Sunset Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Maysville, Missouri.
- Location
- 1201 S Polk, Maysville, Missouri 64469
- CMS Provider Number
- 265745
- Inspections on file
- 20
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Sunset Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a high risk for elopement exited the facility undetected and was later found by a nearby business with a fractured arm. Despite protocols requiring door alarms and supervision, a service entry/exit door lacked an alarm and a key was accessible, allowing the resident to leave. Staff did not hear any alarms, and the resident was not located during initial searches, resulting in the resident sustaining an injury outside the facility.
The facility failed to conduct competency assessments for nurse aides as required by their facility assessment, affecting all residents. Seven randomly selected nurse aides did not have competency assessments completed at hire and every 6 months thereafter. The Director of Nursing and Administrator were unaware of the facility assessment's requirement for these assessments.
The facility did not have a Registered Nurse (RN) on duty for eight consecutive hours per day, seven days a week, as required. On certain days, no RN was present for a 24-hour period. The Administrator mentioned a pending waiver application for RN coverage and relied on staffing agencies and an on-call RN system. The facility admitted residents on Medicare services but lacked a policy for RN coverage.
The facility failed to maintain a sanitary kitchen environment and adhere to food safety standards. Observations revealed unsanitary conditions, improper handwashing, and inadequate use of sanitizer solutions. Temperature logs for refrigerators, freezers, and dishwashers were incomplete, and food temperatures were not consistently checked. Additionally, outdated and undated food items were found, and staff lacked proper training in food safety protocols.
The facility failed to maintain consistent code status documentation for two residents, leading to discrepancies between physician orders, paper records, and visual indicators. Staff relied on stickers and charts for code status, resulting in confusion. The Social Services Director and other staff were unaware of the mismatches, which were later acknowledged by the Administrator and DON.
The facility did not follow its policy to conduct NA registry checks before hiring staff, affecting three out of five sampled employees, including a DA, an NA, and the DON. The administrator confirmed that these checks are required for all staff before employment, but they were not completed as expected.
The facility failed to provide written transfer notices to two residents when they were transferred to hospitals. One resident, with no cognitive impairment, was hospitalized after a fall, while another, with moderate cognitive impairment, was admitted for pneumonia. Interviews revealed that transfer forms were not completed as required, and the Social Services Director and Administrator confirmed the oversight.
The facility failed to provide and document a bed hold policy notice for two residents during hospital transfers, despite the policy requiring notification upon admission and transfer. One resident, with no cognitive impairment, was hospitalized after a fall, while another, with moderate cognitive impairment, was hospitalized for pneumonia. The Social Services Director and Administrator acknowledged the oversight, highlighting a deficiency in policy adherence.
The facility failed to provide complete and individualized care plans for residents, missing key diagnoses and activity preferences. A resident's care plan lacked provisions for PTSD, oxygen use, and COPD, while others did not address activity preferences, leading to dissatisfaction with available activities. Staff were unaware of certain resident needs, and activity tracking was insufficient.
The facility failed to update care plans and conduct quarterly meetings, affecting residents' care. A resident's care plan did not reflect discontinued use of weighted utensils, and two residents were not involved in care plan meetings. The DON admitted no meetings had been held since April 2023.
The facility failed to provide meaningful activities for several residents, leading to a deficiency in meeting their individual needs. Residents expressed dissatisfaction with the lack of interesting activities and inadequate communication about scheduled events. Observations confirmed that activities were not consistently offered, and residents were not adequately reminded or assisted to attend them. The Activity Director admitted to not tracking activities with each resident, and the Director of Nursing acknowledged the deficiency, noting that the Activity Director had other tasks that limited their ability to conduct more activities.
The facility failed to ensure proper CPAP administration and maintenance for two residents, lacking physician orders and proper cleaning protocols. One resident's CPAP mask was improperly stored, and another's equipment was undated, with open distilled water containers. Staff interviews revealed a lack of awareness about cleaning requirements and the need for physician orders.
The facility failed to assess residents for bed rail entrapment risks and did not obtain necessary physician's orders or informed consent before installation. This affected several residents, with missing assessments and documentation, indicating a systemic issue in safety protocols and communication.
The facility failed to ensure two nurse aides completed their training within four months of employment. Despite the requirement for nursing staff to have current certifications and for nurse aides to be enrolled in training within 120 days, one aide received certification late, and the other had no certification. Both aides missed classes, and the Administrator was unsure why they remained employed beyond the four-month period.
The facility failed to provide the required twelve hours of annual in-service education for nurse aides, did not conduct annual performance reviews, and lacked a system to track training hours. This affected five out of seven sampled CNAs and potentially impacted all staff and residents. The DON and Administrator were unaware of the deficiencies, and there was no policy for staff education.
