Quail Run Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cameron, Missouri.
- Location
- 1405 West Grand Ave, Cameron, Missouri 64429
- CMS Provider Number
- 265353
- Inspections on file
- 16
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Quail Run Health Care Center during CMS and state inspections, most recent first.
A resident with schizophrenia, bipolar disorder, depression, anxiety, obesity, and a history of significant behavioral and psychiatric issues was admitted after a preadmission review deemed the individual appropriate for care, with a care plan noting anger, threats, suicidal thoughts, and need for 2-person assistance. Nursing notes described escalating anxiety, frequent requests for hospice, excessive call light use, attempts to pull staff into bed, and an episode involving chest pain, suicidal/homicidal statements, and object throwing that led to EMS transport to a hospital. After the hospital treated the resident and sought to return the individual, facility social services informed the hospital and the guardian that the resident would not be accepted back, and the Administrator cited behavioral concerns and need for psychiatry as reasons; however, the facility failed to document in the medical record any reason why the resident’s needs could not be met at the time of attempted return, contrary to its own transfer/discharge policy.
The facility failed to maintain resident dignity and respect, as evidenced by incidents involving three residents. One resident with cognitive impairment was not assisted during a meal, leading to unsanitary eating conditions. Another resident wore stained clothing and was not offered a change, while their meal was also compromised by flies. A third resident expressed dissatisfaction with being addressed by nicknames, which staff continued to use despite the resident's preferences.
The facility failed to ensure call lights were within reach for two residents with severe cognitive impairment. Observations showed call lights on the floor, inaccessible to the residents, despite staff entering and exiting their rooms. The DON confirmed the expectation for call lights to be within reach at all times.
The facility failed to address and communicate resident council concerns, as meeting minutes showed unresolved issues like laundry problems, cold food, and cleanliness. Ten residents were unaware of the grievance process, and interviews revealed a lack of follow-up on grievances, indicating a breakdown in communication and accountability.
The facility failed to invoke the Durable Power of Attorney for a resident with severe cognitive impairments before allowing them to sign an OHDNR form. Additionally, the facility did not document another resident's code status, despite their intact cognitive skills and multiple diagnoses. Staff interviews confirmed that these deficiencies were against facility policy, which mandates proper documentation and respect for residents' treatment preferences.
The facility failed to maintain a sanitary and comfortable environment, with observations of unclean floors, sticky bathroom surfaces, and persistent urine odors in several areas. Maintenance issues included missing call light cords, a difficult-to-open dining room door, and a lack of backflow preventers on shower hoses. Interviews revealed a lack of awareness and communication regarding necessary repairs and cleaning duties, with high staff turnover contributing to the problem.
The facility failed to ensure that ten out of eleven residents knew who the Grievance Official was and how to file a grievance. Despite having a grievance policy, the residents were not informed about their rights or the grievance process, as evidenced by the lack of discussion in resident council meeting minutes. Interviews with staff revealed that the Activity Director and Administrator did not effectively communicate this information to the residents.
The facility failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. One resident's care plan only addressed a fall, lacking coverage for obesity, urinary incontinence, and diabetes. Another resident's care plan did not include their code status, and a third resident's care plan failed to address their dialysis needs. The facility also lacked a care plan policy.
The facility failed to update care plans quarterly for two residents, leading to deficiencies in care management. One resident's care plan lacked updates for verbal behaviors, while another resident was not invited to care plan meetings. Staff interviews revealed inconsistencies in inviting residents and maintaining documentation.
The facility failed to obtain a physician's order for a resident's dialysis and did not properly monitor low air loss mattress settings for two residents. One resident lacked a care plan addressing dialysis, while two others had mattresses set incorrectly, with no physician's orders or proper documentation. Staff interviews revealed inconsistencies in monitoring and knowledge of correct settings.
The facility failed to provide adequate perineal care and maintain personal hygiene for several residents, leading to deficiencies in care. Observations revealed improper cleaning practices and inconsistent shower schedules, affecting residents' well-being. A resident was found in a saturated incontinence brief with skin issues, indicating a lack of timely care.
The facility did not ensure that three CNAs completed required competencies upon hire and annually. The Administrator could not find competency records for these CNAs and acknowledged that competencies were not being completed as expected. Additionally, the facility lacked a policy for CNA competencies.
