Rehab Of Kansas City South
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Missouri.
- Location
- 8033 Holmes, Kansas City, Missouri 64131
- CMS Provider Number
- 265758
- Inspections on file
- 37
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Rehab Of Kansas City South during CMS and state inspections, most recent first.
A cognitively intact resident with paraplegia, cognitive communication deficit, and major depressive disorder received a 30‑day involuntary discharge notice for non‑payment that contained an incorrect discharge date and lacked complete receiving‑facility information. The facility proceeded with discharge planning despite a care plan entry indicating the resident opted to stay and despite the resident’s expressed desire to remain where they had friends. After the resident’s family notified the facility and the Ombudsman by email that they were appealing the discharge, the facility did not review the appeal email until after the resident had been transported by facility van to another facility and did not allow the resident to return while the appeal was pending, contrary to policy and appeal protections.
Persistent and strong odors of feces and urine were present throughout a hallway, as reported by a family member and confirmed by staff and direct observation. The Housekeeping Supervisor attributed the odors to a resident's medical condition and stated that cleaning and deodorizing would occur if odors were noticed. The strong odor was acknowledged by a Regional RN Consultant.
A resident with significant impairments had a $300 charge from their CashApp account traced to a nurse, but the allegation was not promptly investigated or reported. Multiple mandated reporters, including the Social Worker, HR, and BOM, were aware of the incident but deferred action to the interim Administrator, who did not initiate an investigation or notify authorities as required by facility policy.
Multiple spa room toilets were found unbolted and easily movable, with some spa rooms inaccessible or blocked by equipment. A resident with hemiplegia and hemiparesis was unable to use their own inoperable toilet and reported feeling unsteady and fearful when using the unsecured spa toilets. Staff were unaware of these issues prior to surveyor observation, and maintenance had not received related work orders.
Two separate incidents occurred in which residents with behavioral and mental health diagnoses engaged in physical altercations, resulting in one resident being punched in the face and another being pushed to the ground and injured. Staff were present but did not prevent the escalation to physical abuse, and required behavioral monitoring was not in place for one resident prior to the incident.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or infections, as observed by the absence of EBP signage and PPE in hallways and rooms. Staff lacked awareness of EBP protocols, performing care without necessary PPE. Documentation did not consistently reflect EBP needs, and protocols were only implemented after the survey began.
The facility failed to ensure complete and accurate documentation for residents requiring dialysis, as required by their Dialysis Care policy. Several residents' records lacked comprehensive communication tools, and assessments of dialysis access sites were inconsistently documented. Interviews revealed that staff struggled to obtain complete documentation from the dialysis provider, and there was inadequate follow-up on missing information, potentially impacting resident care.
The facility did not post complete daily nurse staffing information, omitting the total hours worked for RNs, LPNs, and CNAs. The Staffing Coordinator used an incorrect form, and neither the Administrator nor the DON verified the postings, leading to non-compliance with the facility's policy.
A facility failed to ensure proper medication storage and administration, with medications left unattended at residents' bedsides and unlocked medication carts. The medication room was unclean, and refrigerator temperatures were not consistently monitored. Staff interviews revealed non-compliance with facility policies.
A facility failed to provide written notification to a resident and their family before transferring the resident to a hospital. The resident, who was moderately cognitively impaired, experienced a change in condition, prompting a transfer to the emergency room. Interviews revealed that staff did not adhere to the facility's policy requiring advance written notice of transfers.
The facility failed to properly store respiratory equipment and obtain necessary physician orders for two residents. One resident's nebulizer was not stored in a plastic bag, and there was no physician's order for its use, despite receiving medication. Another resident used a BiPAP machine without a documented order, and the mask was found uncovered. Staff interviews revealed a lack of awareness and adherence to facility policies regarding equipment storage and documentation.
Three residents who were dependent on staff for bathing and hygiene did not have their preferences for shower frequency accommodated, with some going up to two weeks without a shower and expressing feelings of uncleanliness. Care plans lacked documentation of individual preferences, and staff interviews revealed that showers were not always provided according to a set schedule, with decisions sometimes based on staff observation or staffing limitations rather than resident choice.
A resident with significant mobility impairments was not fully secured in a motorized wheelchair during van transport, as only three straps were used instead of the required four. During a turn, the wheelchair tipped, causing the resident to hit their head on the window. Staff interviews revealed confusion about proper securing procedures and a lack of verification by the driver, leading to the incident.
The facility failed to ensure a safe and homelike environment when multiple leaks occurred, affecting two residents. Additionally, the facility did not maintain clean floors in the rooms of three residents. The facility's policies and communication were inadequate, contributing to the residents' discomfort and the unsafe environment.