The facility failed to serve food at safe and appetizing temperatures, as required by policy. Observations and interviews revealed that food temperatures were not checked before serving, resulting in residents receiving cold meals. Staff lacked training on proper temperature checking procedures.
The facility staff did not ensure that all shower hoses had a back flow preventer device, which is essential to prevent contamination of the potable water supply. An observation revealed that the shower hose in a specific shower room lacked this device, and the Maintenance Supervisor was unaware of the requirement.
The facility's pest control program was ineffective, with gnats in corridors and brown recluse spiders in a sprinkler riser room. Pest control logs lacked specific treatments for these pests. A resident returned from a family outing with a possible spider bite, leading to medical treatment. The facility's staff acknowledged the lack of targeted pest control measures for spiders.
The facility failed to provide the required 12 hours of annual in-service education for nurse aides, including necessary training in Dementia Care and other competencies. This affected several CNAs and potentially all staff and residents. The facility lacked a policy and tracking system for education, and the DON and Administrator were unaware of the deficiencies in training hours and competency requirements.
A facility failed to provide trauma-informed care to a resident with PTSD, lacking a care plan and behavioral interventions. The resident experienced anxiety and nightmares, but was not informed about professional mental health options. Staff interviews revealed reliance on a contracted office for behavioral health appointments and acknowledged the absence of a PTSD care plan.
Failure to Prevent Elopement and Injury of High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a high risk for elopement was able to leave the facility without staff knowledge. The resident, who had diagnoses including dementia, Parkinson's disease, anxiety, depression, bipolar disorder, psychotic disorder, schizophrenia, and PTSD, was assessed as a high elopement risk according to the facility's own assessment tool. Despite this, the resident was last seen by staff in the early morning hours and was later found by a nearby business lying on the ground, having sustained a fractured left arm. The resident was transported to the hospital for evaluation and treatment. The facility's elopement protocol required identification of residents at risk for elopement, use of door alarms, and regular testing of these alarms, as well as staff training on elopement procedures. On the day of the incident, staff did not hear any door alarms, and the resident was not located during initial searches of the building. Interviews and observations revealed that a service entry/exit door in the kitchen area did not have an alarm, and a key was left hanging by the door, which may have allowed the resident to exit undetected. Staff interviews indicated that the resident was last seen in the dining room and at the nurse's station, but there was a gap in supervision that allowed the resident to leave the secured unit. The resident was found outside the facility by a staff member who had joined the search after being notified of the missing resident. The resident was lying on the ground, wet, and complained of pain in the left arm. The incident report and interviews confirmed that the required supervision and environmental safeguards were not sufficient to prevent the resident's elopement and subsequent injury. The facility's failure to ensure all exit doors were properly alarmed and monitored contributed to the resident's ability to leave the premises unnoticed.
Failure to Conduct Required Competency Assessments for Nurse Aides
Penalty
Summary
The facility failed to conduct competency assessments for nurse aides as required by their facility assessment, affecting all residents. Specifically, 7 randomly selected nurse aides did not have competency assessments completed at hire and every 6 months thereafter, as stipulated in the facility's assessment. The facility's assessment outlined that competencies such as person-centered care, activities of daily living, disaster procedures, infection control, medication administration, wound care, measurements, resident assessments and observations, care for residents with dementia, specialized care, and care for residents with mental and psychological disorders should be tested every 6 months and at hire for nursing staff. However, the facility did not provide a policy for competency and education, and the employee files reviewed showed no competency assessments for the year 2024 for any of the selected nurse aides. During an interview, the Director of Nursing (DON) and the Administrator revealed a lack of awareness regarding the facility assessment's requirement for competency assessments every 6 months and at hire. The DON stated that competency assessments were to be completed annually or more often as needed, particularly if there was a concern with care, such as a rise in urinary tract infections. The Administrator mentioned that most education was based on findings from the quarterly Quality Assurance meeting and believed that competency should be completed annually and as needed. Both were unaware of the specific requirements outlined in the facility assessment.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, as required. This deficiency was identified through interviews and record reviews, revealing that there was no RN present in the facility for a 24-hour period on specific dates in July and August. The facility census at the time was 33 residents. The Administrator stated that the facility had applied for a waiver for RN coverage but had not yet received approval from CMS. Despite this, the facility did not have a policy regarding RN coverage and relied on staffing agencies and an on-call RN system. The facility admitted residents on Medicare services, but the Administrator believed there was no care that required an RN on-site at all times.