The facility failed to ensure monthly drug regimen reviews by a licensed pharmacist, affecting three residents. A resident with severe cognitive impairment did not have documented reviews after an attempted dosage reduction. Another resident had no physician response to a pharmacist's recommendation on Haldol use. A third resident's care plan noted risks from psychotropic drugs, but physician notification of recommended dose reductions was lacking.
A LTC facility had a medication error rate of 26.67%, affecting three residents. Errors included improper blood sugar testing, use of expired insulin, incorrect administration of artificial tears, and improper mixing of Metamucil and Miralax. Additionally, Flonase nasal spray was administered incorrectly, with only one spray given instead of two.
The facility failed to maintain a sanitary kitchen environment, with observations of dirt, dust, and broken tiles, and lacked a policy for food storage and sanitation. Improper food handling was noted, with raw chicken left in water without running water and dirty dishes on the clean rack. Staff interviews revealed unmet expectations for cleanliness and repair.
The facility failed to maintain an effective pest control program, leading to a fly infestation affecting all 56 residents. Flies were observed landing on residents and their food in rooms and dining areas. Despite starting a new pest control program, the facility did not provide a pest control policy, and flies were entering through a door gap. The Maintenance Director and Administrator acknowledged the issue and were working with an outside service to address it.
A significant medication error occurred when an LPN administered expired Insulin Lispro to a resident with diabetes mellitus. The insulin was used despite being past its expiration date, as confirmed by the DON. The facility lacked a policy for insulin administration, contributing to the error.
The facility failed to ensure the Dietary Manager had the necessary skills and competencies to manage food and nutrition services. The DM, hired without prior food service training or certification, only had a Food Handler Certificate and lacked managerial experience. Despite working as a dietary aide, the DM had not completed the required dietary manager's course. Interviews with the DM, RD, and Administrator indicated that training was pending, and there was an expectation for the DM to be knowledgeable about kitchen regulations.
Facility staff failed to follow hand hygiene protocols while providing care to a resident with severe cognitive impairment and incontinence. Staff members entered the resident's room, donned gloves, and performed personal care tasks without washing their hands, despite facility policies requiring hand hygiene before and after resident contact and glove changes.
Failure to Document Justification for Refusing Resident Readmission After Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to allow a resident to return from the hospital without a documented reason in the medical record explaining why the resident’s needs could not be met. Facility policy stated that when a resident is sent to an acute care setting, it is considered a transfer with an expected return, and that if the facility does not permit a resident’s return based on inability to meet needs, the facility must notify the resident/representative in writing and document the reason in the record. The policy also required that discharge decisions after an emergency transfer be based on the resident’s status at the time of attempted return, and that nursing notes include documentation of appropriate orientation and preparation prior to transfer or discharge. The resident involved had a PASRR dated several years prior showing manic and depressive episodes, serious functional problems, a history of intense psychiatric treatment, frequent crisis hotline calls with threats of self-harm, difficulty getting along with others, and a need for redirection. The preadmission packet and care plan identified diagnoses of anxiety, diabetes, schizophrenia, bipolar disorder, depression, obesity, and behaviors including becoming angry quickly, making threats, suicidal thoughts without a specific plan, risk for aggression, anxiety, irritability, difficulty getting along with others, and a need for two staff for care due to size and behaviors. The facility’s DON reviewed the preadmission packet and deemed the resident appropriate for admission, and the resident was admitted with the Public Administrator as guardian. Nursing notes documented that after admission the resident was very anxious, repeatedly approached the nurses’ station, requested hospice be called, used the call light frequently for minor issues, attempted to pull staff into bed, and required care in pairs. On the day of transfer, the resident returned from a smoke break, again requested hospice, reported having a mental and physical crisis, complained of chest pain radiating down the left arm, and stated an intention to harm self and everyone around. EMS was called, the resident began throwing things, EMS de-escalated the situation, and the resident was transferred to a hospital. Subsequently, the hospital social worker and the Public Administrator reported that facility social services stated the resident would not be accepted back and delivered a letter declining readmission, while the Administrator stated the facility would not allow return because the resident needed psychiatric evaluation and she felt other residents would not be safe. There was no documented reason in the resident’s medical record at the facility explaining why the resident’s needs could not be met upon attempted return, despite the facility’s decision not to readmit the resident.