Improper Involuntary Discharge and Failure to Honor Appeal Rights
Penalty
Summary
The deficiency involves the facility’s failure to provide an appropriate and lawful discharge and to honor an appeal of an involuntary transfer for one resident. The facility’s transfer and discharge policy, dated June 2020, required that residents be transferred or discharged only for specific reasons, that a 30‑day written notice be provided with the effective date, receiving facility information, and appeal rights, and that residents not be transferred or discharged while an appeal was pending. For this resident, a 30‑Day Notice of Involuntary Discharge dated 1/15/26 cited failure to pay as the reason and listed allowable outstanding charges of $17,809.40, but the form did not include the current facility name and, when later emailed to the Ombudsman, did not include the address of the receiving facility. The notice also contained an incorrect discharge date (2/7/26 instead of 2/17/26), and the facility proceeded with discharge planning based on this notice. The resident had a history of paraplegia, cognitive communication deficit, and major depressive disorder, and was assessed as cognitively intact on the quarterly MDS dated 1/14/26. The Administrator reported that the resident’s family member, who held DPOA that was not enacted, initially agreed via text on 1/15/26 to the transfer and asked where the resident would be moved, and the Administrator identified the new facility. The Administrator stated that a care plan meeting scheduled for 1/15/26 was canceled by the family with the resident’s agreement, and that at first the resident wanted to leave. The day before the scheduled transfer, the resident reported that the family member told them not to leave, but the next morning the resident reportedly said they were okay with the transfer and asked that the family member meet them at the new facility. The resident’s care plan, updated 2/9/26, documented that the resident opted to stay at the facility, indicating a preference to remain. On the day of transfer, the resident was placed in a wheelchair, taken onto the facility van with belongings, paperwork, and medications, and transported to the new facility. The Administrator stated that when the family member arrived and stopped the van, the resident made no indication they wanted to get off and proceeded to the new facility, although the resident later reported that they were taken to the new facility and that they wanted to go back to the original facility where they had friends. The Ombudsman reported that the family member notified their office of an appeal and that on 2/11/26 the facility’s SSD emailed the 30‑day discharge notice, which lacked the address of the receiving facility. The Ombudsman stated that an appeal hearing was scheduled for 4/2/26 and that the resident should have been allowed to return to the facility during the appeal process. The Administrator acknowledged that an email from the family member notifying the facility of the appeal was sent on 2/11/26 at 3:35 P.M., but it was not read until after the resident had already left on 2/12/26, and the resident was not allowed to return during the pending appeal.
Failure to Prevent and Address Pervasive Odors in Resident Hallway
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents on the 300 Hall, as evidenced by persistent and pervasive odors of feces and urine. A family member reported experiencing strong body odor smells during multiple visits over a three-month period, describing the facility as unclean and the odors as overwhelming to the point of being unable to visit their family member. The Housekeeping Supervisor attributed the odors to residents' medical conditions and stated that housekeeping would clean and deodorize areas if odors were detected, with additional deodorizers available if needed. Direct observations confirmed a strong odor around a specific resident room and extending throughout the hallway, which was also acknowledged by the Regional Registered Nurse Consultant.
Failure to Timely Investigate and Report Alleged Misappropriation of Resident Funds
Penalty
Summary
An allegation of possible misappropriation of a resident's funds was not investigated in a timely manner after a family member reported a $300 charge from the resident's CashApp account, which was traced back to a nurse in the facility. The resident involved had diagnoses including legal blindness, muscle weakness, and cognitive communication deficit. The family discovered the unrecognized transaction after retrieving and charging the resident's phone, and requested that the facility involve law enforcement. Multiple staff members, including the Social Worker, Human Resources, and Business Office Manager, acknowledged awareness of the allegation and recognized it as a reportable incident. However, none of these mandated reporters took action to report the incident, each deferring responsibility to the interim Administrator, who was filling in during the Administrator's medical leave. The interim Administrator did not initiate an investigation, did not document attempts to contact the family, and did not report the allegation to the Department of Health and Senior Services or law enforcement, citing a lack of further information from the family. The facility's Abuse and Prohibition Program policy requires immediate reporting and investigation of suspected misappropriation of resident property, with specific timeframes for notifying authorities. Despite these requirements, the incident was not reported or investigated as mandated, and documentation of the facility's response was lacking. The deficiency centers on the failure to follow established protocols for timely investigation and reporting of alleged misappropriation of resident funds.
