Rehabilitation Center Of Independence, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Independence, Missouri.
- Location
- 1800 S Swope Drive, Independence, Missouri 64057
- CMS Provider Number
- 265693
- Inspections on file
- 33
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Rehabilitation Center Of Independence, The during CMS and state inspections, most recent first.
A resident with COPD, CHF, CKD stage 3, MDD, and anxiety, who was moderately cognitively impaired but able to communicate, discovered that money was missing from their bank account after receiving a lump-sum SSA back payment. While reviewing the account with a SW and a therapist, a $350 charge to a wireless carrier bearing the SSD’s name was identified, matching a prior text in which the SSD had asked the therapist to borrow $350 for a phone bill. The resident reported never authorizing the SSD to use their debit card, and bank records showed this payment along with multiple ATM withdrawals totaling several thousand dollars. The SSD denied using the resident’s card or receiving money, but the documented transaction, text messages, and interviews showed that the SSD used the resident’s funds to pay a personal cell phone bill, in violation of the facility’s abuse and misappropriation policy.
A resident with a history of falls and traumatic brain injury experienced a fall resulting in multiple injuries, including facial bruising, a laceration, and broken teeth. Staff notified the physician only about knee pain and did not report the facial injuries or broken teeth, nor did they fully document the extent of injuries or interventions provided. The physician and nurse practitioner were unaware of the full scope of injuries, and facility leadership confirmed that required notifications and documentation were not completed.
A facility failed to manage a diabetic resident's care, leading to hospitalization. The resident's insulin orders were not transcribed, and blood glucose monitoring was inadequate, resulting in hyperglycemia with a blood sugar level of 541 mg/dL. The resident exhibited signs of hyperglycemia, such as excessive hunger and anger, which were not recognized by staff. Interviews revealed a lack of awareness and inadequate processes for ensuring accurate transcription of physician's orders.
The facility failed to maintain adequate nursing staffing levels, as established by their own standards, resulting in a deficiency in providing appropriate care and services to residents. The facility's minimum staffing expectation was 2.8 nursing staff hours per patient per day (PPD), but this was not consistently met, with the lowest recorded at 2.03 PPD. The Administrator and DON acknowledged the routine failure to meet the staffing benchmark, potentially affecting all residents.
The facility failed to provide palatable foods at appropriate temperatures, affecting residents across multiple units. Residents reported meals being cold and served late, often due to staffing shortages. Despite ongoing complaints documented in Resident Council Meeting Minutes, issues persisted, with a test tray evaluation confirming improper food temperatures. The Food Service Supervisor and Administrator acknowledged the concerns.
The facility was unable to provide documentation of regular QAPI meetings and evidence of participation by required parties. The Administrator reported plans for monthly meetings but could not locate all attendance records since the last survey. Records were available for meetings in June, August, September, and October 2024, but no additional evidence of required meetings or attendance documentation was found, affecting all residents.
The facility failed to ensure dignified care for three residents. A resident with intact cognition was not provided with necessary adaptive feeding equipment, leading to frustration. Another resident was left without a bed, resulting in discomfort and inadequate rest. Additionally, a resident experienced a breach of dignity during perineal care when a staff member used profane language in their presence.
The facility failed to address ongoing grievances from residents regarding showers, laundry, and food shortages. Despite repeated reports in Resident Council meetings, issues such as missing laundry items, inadequate food supplies, and unclean rooms persisted. Interviews with the Administrator and DON indicated that while concerns were discussed in meetings, no actions were taken to resolve them.
The facility failed to provide adequate care for activities of daily living, including showers and toileting assistance, due to staffing shortages. Residents reported receiving fewer showers than scheduled, and one resident was left unattended on the toilet for over 20 minutes despite activating the call light. Staff interviews confirmed these issues, and there was no documentation of residents refusing care. The facility's policies on shower frequency and call light response were not followed, affecting the quality of care for multiple residents.