Facility Fails to Maintain Sanitary Kitchen and Food Safety Standards
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by multiple observations of unsanitary conditions and improper food handling practices. Staff did not consistently wash their hands according to the facility's policy, often turning off faucets with bare hands after washing, and failed to use sanitizer solutions on kitchen surfaces. Additionally, the kitchen was observed to be in a state of disarray, with food debris on the floors, stove, and microwave, and improper storage of dishware and utensils. The facility also failed to ensure that refrigerator and freezer temperatures were checked and logged daily, with gaps in the temperature logs noted. Similarly, the dishwasher's temperature logs were incomplete, and the machine itself was found to be unclean. Staff were observed filling in logs retroactively, raising concerns about the accuracy of the recorded data. Furthermore, food temperatures were not consistently measured or logged during meal preparation and service, with staff failing to check temperatures before placing food on the steam table or serving it to residents. In addition to these deficiencies, the facility did not have policies in place for the proper dating and labeling of food items, leading to the presence of outdated and undated food products in storage. Staff interviews revealed a lack of training and understanding of proper food safety protocols, with some staff members admitting to not receiving adequate training or in-services from the dietary manager. The facility's failure to adhere to professional standards for food service safety poses a significant risk to the health and well-being of its residents.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to accurately reflect the residents' code status in their medical records, affecting two residents. For Resident #185, discrepancies were found between the physician's orders, which indicated a DNR status, and the paper medical record, which showed a full code status. The Social Services Director acknowledged the error and corrected the code status in the physician's orders after realizing the mismatch. Interviews with staff revealed that they relied on stickers on residents' doors and paper charts to determine code status, which led to confusion due to inconsistent documentation. Similarly, for Resident #28, the physician's orders indicated a DNR status, while the paper medical record and the resident's nameplate displayed a full code status. The Social Services Director was unaware of the physician's DNR order and believed the resident was a full code. Staff interviews highlighted reliance on visual indicators like stickers and paper charts for code status, which were inconsistent with the electronic records. The Administrator and Director of Nursing expected code status to be consistent across all records, but acknowledged the discrepancies for these two residents.
Failure to Conduct Required NA Registry Checks Before Hiring
Penalty
Summary
The facility failed to adhere to its written policy requiring a complete background check, including a check of the Nurses Aide (NA) registry, before hiring staff to work with residents. This deficiency was identified for three out of five sampled staff members. Specifically, the personnel files for a Dietary Aide (DA), a Nurses Aide (NA), and the Director of Nurses (DON) lacked evidence of completed NA registry checks prior to their employment. The facility's policy explicitly states that individuals with findings on the state nurse aide registry should not be employed. During interviews, the administrator confirmed that the Business Office Manager is responsible for conducting these checks and that all staff, regardless of their role, should be checked against the NA registry before their first day of employment. However, the checks were not completed as expected, leading to a breach of the facility's policy.
Failure to Provide Transfer Notices to Residents
Penalty
Summary
The facility failed to provide written notice of transfer to two residents, Resident #13 and Resident #14, when they were transferred to local hospitals. Resident #13, who had no cognitive impairment and required substantial assistance with daily activities, was hospitalized after a fall and hip fracture. The resident reported not receiving written notice of the transfer, and there was no documentation of a transfer form in the resident's record. Similarly, Resident #14, who had moderate cognitive impairment and was dependent on staff for daily activities, was transferred to the hospital due to difficulty breathing and other critical symptoms. The resident was admitted for pneumonia, but again, there was no transfer form documented in the resident's record. Interviews with facility staff revealed that the Social Services Director typically completed transfer notices, but if a transfer occurred during weekends or after hours, the responsibility fell to the nurse on duty. It was acknowledged that sometimes the transfer forms were not completed. Both the Social Services Director and the Administrator confirmed that transfer forms should have been completed and provided to the residents and their guardians in a comprehensible language, and documented in the residents' charts. However, this procedure was not followed for Residents #13 and #14.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to document and provide a notice of bed hold policy to two residents, Resident #13 and Resident #14, when they were transferred to local hospitals. The facility's bed hold policy requires that all residents and guardians be notified of bed hold guidelines upon admission and at the time of transfer to the hospital. However, during interviews and record reviews, it was found that Resident #13, who had no cognitive impairment and required substantial assistance for daily activities, was not given a bed hold policy form when hospitalized after a fall and hip fracture. Similarly, Resident #14, who had moderate cognitive impairment and was dependent on staff for daily activities, was not provided with a bed hold policy form when transferred to the hospital for pneumonia. The Social Services Director acknowledged that the bed hold policy was signed upon admission but not completed again during hospital transfers. The Administrator confirmed that the bed hold policy form should have been completed and sent with each resident during hospitalization and expected it to be documented in the resident's chart. The lack of documentation and provision of the bed hold policy form during hospital transfers for these residents constitutes a deficiency in the facility's adherence to its own policy.