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by several incidents involving three residents. One resident, who had severe cognitive impairment and required assistance with daily activities, was not properly assisted during a meal. The resident was seated too far from the dining table, resulting in food falling onto the table and their lap. Despite the presence of staff, the resident was left to eat food directly off the table, which was also being landed on by flies, without any assistance or intervention from the staff. Another resident, also with severe cognitive impairment, was observed wearing stained clothing and was not offered a change of clothes by the staff. This resident's meal was also affected by flies, yet the staff did not provide a new plate of food. The resident attempted to address the fly issue themselves by retrieving a fly swatter, but no staff intervention was noted to ensure the resident's meal was sanitary or to address their soiled clothing. A third resident, who had intact cognitive skills, expressed dissatisfaction with being addressed by nicknames such as "honey" or "sweetie," which they found disrespectful. Despite the resident's preference to be called by their given name or formal titles, staff continued to use these nicknames. Interviews with staff revealed a lack of awareness and adherence to the resident's preferences, indicating a failure to respect the resident's right to self-determination and dignity.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents by not ensuring their call lights were within reach while they were in their rooms. Resident #46, who had severe cognitive impairment and required assistance for mobility and personal care, was observed multiple times with the call light lying on the floor behind the bed, out of reach. Despite the resident's inability to reach the call light, staff members, including a CNA, entered and exited the room without providing the call light to the resident. Similarly, Resident #39, also with severe cognitive impairment and dependent on staff for personal care, was observed with the call light cord draped across the bed frame and the call light resting on the floor. Staff members assisted the resident with care but failed to ensure the call light was accessible. Interviews with staff, including the Director of Nurses, confirmed the expectation that call lights should be within reach at all times, which was not adhered to in these instances.
Failure to Address and Communicate Resident Council Concerns
Penalty
Summary
The facility failed to adequately address and communicate the concerns and recommendations of the resident council, as evidenced by the lack of follow-up on issues raised during council meetings. The resident council meeting minutes from August, October, and November indicated recurring issues such as laundry problems, call light response times, trash accumulation, missing clothes, cold food, and cleanliness concerns. However, the meeting forms did not document how these issues were resolved, who was responsible for addressing them, or whether the resolutions were satisfactory to the residents. This lack of documentation and follow-up suggests a failure in the facility's grievance process. Additionally, during a group interview, ten out of eleven residents reported being unaware of the grievance official and the process for filing grievances. They also expressed that they did not receive follow-up from the staff regarding their concerns. Interviews with the Activity Director and the Administrator revealed that while resident concerns were discussed in meetings, there was an expectation that grievances should be followed up on, which was not happening. This indicates a breakdown in communication and accountability within the facility's grievance handling process.
Failure to Properly Invoke DPOA and Document Code Status
Penalty
Summary
The facility failed to ensure that staff properly invoked the Durable Power of Attorney (DPOA) for a resident before allowing them to sign an Outside of Hospital Do Not Resuscitate (OHDNR) form. This affected one resident who had severe cognitive impairments, including dementia and traumatic brain injury, and was dependent on staff for daily activities. Despite these impairments, the resident was allowed to sign the OHDNR form without the activation of the DPOA, which should have been done given the resident's incapacity to make informed decisions. Additionally, the facility did not obtain advance directives for another resident's code status, which is crucial for determining whether the resident wished to have cardiopulmonary resuscitation (CPR) in case of cardiac or respiratory arrest. This resident had intact cognitive skills and multiple diagnoses, including cancer and congestive heart failure, but their care plan, physician order sheet, and face sheet did not address their code status. Interviews with staff, including the MDS/Care Plan Coordinator and the Director of Nursing, confirmed that the resident's code status should have been documented and care planned. The report highlights a lack of adherence to the facility's policy on advance directives, which mandates that residents' treatment preferences be documented and respected. Interviews with various staff members, including the Social Services Designee and the Administrator, revealed a lack of clarity and action regarding the residents' decision-making capacities and the necessary steps to ensure their rights and preferences were upheld. This oversight resulted in a failure to properly document and respect the residents' advance directives and code status preferences.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for its residents, as evidenced by multiple observations of unclean and poorly maintained areas. Observations revealed dirt and debris on floors, sticky bathroom floors, and brown debris in toilet bowls in several rooms. Additionally, the shower room on the South Hall had broken floor tiles, a cracked light cover, and broken window blinds. The facility also had issues with call light cords being missing or too short in several bathrooms, and a dining room door that was difficult for residents to open. Furthermore, the South Hall and several rooms consistently smelled of urine over multiple days. Interviews with the Maintenance Supervisor and Housekeeping Supervisor highlighted a lack of awareness and communication regarding necessary repairs and cleaning duties. The Maintenance Supervisor was unaware of the need for backflow preventers on shower hoses and did not have work orders for missing call light cords. The Housekeeping Supervisor acknowledged high staff turnover and the need to get back on track with cleaning duties. The Administrator expressed expectations for a clean and odor-free facility in good repair, but these standards were not met, as evidenced by the observations and interviews.