The facility did not employ a qualified social worker as required for facilities with more than 120 beds, impacting all 96 residents. The social worker held a Bachelor of Arts in Human Services but was not licensed by the state and lacked the required year of supervised experience. The social worker confirmed these deficiencies during an interview.
The facility failed to ensure proper infection control during wound care for two residents, as the LVN did not perform hand hygiene before donning gloves and touched surfaces before starting care. Additionally, Enhanced Barrier Precautions were not implemented for a resident with a pressure injury and catheter, as required by the care plan. Observations showed no signage or PPE available, and the DON acknowledged the oversight.
A resident's room was changed without prior notice while they were out for an appointment, leading to a misunderstanding with their former roommate. The facility's policy requires advance notice for room changes, but this was not followed, as confirmed by the social worker and acknowledged by the administrator.
A resident, who required a Hoyer lift for transfers, reported falling during a transfer by a Restorative Nursing Aide and Maintenance Supervisor. The staff did not notify the nurse or physician, and the incident was not documented in progress notes. The resident, with a history of brain injury and repeated falls, was later found with unreported abrasions on the left knee.
The facility did not provide appropriate notification of pending Medicare benefit changes for a resident. A review revealed that there was no documentation available for the required Beneficiary Notice for a resident discharged within the last six months. The Social Worker, new to the position, could not provide proof of notification letters sent to the resident.
A resident with a history of metabolic encephalopathy and CVA was transferred to a hospital due to a change in condition without the required written notice being sent to the resident or their representative. Facility staff, including an LPN and the DON, confirmed the oversight, which was against the facility's policy.
A resident was transferred to a hospital without receiving a written notice of the facility's bed-hold policy, as required by the facility's transfer and discharge policy. The resident, with a history of metabolic encephalopathy and hemiparesis, was transferred due to a change in medical condition. Interviews with staff confirmed the oversight, as the notice was not provided to the resident or their representative.
A facility failed to accurately document a resident's skin condition, compromising care. The resident, with a history of brain injury and falls, sustained abrasions during a transfer on admission day, which were not documented by the LVN. The resident reported falling, but staff stated the resident slipped without falling. The RNA involved was suspended and unavailable for comment.
A facility failed to timely obtain a physician-ordered urinalysis (UA) sample for a resident with multiple health conditions, including cellulitis and diabetes. The UA order was dated over a year before the sample was collected, with no explanation for the delay provided by the DON.
The facility failed to provide meaningful weekend activities for two residents and did not assist a resident in attending desired activities. A resident with intact cognitive status was not helped out of bed to attend bingo, while two other residents reported a lack of weekend activities, leading to boredom. Activity records confirmed limited participation in weekend activities, and the Activity Director acknowledged the absence of staff supervision on weekends.
The facility failed to supervise two residents while smoking, as required by its policy, leading them to smoke unsupervised in non-designated areas. Despite the policy mandating supervision and designated smoking areas, observations showed residents smoking near the front door without staff present. Interviews revealed that staff shortages and inaccessible designated areas contributed to this deficiency.
A resident with multiple diagnoses, including overactive bladder and chronic pain syndrome, did not receive proper perineal care as per facility policy. An RNA failed to adequately spread the resident's knees for cleaning, citing the resident's contracted state, while a CNA disagreed with the RNA's method. The resident, cognitively intact and dependent on staff for toileting, expressed dissatisfaction with the care, stating it was not done correctly.
A resident with dementia and a gastrostomy tube was not given prescribed supplemental feeding despite low meal intake. Observations and records showed the resident ate less than 50% of meals on several occasions, yet staff failed to administer Glucerna 1.5 as ordered. The DON confirmed that staff were expected to monitor intake and provide supplemental feeding as needed.
The facility did not follow the prescribed pureed diet menu for two residents, as observed during a meal service. The menu included pureed BBQ meatballs, mashed potatoes with gravy, pureed buttered peas, pureed brownie, and pureed buttered white bread. However, the bread was not pureed and served to the residents, which was acknowledged by the Food Services Manager.