Deficiencies in Resident Care Plans and Activity Preferences
Penalty
Summary
The facility failed to ensure that residents had complete, accurate, and individualized care plans to address their specific needs. For Resident #30, the care plan did not include provisions for PTSD, use of oxygen, CPAP, or COPD, despite the resident's diagnoses and needs. Observations showed the resident experiencing symptoms such as shortness of breath, anxiety, and depression, and the resident reported not seeing a mental health professional. A CNA was unaware of the resident's PTSD, indicating a lack of communication and documentation. Resident #2's care plan did not address the resident's activity preferences, despite the resident expressing interest in activities such as bingo and jeopardy. The resident felt there were not enough activities to interest them, and there were no activity notes documented in the progress notes. Similarly, Resident #13's care plan addressed potential social isolation but did not include specific activity preferences, and the resident felt that activities were not geared towards men. Resident #20's care plan also lacked documentation of activity preferences, despite the resident expressing interest in outdoor activities and group participation. The Activity Director acknowledged not tracking activities with each resident and not offering specific activities geared towards men. The facility's Administrator and Director of Nursing expected care plans to include activity preferences and PTSD, but this was not reflected in the care plans reviewed.
Failure to Update Care Plans and Conduct Quarterly Meetings
Penalty
Summary
The facility failed to ensure that care plans were developed and updated in accordance with residents' specific conditions and needs. For one resident, the care plan did not reflect the discontinuation of weighted utensils, despite the resident no longer using them and having no current orders for them. Observations confirmed the resident was using regular silverware, and interviews with staff indicated a lack of awareness about the updated orders. The facility's policy required care plans to be updated with changes, but this was not adhered to. Additionally, the facility did not conduct quarterly care plan meetings for two residents. One resident, who had no cognitive impairment, expressed that they had never been invited to a care plan meeting and wished to participate in their care planning. Another resident, with severe cognitive impairment, was unaware of what a care plan was but expressed a desire to be involved in their care planning. The facility's policy required quarterly care plan meetings, but this was not followed. The Director of Nursing (DON) acknowledged responsibility for writing care plans and coordinating meetings but admitted that no care plan meetings had been held since their employment began in April 2023. This lack of adherence to care planning protocols and meeting schedules resulted in deficiencies affecting the quality of care for the residents involved.
Deficiency in Providing Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities for five of the twelve sampled residents, leading to a deficiency in meeting the individual needs of the residents. The activity policy outlined that activities should be planned and organized to meet the residents' needs, including a variety of activities such as spiritual, physical, emotional, cognitive, sensory, recreational, and work service-related activities. However, observations and interviews revealed that the facility did not adhere to this policy, as residents were not informed or invited to participate in activities, and there was a lack of an activity calendar in common areas or residents' rooms. Resident #17, with severe cognitive impairment, expressed that they did not participate in activities because they were not informed or invited, and the activities offered did not interest them. Similarly, Resident #21, with moderate cognitive impairment, enjoyed playing Bingo but desired more music activities and was not consistently informed about upcoming events. Resident #2, who had moderate cognitive impairment and mobility issues, also reported a lack of interesting activities and the absence of an activity calendar in their room. Observations confirmed that scheduled activities were not consistently offered, and residents were not adequately reminded or assisted to attend them. Resident #13, with intact cognition but dependent on a wheelchair, felt that activities were not geared towards men and lacked access to an activity schedule in their room. Resident #20, with moderate cognitive impairment and multiple health issues, expressed dissatisfaction with the limited activities and the lack of staff to offer individual activities. The Activity Director admitted to not tracking activities with each resident and not having a system for informing bed-bound residents about daily activities. The Director of Nursing acknowledged the deficiency, noting that the Activity Director had other tasks that limited their ability to conduct more activities, and expected more activities to be completed and calendars to be up-to-date.
