies
Penalty
Summary
The facility failed to store medications in a locked storage area, leaving medications in pill cups on dining tables for residents. This was observed with multiple residents, including one who had a cup of pills left in front of them at the dining room table and another who had six medications left in a pill cup while eating breakfast. These residents did not have orders for self-administration of medications, nor were there any assessments for self-administration in their medical records. Staff did not maintain observation of the medications, leaving them unattended and accessible to unauthorized individuals. Additionally, the facility failed to properly manage and label medications. An opened vial of tuberculin purified protein derivative was found without a date, and another vial was found with an expired date. An opened insulin pen was also found without a date. The facility's policy required that all refrigerated liquid medications be labeled with the date they were opened, but this was not followed. The Administrator and DON acknowledged that the medications should have been dated and discarded appropriately. The facility's failure to ensure medications were stored securely and properly labeled led to deficiencies in medication management. Staff interviews revealed that medications were sometimes left with residents without proper supervision, and there were no assessments or orders for self-administration. The facility's policies were not adhered to, resulting in medications being left unattended and improperly managed.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food and drink served to residents were palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that hot and cold foods were not served at appropriate temperatures, and pureed foods were not made to the proper consistency. Specifically, oatmeal was served cold, and other foods were often not warm when served. Additionally, pureed foods were found to be either too thin or lacking in taste, failing the required consistency tests. These issues affected three of twelve sampled residents, who reported dissatisfaction with the food temperature and consistency. Resident #22, who had moderate cognitive impairment and required assistance with eating, reported that oatmeal was often served cold. Resident #39, who also had moderate cognitive impairment and was independent with eating, mentioned that food was frequently served cold and that the facility had changed its kitchen supplier, resulting in smaller portions and repetitive meal options. Resident #34, who was cognitively intact but required substantial assistance with eating, expressed a desire for more varied food options and noted that food was often barely warm when served. Observations on specific dates showed that food temperatures were not consistently checked before serving. For instance, pork loin, potatoes, and green beans were found to be excessively hot on the steam table, but no temperatures were recorded when the food was plated and served. A test tray revealed that the pork loin was below the required serving temperature, and pureed pineapple and corn were not at the correct consistency or temperature. Interviews with the dietary manager and administrator confirmed that food temperatures should be checked before and during meal service, but this was not consistently done, leading to the deficiencies observed.
Deficiencies in Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards of food service safety. Observations revealed multiple areas of the kitchen were not cleaned and sanitized properly, including a grease trap full of grease and food, stove tops covered with dried food particles, and a microwave with food particles and crumbs inside. Additionally, the trash can lid was stuck in the up position, and trash was overflowing. Interviews with the Dietary Manager and staff indicated a lack of a cleaning sign-off sheet and inconsistent cleaning routines, contributing to the unsanitary conditions observed in the kitchen. The facility also failed to properly label and date food items, leading to the presence of expired and undated food in storage areas. Observations showed various food items in the walk-in cooler, spice shelf, and free-standing refrigerator that were either undated or past their expiration dates. Interviews with the Dietary Manager and staff revealed inconsistent practices regarding the labeling and dating of food, with some staff not adhering to the facility's policies on food storage and handling. This inconsistency in food labeling and dating practices increased the risk of serving expired or contaminated food to residents. Furthermore, the facility did not ensure proper hand hygiene and sanitation practices among dietary staff. Continuous observations showed dietary aides and cooks frequently handling food and serving residents without washing their hands or sanitizing between tasks. The reuse of plate covers without proper sanitation was also noted. Interviews with the Dietary Manager and staff indicated a lack of training and adherence to hand hygiene protocols, which compromised the overall food safety and sanitation standards in the facility. Additionally, the facility failed to maintain and document sanitizer solution levels and the cleanliness of the ice machine, further contributing to the deficiencies in food service safety.
Failure to Maintain Resident Hydration
Penalty
Summary
The facility failed to assist Resident #6 in maintaining hydration status by not providing water in the resident's room. The resident, who had severe cognitive impairment and required assistance with various activities, was on a pureed diet with thickened liquids due to a condition affecting the autonomic nervous system. Despite the care plan indicating that the resident should have a water jug in the room at all times, observations on multiple occasions revealed that the resident did not have water available. The resident expressed feeling extremely thirsty and reported that staff often forgot to bring water, leading to dry and scaly skin, chapped lips, and a persistent headache. Interviews with staff confirmed that the resident was not on fluid restriction and should have access to water. However, it was noted that the water glass was kept at the nurses' station because it required thickener, and there was no glass available at the time of observation. The Director of Nursing and the Administrator both acknowledged that residents should have access to fluids unless restricted by a physician's order. Despite this, the facility did not provide a policy on hydration, contributing to the deficiency in care for Resident #6.
Deficiency in Dietary Management Competency
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) had the appropriate competencies and skills to carry out the functions of the food and nutrition services. The DM admitted to not having any dietary certification, was currently enrolled in college out of state, and did not have any completed training certificates. Additionally, there was no one in the facility who was certified in dietary management. The facility dietician, who was contracted to come in once a month, had not provided any training to the facility staff. The facility administrator confirmed that the DM was working on his/her certification and that there was no certified dietary manager currently in the building. The facility relied on a consulting dietician who visited monthly and regional support who came quarterly. The dietary managers participated in corporate training over the phone every other week. Despite these measures, the lack of a certified dietary manager on-site and the infrequent presence of the consulting dietician contributed to the deficiency in ensuring the dietary services were managed by qualified personnel.
Failure to Follow Infection Control Standards for Catheter Care
Penalty
Summary
The facility failed to follow infection control standards and guidelines for catheter care when staff did not ensure that a urinary catheter drainage bag was kept off the floor for one of the sampled residents. The resident, who had no cognitive impairment and required substantial assistance with toileting and personal hygiene, was observed on two separate occasions with the catheter drainage bag touching the floor and hooked on the edge of a trash can. The resident's care plan indicated a self-care performance deficit related to multi-system degeneration of the autonomic nervous system, and the resident had an indwelling catheter with a physician's order to change it monthly and as needed. Interviews with staff, including a Nurses Aide and a Licensed Practical Nurse (LPN), confirmed that the catheter drainage bag should not be touching the floor or hanging on a contaminated surface. Both staff members acknowledged that they assist the resident with transfers and toileting and should ensure the drainage bag is off the floor before leaving the room. The Administrator and Director of Nursing (DON) also confirmed that indwelling urinary catheter drainage bags should not be touching the floor or hanging on a contaminated surface.
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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