Misappropriation of Resident Funds by Social Services Director
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when the Social Services Director (SSD) used the resident’s debit card to pay the SSD’s personal cell phone bill in the amount of $350.00. The facility’s Abuse Prevention and Prohibition Program stated that each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property, and that the facility is committed to protecting residents from abuse by anyone, including staff. Despite this policy, the SSD’s name appeared on a $350.00 wireless cell phone carrier transaction drawn from the resident’s bank account, and the resident later reported missing money and denied authorizing the SSD to use the debit card for this purpose. The resident involved had multiple medical and psychosocial conditions, including COPD, chronic systolic (congestive) heart failure, chronic kidney disease stage 3, major depressive disorder (recurrent, moderate), and anxiety. A quarterly MDS showed the resident was moderately cognitively impaired but able to understand others and be understood. The resident’s care plan documented psychosocial well-being problems related to depression, anxiety, cognitive communication deficit, chronic pain, and respiratory insufficiency, and noted that the resident discovered missing money, which prompted an investigation and involvement of the police. Following discovery of the missing funds, the resident displayed increased tearfulness and reported never giving the SSD permission to use the debit card to pay a cell phone bill. Interviews and record reviews showed a sequence of events linking the SSD to the misappropriation. Therapist A reported receiving a text message from the SSD asking to borrow $350.00 to pay a cell phone bill; Therapist A declined. Later, while assisting the resident and Social Worker (SW) A in reviewing the resident’s bank account, Therapist A observed a $350.00 charge to a wireless carrier with the SSD’s name on it and took a picture of the transaction before reporting it to the Administrator. SW A stated that the resident came to the office upset that all of the resident’s money was gone, and that review of the account revealed the SSD’s cell phone bill payment. The resident had recently received a lump-sum Social Security back payment, paid the facility balance, and had about $9,000 remaining, with only about $1,000 left when the concern was raised. The Administrator reported that a total of $8,000 was missing from the resident’s account with multiple ATM withdrawals, that $350.00 was verified as taken by the SSD to pay a cell phone bill, and that law enforcement and the bank were investigating. Although the SSD denied using the resident’s debit card or receiving money or gifts from the resident, the bank record, the therapist’s text messages, and the resident’s statements collectively supported that the SSD used the resident’s funds without authorization, constituting misappropriation of property.
Failure to Notify Physician of All Resident Injuries After Fall
Penalty
Summary
The facility failed to ensure that a resident's physician was notified of all injuries sustained after a fall, as required by facility policy. The resident, who had a history of muscle weakness, repeated falls, and a traumatic subdural hemorrhage, experienced a fall resulting in multiple injuries, including a bruise to the right knee, facial bruising, swelling, a laceration to the top lip, and broken implanted teeth. While the fall was reported and an x-ray was ordered for the knee, there was no documentation that the physician was informed of the facial injuries or the broken teeth. The resident reported pain in the knee, hand, chin, and mouth, and described significant facial swelling and bruising, but these complaints and injuries were not fully communicated to the physician or addressed in the medical record. Interviews with staff revealed that the LPN who responded to the fall focused primarily on the resident's knee pain and did not recall informing the provider about the facial injuries or broken teeth. Other nursing staff assumed that all necessary notifications had been made and did not contact the physician regarding the additional injuries. Documentation in the progress notes and medical record was incomplete, with missing details about the location of pain, the extent of facial injuries, and the interventions provided, such as the application of steri-strips and ice packs. The physician and nurse practitioner both stated that they were not made aware of the full extent of the resident's injuries following the fall. Facility leadership, including the DON and Administrator, confirmed that their expectations were for all injuries and relevant facts to be reported to the physician and documented in the medical record. However, the investigation found that the required notifications and documentation did not occur, particularly regarding the resident's facial injuries and broken teeth. The lack of comprehensive assessment, notification, and documentation following the fall constituted a failure to follow facility policy and ensure appropriate medical oversight for the resident's injuries.