Unsecured and Inaccessible Spa Room Toilets Affect Resident Safety
Penalty
Summary
The facility failed to maintain several spa room toilets in a safe and operable condition, as observed and confirmed through interviews and record reviews. Specifically, the toilets in the 100 and 300 Hall Spa Rooms were not securely bolted in place and could be moved easily, while the 200 Hall Spa Room toilet was inaccessible due to being blocked by stored equipment. The 400 Hall Spa Room was also inaccessible, and the toilet in one resident's room was inoperable for a period of time. These deficiencies were directly observed during facility rounds and confirmed by staff interviews, with staff expressing surprise and concern upon discovering the unsecured toilets. A resident with hemiplegia and hemiparesis following a stroke was unable to use their own bathroom due to the inoperable toilet and reported feeling unsteady and fearful when attempting to use the unsecured spa room toilets. The resident also noted that other toilets in the facility were not bolted down. Staff interviews revealed a lack of awareness regarding the unsecured toilets and the blocked or inaccessible spa rooms, and maintenance staff had not received prior reports or work orders related to these issues, except for the clogged toilet. The facility census at the time was 89 residents, and the issues potentially affected all residents utilizing the spa bathroom toilets.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse between residents, resulting in two separate altercations involving four residents. In the first incident, two residents with significant physical and mental health diagnoses, including bilateral leg amputations, schizophrenia, anxiety disorder, and traumatic brain injury, were involved in a physical altercation on the back patio. Video footage showed one resident attempting to enter the building while the other was blocking the doorway, leading to a verbal exchange, physical contact, and ultimately one resident punching the other in the face. Staff were present and intervened after the physical abuse occurred. In the second incident, two cognitively intact residents with histories of schizophrenia, schizoaffective disorder, anxiety disorder, major depressive disorder, and PTSD were involved in an altercation in the dining room. The altercation began as a verbal dispute over money, escalating when one resident allegedly pushed the other to the ground. The resident who fell sustained injuries to the nose and left knee. Staff entered the dining room after the incident and separated the residents. It was noted that behavioral monitoring, which should have been in place for one of the residents, was not implemented prior to the incident. Both incidents were confirmed by staff interviews and facility investigation summaries as physical abuse. The facility's policies defined abuse and outlined staff responsibilities for intervention and redirection of residents exhibiting behavioral symptoms. However, in both cases, staff failed to prevent the escalation of resident-to-resident altercations, resulting in physical harm.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or infections. Observations revealed that there were no signs indicating EBP on the doors of residents who required such precautions, nor were there isolation carts with personal protective equipment (PPE) available in the hallways or resident rooms. This deficiency was noted for residents undergoing dialysis and a resident with a feeding tube, among others. Interviews with staff, including CNAs, LPNs, and the Infection Preventionist, indicated a lack of awareness and understanding of EBP protocols. Staff members were observed performing care activities without wearing the necessary PPE, such as gowns, despite the presence of residents with conditions that warranted EBP. The staff's lack of knowledge was further highlighted by their inability to recall recent training on EBP or the specific PPE required for different care activities. The facility's documentation, including care plans and physician orders, did not consistently reflect the need for EBP for residents with conditions like dialysis shunts, PICC lines, or open wounds. The Infection Preventionist admitted that EBP protocols and signage were only implemented after the survey began, indicating a reactive rather than proactive approach to infection control. This oversight in infection prevention measures posed a risk of transmission of resistant organisms within the facility.