Residents Unaware of Grievance Process
Penalty
Summary
The facility failed to ensure that ten out of eleven sampled residents who participated in a group meeting were aware of who the Grievance Official was and how to file a grievance. The facility's grievance policy, which was undated, outlined that residents have the right to voice grievances without fear of discrimination or reprisal and that the facility must make prompt efforts to resolve these grievances. However, during a group meeting, it was found that the majority of the residents did not know the identity of the Grievance Official or the process for filing a grievance. This lack of awareness was also reflected in the resident council meeting minutes, which did not indicate whether resident rights or grievance procedures were reviewed or discussed. Interviews conducted with facility staff revealed gaps in communication and education regarding the grievance process. The Activity Director, who had been in the position since September, was responsible for setting up resident council meetings but did not ensure that residents were informed about their rights or the grievance process. The Administrator acknowledged that residents should be aware of the Grievance Official and the procedure for filing grievances. Additionally, the Regional Quality Assurance Nurse mentioned addressing grievances with residents back in April, but this information did not seem to have been effectively communicated or retained by the residents.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #25, who had minimal cognitive deficit and required assistance for hygiene and transfers, only had a care plan addressing a fall, lacking a comprehensive plan for other needs such as obesity, urinary incontinence, and diabetes. Resident #18, with intact cognitive skills and multiple diagnoses including cancer and COPD, did not have their code status addressed in the care plan, physician order sheet, or face sheet, which was acknowledged as necessary by the MDS/Care Plan Coordinator and the Director of Nursing. Resident #49, who had severely impaired cognitive skills and required dialysis, did not have this critical aspect of their care included in their care plan. The MDS/Care Plan Coordinator and the Director of Nursing both confirmed that the care plan should have addressed the resident's dialysis needs. The facility also lacked a care plan policy, which contributed to these deficiencies, as evidenced by the absence of comprehensive care plans for the sampled residents.
Failure to Update Care Plans Quarterly
Penalty
Summary
The facility failed to review and update care plans quarterly for two residents, leading to deficiencies in their care management. Resident #36's care plan was not updated since May 2024, and it did not address verbal behaviors identified in the most recent MDS assessment. This resident had a mild cognitive deficit, Alzheimer's disease, urinary incontinence, and required assistance with daily activities. The lack of updates in the care plan indicates a failure to incorporate current assessments into the resident's care strategy. Resident #43's care plan conference summary from May 2024 was the only documentation available, and it did not indicate whether the resident was invited or attended the meeting. The resident, who had intact cognitive skills, upper extremity impairment, and was frequently incontinent, reported not being invited to any care plan meetings. Interviews with facility staff revealed inconsistencies in inviting residents and responsible parties to care plan meetings and maintaining documentation of these meetings. The Director of Nursing confirmed that care plans should be updated quarterly and as needed, but this was not adhered to in these cases.
Deficiencies in Dialysis Orders and Mattress Settings
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality care, as evidenced by the lack of a physician's order for a resident to attend dialysis. This deficiency affected one resident who had severe cognitive impairment and multiple diagnoses, including stroke, COPD, and diabetes mellitus. The resident's care plan did not address the need for dialysis, and there was no physician's order documented in the resident's records. Interviews with facility staff, including the MDS/Care Plan Coordinator, LPN, and DON, confirmed that the care plan should have included dialysis and that a physician's order was necessary. Additionally, the facility did not properly monitor the settings of low air loss mattresses for two residents. One resident, with moderately impaired cognitive skills and a history of pressure ulcers, had a mattress set incorrectly at 300 pounds, despite weighing significantly less. The resident's care plan did not include a physician's order for the mattress or its settings. Observations showed that the mattress settings were not adjusted according to the resident's weight, and staff interviews revealed a lack of documentation and knowledge regarding the correct settings. The second resident, with severe cognitive impairment and multiple diagnoses, also had a low air loss mattress set incorrectly at 230 pounds, despite weighing more. Similar to the first case, there was no physician's order for the mattress or its settings in the resident's care plan. Interviews with nursing staff indicated that while they were responsible for monitoring the mattress settings, there was no consistent documentation or understanding of the correct settings. The Regional QA nurse confirmed that a physician's order should guide the mattress settings based on the manufacturer's guidelines.