Failure to Manage Diabetic Care Leads to Hospitalization
Penalty
Summary
The facility failed to provide appropriate care for a diabetic resident, leading to a significant health deficiency. Upon admission, the resident had a medical history of metabolic encephalopathy and diabetes, with specific orders for insulin administration and blood glucose monitoring. However, the facility staff did not transcribe or verify these orders, resulting in the omission of critical insulin doses and inadequate blood glucose monitoring. This oversight led to the resident experiencing hyperglycemia, with blood sugar levels reaching 541 mg/dL, and subsequent hospitalization. The resident exhibited signs of hyperglycemia, such as excessive hunger, anger, and frequent urination, which were not recognized or addressed by the facility staff. Despite the resident's disruptive behaviors and physical aggression, the staff did not assess or manage the resident's blood sugar levels appropriately. The facility's failure to implement the necessary care and services, as ordered by the medical provider, contributed to the resident's deteriorating condition and eventual transfer to a hospital. Interviews with the Administrator and the DON revealed a lack of awareness regarding the resident's unmonitored blood glucose levels and the unfulfilled insulin orders. The DON acknowledged the symptoms indicative of uncontrolled hyperglycemia but did not recognize them at the time of the resident's transfer. The facility's process for ensuring accurate transcription of physician's orders was inadequate, as evidenced by the missing checklist for the resident's admission. This deficiency highlights a critical lapse in the facility's care for diabetic residents, resulting in adverse outcomes for the resident involved.
Inadequate Nursing Staffing Levels
Penalty
Summary
The facility leadership failed to maintain adequate nursing staffing levels as established by their own standards, which resulted in a deficiency in providing appropriate nursing care and services to meet the needs of residents. The facility had set a minimum nurse staffing expectation of 2.8 nursing staff hours per patient per day (PPD), but a review of the facility's daily staffing hours for December 2024 revealed that this benchmark was not consistently met. On multiple days, the actual nursing staff hours worked were below the established minimum, with the lowest recorded at 2.03 PPD. During an interview with the Administrator and Director of Nursing (DON), it was acknowledged that the facility was routinely failing to meet the staffing benchmark. This deficiency had the potential to affect all residents living in the facility, as the inadequate staffing levels could compromise the quality of care and services provided to them. The report does not mention any specific residents or their conditions, focusing instead on the overall staffing inadequacies and the facility's failure to adhere to its own staffing standards.
Deficiency in Food Service Quality and Temperature
Penalty
Summary
The facility failed to provide palatable foods per resident preferences for taste and temperature, as evidenced by improper food temperatures and delayed meal services. Multiple residents across four out of five units expressed concerns about the quality of food, specifically noting that meals were often cold and served later than the posted times. These issues were attributed to staffing shortages, which resulted in food trays sitting in hallways for extended periods before being served. Residents reported dissatisfaction with the taste and temperature of the food, with some opting to skip meals or order food from outside the facility. Resident interviews revealed consistent complaints about the food service, with residents describing meals as cold, unappetizing, and not served at the scheduled times. The Resident Council Meeting Minutes from the past five months documented ongoing issues with meal delays, lack of condiments, and unmet food preferences. Despite these documented complaints, the issues persisted, with residents continuing to express dissatisfaction with the food service during a recent Resident Council meeting. An observation of a breakfast meal service confirmed the residents' complaints, as a test tray evaluation showed that food temperatures were below acceptable levels. The Food Service Supervisor acknowledged that the food was too cold and had been left in the hallway for too long. The facility administrator also recognized the food complaints as a concern, indicating awareness of the deficiency but no immediate corrective actions were noted in the report.