Incomplete Dialysis Documentation and Communication
Penalty
Summary
The facility failed to ensure complete and accurate documentation related to dialysis care for several residents. The facility's Dialysis Care policy required comprehensive communication and documentation between the facility and the dialysis provider, including pre- and post-dialysis vital signs, weights, and any issues encountered during dialysis. However, for multiple residents, the Dialysis and Nursing Home Handoff Communication Tools were either incomplete or missing entirely. For instance, one resident's records showed only partial documentation of weights and vital signs, and there was no follow-up by facility staff to retrieve missing information from the dialysis provider. Additionally, the facility did not consistently document assessments of residents' dialysis access sites, as required by their care plans and physician orders. For some residents, the Nurses' Administration Records showed inconsistent or incorrect documentation codes, and there was no evidence that the facility staff followed up on missing or incomplete documentation. Interviews with staff, including the Director of Nursing (DON) and Licensed Practical Nurses (LPNs), revealed that the facility struggled to obtain complete documentation from the dialysis provider and that staff did not always ensure that the necessary information was recorded in the residents' medical records. The facility's failure to maintain accurate and complete documentation of dialysis care and communication with the dialysis provider was further compounded by inadequate follow-up on missing information. The DON acknowledged that the facility had ongoing issues with receiving complete documentation from the dialysis provider and that staff were not consistently documenting assessments of dialysis access sites in a standardized manner. This lack of documentation and follow-up could potentially impact the quality of care provided to residents requiring dialysis.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information that included the facility name, daily census, and actual hours worked per shift for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs)/Certified Medication Technicians (CMTs) responsible for resident care. Observations on multiple dates revealed that the posted staffing sheets did not display the total number of hours worked for RNs, LPNs, or CNAs. The facility's Nurse Staffing Posting Policy, revised in June 2020, required this information to be posted daily at the beginning of each shift in a clear and readable format accessible to residents and visitors. Interviews with the Staffing Coordinator, Administrator, and Director of Nursing (DON) revealed a lack of awareness and understanding of the requirements for posting staffing information. The Staffing Coordinator admitted to using a form that did not include a space for actual hours worked and was unaware of the need to include total hours worked per job title. The Administrator and DON both acknowledged that they did not verify the accuracy of the posted staffing information and were unaware that the facility was using an incorrect form that lacked the required details.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the proper storage and handling of medications, as evidenced by several observations and interviews. Medications were left unattended at the bedside for three residents, despite the absence of physician orders permitting such practice. This was observed in the cases of a resident who was not present in their room, with pills found on the bedside tray and under the bed, and another resident who reported that staff routinely left medications at their bedside. Additionally, medication carts were found unlocked and unattended in the hallway, posing a risk of unauthorized access by residents. The medication storage areas, including carts and the medication room, were not maintained in a clean and organized manner. Loose pills were found in the drawers of medication carts, along with personal items such as hair clips and car fobs. The medication room was also found to be lacking in cleanliness, with a dirty sink and no paper towels available for handwashing. Furthermore, the medication refrigerator's temperature was not consistently monitored, with records showing temperatures below the recommended range, potentially compromising the integrity of stored medications. Interviews with staff, including LPNs, CMTs, and the DON, revealed a lack of adherence to the facility's policies regarding medication storage and administration. Staff acknowledged that medication carts should be locked when not in use and that medications should not be left at the bedside without a physician's order. The responsibility for monitoring refrigerator temperatures and ensuring cleanliness in medication storage areas was not consistently upheld, leading to the observed deficiencies.
Failure to Provide Written Notification Before Resident Transfer
Penalty
Summary
The facility failed to provide written notification to a resident and their family prior to the resident's transfer to a hospital. The deficiency involved a resident who was moderately cognitively impaired according to their Minimum Data Set (MDS) assessment. On the day of the incident, the resident exhibited a change in condition, including leaning to one side, facial drooping, and an elevated pulse rate. The physician was notified, and an order was given to send the resident to the emergency room for evaluation and treatment. However, there was no documentation of written notification to the resident or their family regarding the transfer. Interviews with facility staff revealed a lack of adherence to the facility's Transfer and Discharge policy, which requires reasonable advance notice of transfer or discharge. The social worker and an LPN both indicated that they did not provide written notices to residents or their families when a transfer occurred. The Director of Nursing stated that the responsibility for providing written notification lay with the licensed nurse on duty at the time of transfer, but there was no evidence that this procedure was followed. This oversight resulted in the failure to inform the resident and their family in writing about the transfer to the hospital.
Deficiency in Respiratory Equipment Management
Penalty
Summary
The facility failed to ensure proper storage and physician orders for respiratory equipment for two residents. Resident #55, diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and Obstructive Sleep Apnea, had a nebulizer mouthpiece that was repeatedly observed not stored in a plastic bag as required by facility policy. Additionally, there was no physician's order for the nebulizer treatment, despite the resident receiving medication for it. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed the absence of a physician's order and acknowledged the responsibility of nursing staff to maintain the equipment in a sanitary condition. Resident #57, with diagnoses including abnormalities of breathing and heart failure, was using a BiPAP machine without a documented physician's order. The BiPAP mask was found uncovered in the resident's dresser drawer, contrary to the facility's policy that requires such equipment to be stored in a plastic bag when not in use. Interviews with various staff members, including a Certified Nursing Assistant (CNA), Certified Medication Technician (CMT), and the MDS nurse, revealed a lack of awareness regarding the resident's use of a BiPAP machine and the absence of corresponding orders in the care plan. The facility's failure to adhere to its policies regarding respiratory equipment storage and physician orders was evident in both cases. The Assistant Director of Nursing (ADON) and other staff members acknowledged the oversight in maintaining equipment cleanliness and ensuring proper documentation. The DON admitted to not being aware of the missing orders for Resident #57's BiPAP machine, highlighting a breakdown in communication and documentation processes within the facility.