Deficiencies in Resident Hygiene and Care
Penalty
Summary
The facility failed to provide adequate perineal care and maintain personal hygiene for several residents, leading to deficiencies in care. Observations revealed that staff did not clean all areas of the skin where urine or feces had touched, and they used the same area of a wipe to clean different areas, which is against proper hygiene practices. For instance, Resident #21, who was always incontinent of bowel and bladder and dependent on staff for personal hygiene, did not receive complete perineal care. Staff members were observed not separating and cleaning all areas of the skin, and they did not wash their hands between glove changes. Additionally, the facility did not ensure that residents received showers or bed baths as per their preferences and care plans. Resident #43, who required assistance due to hemiplegia, reported not receiving showers on scheduled days, which affected their sense of cleanliness and well-being. The facility lacked a dedicated shower aide, and the shower schedule was inconsistently followed, leading to some residents not receiving their showers as planned. This inconsistency was further exacerbated by a change in the facility's computer program, which disrupted the documentation of shower schedules. Resident #25, who required assistance for hygiene and was bound to a wheelchair, was found in a saturated incontinence brief with a strong odor of urine, indicating a lack of timely care. The resident's skin was dark red and had an open slit, suggesting prolonged exposure to moisture and inadequate care. Staff interviews confirmed that the resident had not been checked or cleaned since early morning, despite the expectation of providing incontinent care every two to three hours. The facility's failure to address these care needs highlights significant deficiencies in maintaining residents' personal hygiene and dignity.
Failure to Complete CNA Competencies
Penalty
Summary
The facility failed to ensure that three certified nurse aides (CNAs) completed required competencies upon hire and annually. The staff roster indicated that CNA E was hired on February 21, 2024, CNA D on August 21, 2023, and CNA C on April 15, 2024. During an interview, the Administrator admitted that she could not locate the competency records for these CNAs and acknowledged that competencies were not being completed as expected. The facility did not have a policy in place for CNA competencies, contributing to this oversight.
Failure in Monthly Drug Regimen Review and Physician Notification
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a comprehensive monthly drug regimen review for each resident, which included assessing for unnecessary medications, psychoactive medication management, and drug irregularities. This deficiency affected three residents, who did not receive appropriate medication reviews or physician notifications regarding the pharmacist's recommendations. For instance, Resident #4's records showed an attempted gradual dosage reduction for Trazodone and Zoloft, but no further drug regimen reviews were documented. The resident had severe cognitive impairment and was dependent on staff for daily activities, receiving multiple psychotropic medications for conditions such as depression and dementia. Similarly, Resident #51's records indicated that the pharmacist recommended a 14-day limit on Haldol prescriptions, but there was no documented response from the physician. This resident was at risk for side effects from antidepressant and antipsychotic use. Resident #1's care plan highlighted the risk of side effects from psychotropic drugs, yet there was no evidence that the physician was notified of the pharmacist's recommendations for gradual dose reductions of several medications. The Regional Quality Assurance Nurse confirmed that drug regimen reviews should be completed monthly and that the previous Director of Nursing did not consistently fulfill this requirement.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 26.67% with eight errors out of 30 opportunities. This affected three residents, including one who had their blood sugar checked improperly and was administered expired insulin. The Licensed Practical Nurse (LPN) involved did not allow the alcohol to dry completely before pricking the resident's finger and used insulin that was past its expiration date. Another resident received incorrect administration of artificial tears and a mixture of Metamucil and Miralax. The Certified Medication Technician (CMT) touched the resident's eyelid and eyelashes with the eye dropper and did not apply lacrimal pressure for the recommended duration. Additionally, the CMT mixed Metamucil and Miralax in the same cup with insufficient water, contrary to the instructions on the labels. A third resident was administered Flonase nasal spray incorrectly. The CMT did not shake the bottle, have the resident blow their nose, or close one nostril before administering the spray. Only one spray was given instead of the prescribed two. The CMT also improperly administered artificial tears by touching the resident's eyelid and eyelashes with the dropper and not applying lacrimal pressure for the recommended time.