Lack of Documentation for QAPI Meetings
Penalty
Summary
The facility was found deficient due to its inability to provide documentation of regular Quality Assurance Performance Improvement Plan (QAPI) meetings and evidence of participation by the required parties. During an interview, the Administrator stated that the committee planned to meet monthly but could not locate all verification of attendance for the QAPI meetings held since the last survey in June 2023. The Administrator provided records for meetings held in June, August, September, and October 2024, but there was no additional evidence of required meetings or documentation regarding those in attendance. This deficiency affected all facility residents.
Failure to Ensure Dignified Care for Residents
Penalty
Summary
The facility failed to ensure a dignified existence for three residents, as observed during a survey. Resident #39, who had intact cognition and required setup or clean-up assistance for eating, was not provided with the necessary adaptive feeding equipment. Despite having an occupational therapy order for a built-up utensil, the resident was left without assistance, leading to frustration and a feeling of disrespect when staff were unavailable to help with meals. Resident #66, who had intact cognition and was typically independent with toileting, was found to be sleeping in a manual wheelchair due to the absence of a bed in the room. The resident reported difficulty with the provided rocking recliner and expressed a preference for a bed, which was not accommodated by the facility. The resident's care plan did not address the need for assistance with transferring from the recliner, leading to discomfort and inadequate rest. Resident #82, who was cognitively intact and dependent on staff for toileting hygiene, experienced a breach of dignity during perineal care. A Restorative Nursing Aide used profane language directed at another staff member in the resident's presence, compromising the resident's right to a respectful environment. This incident was reported to the facility's administration, highlighting a failure to maintain a dignified and respectful atmosphere during care interactions.
Facility Fails to Address Resident Grievances
Penalty
Summary
The facility failed to address and resolve grievances raised by residents during multiple Resident Council meetings. Over several months, residents consistently reported issues such as not receiving showers, missing laundry items, and inadequate food supplies. Specific concerns included the dietary department running out of milk, yogurt, and condiments, as well as meal trays not matching dining tickets due to food shortages. Additionally, residents reported that their rooms were not being cleaned daily, and they were not receiving their clothing back from the laundry department in a timely manner. Despite these ongoing complaints, there was no evidence in the meeting minutes that facility leadership had addressed the residents' concerns. During an observation of a Resident Council meeting, residents continued to report issues with lost or damaged laundry, shortages of paper towels and hand soap, and rooms not being cleaned daily. Interviews with the Administrator and the DON revealed that while the concerns were discussed in leadership and Interdisciplinary Team meetings, no concrete responses or actions were provided to address the issues raised by the residents.
Deficiencies in ADL Care and Response to Call Lights
Penalty
Summary
The facility failed to provide necessary nursing care and services for activities of daily living to several residents, as observed in multiple instances. Resident #2, who has cerebral palsy and requires substantial assistance for showers and transfers, reported receiving fewer showers than scheduled due to staff shortages. The resident's care plan indicated a need for two showers per week, but records showed inconsistencies in meeting this requirement. Interviews with staff confirmed that short staffing often led to rescheduling or skipping showers, and there was no documentation of the resident refusing showers. Resident #58, with diagnoses including seizure and chronic obstructive pulmonary disease, also experienced a reduction in scheduled showers due to understaffing. Despite the care plan specifying two showers per week, the resident reported receiving only one per week and expressed frustration over the lack of assistance, particularly on weekends. The facility's policy required residents to sign a form if they refused showers, but there was no record of such refusals for Resident #58. Additionally, Resident #70, who is dependent on staff for toileting assistance, was left unattended on the toilet for over 20 minutes despite activating the call light. Observations showed multiple staff members, including maintenance employees and a COTA, ignoring the call light. The resident expressed frustration over the delay in assistance, which was confirmed by interviews with staff. The facility's policy emphasized timely responses to call lights, but this was not adhered to in Resident #70's case. Similar issues were noted for Residents #39 and #82, who did not receive adequate personal hygiene care and assistance with adaptive eating equipment as per their care plans.