Failure to Accommodate Resident Bathing Preferences
Penalty
Summary
The facility failed to accommodate the bathing and showering preferences of three sampled residents, all of whom were dependent on staff for personal hygiene due to significant physical or cognitive impairments. The facility's policy required that residents' individual needs and preferences be accommodated unless health or safety would be endangered, but care plans and documentation did not consistently reflect or address residents' stated preferences for shower frequency or timing. For example, one cognitively intact resident reported going up to two weeks without a shower and expressed a desire for more frequent showers, especially around holidays and when expecting visitors. Another resident, also cognitively intact, stated a preference for daily showers but was only receiving them once every two weeks at times, and reported feeling unclean and that this affected their mood. A third resident, who was severely cognitively impaired, also indicated a desire for more frequent showers than were being provided. Observations and interviews revealed that residents sometimes had visible signs of uncleanliness, such as crumbs and stains on clothing or body odor. Staff interviews indicated that showers were not always provided according to a set schedule, and that decisions about when to shower residents were sometimes made based on staff observation rather than resident preference or a documented schedule. Documentation of shower refusals was incomplete, with no reasons recorded for refusals, and staff acknowledged that showers were sometimes missed due to staffing issues or because the shower aide was assigned to other duties. The care plans reviewed did not consistently document residents' specific bathing or showering preferences, and there was a lack of clear scheduling or communication regarding when showers would be provided. Residents reported not being offered showers as frequently as they desired, and staff confirmed that the established shower schedule was not always followed. The facility census at the time was 91 residents, and the deficiency was identified through observation, interview, and record review.
Resident Not Properly Secured During Van Transport
Penalty
Summary
A deficiency occurred when a resident with multiple sclerosis, bilateral upper and lower extremity impairments, and a left knee contracture was not properly secured during transport in the facility van. The facility's Safe Transportation Unloading Procedure required that wheelchairs be locked and secured with tie-down hooks, and that four straps be used to secure each wheelchair. On the day of the incident, the resident was transported in a motorized wheelchair along with another resident. The transportation escort attached only three straps to the resident's wheelchair, and the driver did not verify that all four straps were used or properly secured. During the trip, the resident's wheelchair tipped over when the van turned a corner, causing the resident to hit their head on the window. The wheelchair was found leaning against the other resident's wheelchair, and the left-side straps were not attached to the van floor. Interviews revealed that the transportation escort was not fully aware of the protocol, believing that two to four straps could be used, and had previously experienced a strap coming loose from the van floor with another resident. The driver acknowledged responsibility for ensuring all wheelchairs were properly secured but failed to double-check the straps before transport. The maintenance director, who supervised the driver, stated that drivers were trained to use four straps but had not provided education to the escort. The facility's records did not indicate any new interventions or plans to prevent recurrence following the incident. The resident involved was cognitively intact and dependent on staff for all transfers and mobility, using a motorized wheelchair. After the incident, the resident reported head pain and sought hospital evaluation. The lack of adherence to the facility's transportation safety procedures and insufficient staff training and oversight directly led to the resident not being fully secured, resulting in the accident during van transport.
Facility Fails to Ensure Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a safe and homelike environment when multiple leaks occurred, affecting two residents. Resident #3, who has diagnoses including osteomyelitis, diabetes, and COPD, reported the leak around 5:00 A.M. after it worsened. The facility's response was limited to placing towels and a bucket under the leak, causing Resident #3 to feel upset and unsafe. Resident #2, who has pneumonia and unspecified psychosis, also experienced discomfort due to the leak, which started around 3:00 A.M. and worsened by 7:30 A.M. Despite informing the staff, the resident's bed remained wet, and the facility did not take adequate measures to address the issue promptly. Additionally, the facility failed to maintain clean floors in the rooms of three residents. Resident #10's room had a buildup of brown grime and debris, and Resident #6's room had debris and red stains on the floor. Resident #4's room had a heavy buildup of debris between the bed and the wall. The housekeeping staff did not adequately clean these areas, and the Housekeeping Supervisor acknowledged noticing similar issues in the past but did not ensure proper cleaning. The facility's policies and communication were also inadequate. The Rapid Response Guide: Flood did not specifically address water leaks in resident rooms. Staff members, including the DON and the Maintenance Director, were not promptly informed about the leaks. The Administrator and DON were only made aware of the situation through a group text and did not take immediate action to relocate the affected residents or address the leaks effectively. This lack of timely communication and action contributed to the residents' discomfort and the unsafe environment.
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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