Unsanitary Kitchen Conditions and Improper Food Handling
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, which had the potential to affect all residents. Observations revealed several unsanitary conditions, including a light switch covered in dirt, a vent above the hand washing sink covered in dust and debris, and food particles on the back-splash behind the stove. Additionally, the light in the dish-room was cracked, multiple tiles on the kitchen and dish room floors were broken, and there was a black substance on the wall behind the three-compartment sink. The facility did not have a policy addressing food storage, kitchen cleaning, and sanitation. Further observations and interviews highlighted improper food handling practices. Raw chicken quarters were found sitting in water in the middle compartment of the three-compartment sink without running water, a method instructed by the Dietary Manager. The chicken had been in the sink for an hour. Additionally, a pan from the clean dish rack was found with food debris, indicating it was not properly cleaned. Interviews with the Registered Dietitian and Maintenance Supervisor revealed expectations for cleanliness and repair were not met, and there was a lack of awareness regarding the necessary repairs and cleaning schedules.
Facility Fails to Control Fly Infestation Affecting Residents
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant presence of flies within the premises, potentially affecting all 56 residents. Observations on multiple occasions revealed flies landing on residents and their belongings, particularly in their rooms and the dining area. During meal times, flies were seen landing on residents' food, and residents were observed swatting at the flies with their hands. Despite the presence of flies, residents consumed the food that the flies had landed on, indicating a lack of effective pest control measures. Interviews with the Maintenance Director and the Administrator highlighted that the facility had recently initiated a new pest control program. However, the Maintenance Director acknowledged that flies were entering the facility through a door gap by the gazebo exit door. Both the Maintenance Director and the Administrator agreed that residents should not have flies in their rooms or dining areas, nor should flies land on their food. The facility was in the process of working with an outside pest control service to develop a fly control program, but at the time of the survey, the facility did not provide a pest control policy when requested.
Expired Insulin Administered to Resident
Penalty
Summary
The facility failed to ensure a safe and effective medication administration system, resulting in a significant medication error involving the use of expired insulin. Specifically, a Licensed Practical Nurse (LPN) administered four units of expired Insulin Lispro to Resident #48, who had a physician's order for insulin administration based on a sliding scale for diabetes mellitus. The insulin vial used was opened and expired, yet it was still administered to the resident. During an interview, the Director of Nursing (DON) confirmed that staff should check insulin vials for expiration dates and should not use them if expired. The facility did not provide a policy for the administration of insulin, contributing to this oversight.
Inadequate Competency of Dietary Manager
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the necessary competencies and skills to effectively manage the food and nutrition services. The DM was hired on March 1, 2024, as a Food Service Manager but lacked prior food service training and did not hold any certification in food service management or as a dietary manager. The DM only possessed a Food Handler Certificate obtained on November 5, 2024, from Always Safe Food Company. Despite having worked as a dietary aide, the DM had no managerial experience and had not completed the required dietary manager's course. Interviews with the DM, Registered Dietitian (RD), and the Administrator revealed that the facility was in the process of initiating the DM's training, but it had not yet been completed. The RD and Administrator both expressed expectations that the DM should have completed the necessary training to manage the kitchen and be knowledgeable about all relevant regulations.
Failure to Adhere to Hand Hygiene Protocols
Penalty
Summary
The facility staff failed to adhere to hand hygiene protocols during the care of a resident with severe cognitive impairment and multiple diagnoses, including stroke, heart disease, and schizophrenia. The resident was dependent on staff for personal hygiene and was incontinent of bowel and bladder. During an observation, two staff members, NA A and CNA D, entered the resident's room without performing hand hygiene. They proceeded to put on gloves without washing their hands and engaged in personal care tasks, including washing the resident's face and performing perineal care, without adhering to proper hand hygiene practices. NA A removed gloves and left the resident's room without performing hand hygiene, then returned with clean linens, again failing to wash hands before resuming care. Interviews with RN A and the Director of Nursing revealed that staff were expected to perform hand hygiene upon entering and exiting resident rooms, before and between glove changes, and when hands were visibly soiled. The failure to follow these protocols was observed during the care of the resident, indicating a deficiency in the facility's infection prevention and control program.
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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