Facility Lacks Qualified Social Worker for 120+ Bed Requirement
Penalty
Summary
The facility failed to employ a qualified social worker as required for facilities with more than 120 beds, affecting all 96 residents. The job description for the social worker position required a license in the state of practice, a bachelor's degree in social work or a related human services field, and one year of supervised social work experience in a healthcare setting with geriatric individuals. However, the social worker employed held a Bachelor of Arts in Human Services but was not licensed by the state and lacked the required year of supervision. During an interview, the social worker confirmed the absence of a license and the necessary supervised experience.
Infection Control Deficiencies in Wound Care and Barrier Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control during wound care for two residents. For Resident #82, the Licensed Vocational Nurse (LVN) did not perform hand hygiene before donning gloves and touched the curtain and bedside table before starting wound care. This resident had a stage three pressure injury and intact cognition. Similarly, for Resident #26, the LVN also failed to perform hand hygiene before donning gloves and touched the curtain and bedside table before starting wound care. This resident had a stage four pressure injury and was moderately cognitively impaired. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for Resident #37, who had a pressure injury and a suprapubic catheter. The care plan required EBP, including wearing a clean gown and gloves during high-contact activities. However, observations revealed no signage indicating EBP, and no personal protective equipment (PPE) was available inside or outside the resident's room. The Director of Nursing acknowledged the oversight and the need for proper signage and precautions.
Resident Room Change Without Notice
Penalty
Summary
The facility staff failed to protect the rights of a resident by changing their room without prior notice. The incident involved a resident who was admitted with multiple diagnoses, including diabetes, kidney failure, and anxiety disorder. The resident left the facility for an appointment and returned to find that their belongings had been moved to a different room without any prior notification. This unexpected change led to a misunderstanding between the resident and their former roommate, as each believed the other had requested the move. The facility's policy on room changes requires that residents and their representatives receive timely advance notice of any room changes, including written notice when the change is initiated by the facility. However, in this case, the social worker confirmed that the move was a clinical decision and acknowledged that the resident was not informed beforehand. The facility administrator stated that staff were expected to implement the policy correctly, indicating a failure in adhering to the established procedures for room changes.
Failure to Notify of Fall During Transfer
Penalty
Summary
The facility failed to ensure appropriate notification following a fall during a transfer for one of the residents. The resident, who was cognitively intact and required a mechanical Hoyer lift with two staff members for transfers, reported falling while being transferred from a wheelchair to the bed by a Restorative Nursing Aide and the Maintenance Supervisor. The staff involved did not notify the nurse or physician of the incident, as required, and there was no evidence in the progress notes that a fall had been reported. This oversight compromised the resident's right to prompt assessment and care. The resident had a history of diffuse traumatic brain injury, cerebral infarction, morbid obesity, muscle weakness, and repeated falls. During a skin assessment, the resident was found to have two closed abrasions below the left knee, which were not previously reported to the nurse. The Maintenance Supervisor admitted to assisting with the transfer and stated that the resident's admission paperwork did not indicate the need for a mechanical Hoyer lift. The incident was not properly documented or communicated, potentially placing the resident at risk for unrecognized or untreated injuries.
Failure to Provide Medicare Benefit Change Notification
Penalty
Summary
The facility failed to provide appropriate notification of pending benefit changes to Medicare services for one of the three residents sampled for beneficiary notices. During a review conducted on January 10, 2025, it was found that there was no documentation available for one resident regarding the Beneficiary Notice, which is required for residents discharged within the last six months. The Social Worker, who had been in the position since August 2024, was unable to provide proof of notification letters sent to the resident in question.
Failure to Notify Resident and Representative of Emergency Hospital Transfer
Penalty
Summary
The facility failed to notify a resident and the resident's representative of a facility-initiated emergency transfer to an acute care hospital. This deficiency affected one of the two residents reviewed for hospitalizations. The facility's policy required staff from Social Services or a designee to prepare a written transfer notice to accompany the resident during an emergency transfer. However, a review of the medical record for the affected resident revealed no evidence of such a notice being sent. The resident in question had a medical history that included metabolic encephalopathy, hemiparesis affecting the left side, and a history of cerebrovascular accident (CVA). The resident was transferred to the hospital due to a change in medical condition, but the required written notice of transfer was not completed or sent with the resident. Interviews with facility staff, including an LPN and the DON, confirmed that the notice was not sent, and the DON could not recall whether it was completed, despite having signed the resident's discharge summary.
Failure to Provide Bed-Hold Policy Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice of the bed-hold policy to a resident and their representative upon the resident's transfer to an acute care hospital. This deficiency was identified during a review of the facility's policy on resident transfer and discharge, which mandates that such a notice be given at the time of transfer. The deficiency affected one of the two residents reviewed for hospitalizations, specifically a resident with a medical history of metabolic encephalopathy, hemiparesis, and a history of CVA. The resident was transferred to the hospital due to a change in medical condition, but no evidence of the required written notice was found in the resident's medical record. Interviews conducted with facility staff, including an LPN and the DON, confirmed that the notice of bed-hold policy was not provided to the resident or their representative. The LPN stated that the nurse responsible for the transfer should have completed and sent the notice with the resident as part of the transfer paperwork, and a copy should have been kept in the resident's medical record. The DON acknowledged the oversight, confirming that the notice was neither sent with the resident nor to the resident's representative.
Inaccurate Skin Assessment Documentation
Penalty
Summary
The facility failed to ensure the accuracy of a skin assessment for one resident, which compromised the ability to provide appropriate and timely care. The resident, who had a history of traumatic brain injury, cerebral infarction, morbid obesity, muscle weakness, and repeated falls, was admitted with an intact cognition score. The Admission Minimum Data Set (MDS) noted Moisture Associated Skin Damage (MASD) but no other skin problems. However, a Skin/Wound note created by an LVN on December 25th documented no skin issues, despite the resident having sustained an injury during a transfer on the day of admission. An observation on January 9th revealed two closed abrasions on the resident's left leg, which were not documented previously. The resident reported falling during a transfer on the admission day, resulting in a leg injury. The LVN was unaware of the injury or fall and had not documented the abrasions. The staff member involved in the transfer stated that the resident's admission paperwork did not indicate the need for a mechanical Hoyer lift, and the resident began to slip during the transfer but did not fall. The RNA involved was unavailable for an interview due to suspension.
Delayed Urinalysis Sample Collection
Penalty
Summary
The facility failed to obtain a physician-ordered urinalysis (UA) sample in a timely manner for a resident. The resident was admitted with multiple diagnoses, including cellulitis, heart disease, anemia, morbid obesity, infection of an unspecified joint, pain, and diabetes with diabetic neuropathy. A physician's order for a UA was dated 1/3/24, but the sample was not collected until 1/10/25. The Director of Nursing Services (DON) confirmed in an interview that the order was executed on 1/10/25, with no reason provided for the delay in obtaining the sample.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities on weekends for two residents and did not assist one resident in attending activities they wished to participate in. Resident #39, who has intact cognitive status and a preference for group activities, was not assisted by staff to get out of bed to attend activities such as bingo, which they expressed a desire to participate in. The resident also mentioned that they were not taken outside to smoke due to their inability to function independently. Resident #58, who has intact cognitive status and a preference for music, books, news, outside activities, and religious activities, reported a lack of activities on weekends. Despite being in the facility for two years, the resident stated that bingo was rarely offered on weekends, leading to boredom. Activity attendance records confirmed that the resident only attended two bingo activities on Saturdays over a three-month period. Resident #78, who also has intact cognitive status and a preference for group activities, religious activities, and music, expressed dissatisfaction with the lack of weekend activities. The resident noted that bingo was not consistently offered on weekends and expressed a desire for church services to be held at the facility on Sundays. The activity attendance records showed that the resident participated in only two weekend activities over three months. Interviews with the Activity Director revealed that weekend activities were not staffed, and only bingo was supervised every other Saturday.
Failure to Supervise Resident Smoking
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by not adhering to its smoking policy, which mandates that residents smoke only in designated areas under staff supervision. Two residents, both with unimpaired cognition, were observed smoking near the facility's front door without supervision. The facility's policy, revised in November 2023, clearly states that smoking is only permitted in designated areas and must be supervised by staff. However, observations on multiple occasions revealed that these residents were smoking unsupervised in non-designated areas. Resident #13, with a medical history of chronic obstructive pulmonary disease and hemiparesis, was observed smoking unsupervised near the facility's front door on several occasions. Despite being aware of the facility's smoking procedures, Resident #13 reported that staff were not adhering to the established smoking times, leading the resident to smoke independently. Similarly, Resident #20, who also has hemiparesis and uses tobacco, was observed smoking unsupervised with Resident #13. The resident reported that the designated smoking area was inaccessible due to snow, forcing them to smoke in non-designated areas. Interviews with facility staff, including an LPN and the Administrator, confirmed that the designated smoking area was the rear patio and that all residents required supervision while smoking. However, the LPN acknowledged the difficulty in monitoring residents due to limited staff availability. The Administrator confirmed the facility's smoking policy but did not provide a clear explanation of how compliance with the policy was ensured. This lack of supervision and adherence to the smoking policy constitutes a deficiency in maintaining a safe environment for residents.
Inadequate Perineal Care Provided to Resident
Penalty
Summary
The facility failed to provide appropriate perineal care to prevent urinary tract infections for one resident. The facility's policy on perineal care, revised in June 2020, outlines specific procedures for cleaning female residents, including washing, rinsing, and drying from front to back using a clean washcloth for each stroke. However, during an observation, a Restorative Nursing Aide (RNA) did not spread the resident's knees apart adequately, which hindered proper cleaning. The RNA claimed that the resident's contracted state prevented proper leg positioning, but a Certified Nurse Aide (CNA) present disagreed, stating that the RNA did not clean the resident properly and could have done better. The resident involved, who was admitted with diagnoses including ventricular tachycardia, overactive bladder, major depressive disorder, and chronic pain syndrome, was cognitively intact and dependent on staff for toileting hygiene. The resident was frequently incontinent for bladder and always incontinent for bowel. The resident's care plan noted behavior issues related to incontinence care, with the resident expressing dissatisfaction with the way staff performed perineal care. In an interview, the resident confirmed dissatisfaction with the care provided, stating that the RNA did not change or wipe them properly and incorrectly applied the brief.
Failure to Administer Prescribed Supplemental Feeding
Penalty
Summary
Facility staff failed to ensure that a resident with a feeding tube received the appropriate treatment and services to maintain nutritional status. The resident, who has a medical history of dementia and a gastrostomy tube, was observed eating only 25% of a lunch meal, yet the staff did not administer the prescribed supplemental tube feeding as per the physician's orders. The orders specified that if the resident consumed less than 50% of meals, Glucerna 1.5 should be administered via the feeding tube, which was not done. Further review of the resident's records showed a pattern of inadequate meal intake without the corresponding administration of the prescribed supplemental feeding. The resident's care flow records indicated low meal consumption on multiple occasions, yet there was no documentation of the PRN Glucerna being administered. An interview with the Director of Nursing revealed that the nursing staff were expected to monitor meal intake and administer the supplemental feeding as needed, which was not adhered to in this case.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to adhere to the prescribed pureed diet menu for two residents, as observed during a meal service. According to the facility's policy on Therapeutic Diets, each food item in a regular diet should be pureed and served separately for residents on pureed diets. On the specified date, the noon menu for residents with pureed diets included pureed BBQ meatballs, mashed potatoes with gravy, pureed buttered peas, pureed brownie, and pureed buttered white bread. However, during the preparation and serving of the meal, the bread was not pureed and served to the residents as required. The Food Services Manager acknowledged that the menu was not followed, resulting in the deficiency.
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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