Deficiencies in CPAP Administration and Maintenance
Penalty
Summary
The facility failed to ensure proper administration and maintenance of CPAP machines for two residents, leading to deficiencies in respiratory care. For one resident, there was no physician order for the use of the CPAP machine, nor were there orders for cleaning or changing the tubing and masks. Observations revealed that the CPAP mask was improperly stored in a gift bag, and there was condensation in the tubing. The resident reported that staff had cleaned the machine and tubing before, but not on a daily basis. For another resident, the facility did not label or date the CPAP machine's tubing and humidifier, and there were open, undated containers of distilled water. The resident's care plan indicated the use of CPAP at night, but the resident frequently refused staff assistance with placement. Observations showed condensation in the mask tubing, and the resident was unsure about the cleaning schedule of the machine. The resident mentioned that the mask and tubing were changed approximately once a month. Interviews with staff revealed a lack of awareness regarding the daily cleaning requirements for CPAP masks and the need for physician orders for CPAP use. The LPN stated that masks were not cleaned daily and were changed monthly. The DON confirmed that CPAP cleaning should follow the manufacturer's guidelines or be done weekly, and distilled water should be dated and used within 30 days of opening. The Charge Nurse was identified as responsible for the cleaning and care of CPAP machines.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility staff failed to properly assess residents for the risk of entrapment from bed rails before their installation. This deficiency was observed in four residents, where the facility did not ensure that the bed's dimensions were appropriate for the residents' size and weight. Additionally, the facility did not complete the required quarterly assessments for side rail and entrapment risks. The absence of these assessments was noted for Residents #20, #13, #14, and #21, indicating a systemic issue in the facility's adherence to safety protocols. Furthermore, the facility did not obtain the necessary physician's orders prior to the installation of bed rails for Residents #20, #13, and #14. Informed consent was also not obtained for Residents #13, #14, and #21. These lapses in protocol highlight a failure in communication and documentation processes within the facility. The lack of informed consent and physician's orders suggests that the facility did not adequately involve residents or their representatives in decisions regarding their care. The facility's policy on bed rails, which includes conducting regular inspections and ensuring compatibility of bed components, was not followed. Interviews with staff, including the Director of Nursing and the Administrator, revealed a lack of awareness and responsibility regarding the completion of entrapment assessments. Maintenance staff also indicated that they had not been involved in the installation or measurement of bed rails, mattresses, or bed frames, further underscoring the facility's failure to adhere to its own policies and procedures.
Failure to Ensure Timely Completion of Nurse Aide Training
Penalty
Summary
The facility failed to ensure that two nurse aides completed a nurse aide training program within four months of their employment, as required. The facility's assessment indicated that nursing staff must have current and verifiable licenses or certifications, and nurse aides should be enrolled in a Certified Nursing Assistant class within 120 days of hire. However, a review of employee files showed that Nurse Aide A, hired on July 6, 2023, did not have a competency evaluation and received certification on May 24, 2024, while Nurse Aide B, hired on March 14, 2024, also lacked a competency evaluation and had no certification issued. The Missouri CNA Registry confirmed that Nurse Aide A's certification was issued on May 24, 2024, and Nurse Aide B was not found in the registry. During an interview, the Administrator acknowledged that two nurse aides were working in the facility, with one certified in the last 90 days, and both were enrolled in online Certified Nurse Aide training. The Administrator was unsure if the Director of Nursing provided competency evaluations before nurse aides had contact with residents. It was noted that Nurse Aide A and B did not complete their classes within the four-month timeframe due to missed classes, and the Administrator was aware of this issue but unsure why the staff were still employed after four months.
Deficiency in Nurse Aide Education and Competency Tracking
Penalty
Summary
The facility failed to conduct at least twelve hours of nurse aide in-service education per year, did not provide annual individual performance reviews or evaluations for nurse aides, and did not implement a tracking system for monitoring training hours. This deficiency affected five out of seven sampled nurse aides and had the potential to impact all staff and residents. The facility's census was 33. The facility did not have a policy regarding staff education, and the review of the facility assessment indicated that competencies were to be tested every six months and at hire for nursing staff, which was not adhered to. During interviews, the Director of Nursing (DON) and the Administrator acknowledged the lack of a tracking system for education and hours of education. The DON was unaware that the facility assessment required competencies to be done every six months, and the Administrator was not aware that staff did not have the required 12 hours of education. The report highlighted that education is typically completed on paydays, and when a staff member misses a meeting, they must meet with the DON or Administrator one-on-one. However, there was no proof of education tracking or completion of required competencies for several CNAs.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that hot food was not served at an appetizing temperature for four of twelve sampled residents. The facility's policy required hot foods to be at least 120 degrees Fahrenheit when served, but this standard was not consistently met. Residents reported that their food was often served cold, and observations confirmed that food temperatures were not checked before serving. During an observation in the kitchen, it was noted that food items were placed on the steam table without temperature checks. The staff member responsible for serving did not check the temperatures of the food on the steam table prior to serving lunch. Interviews with staff revealed a lack of training on proper food temperature checking procedures. The administrator confirmed that food temperatures should be checked before serving, but this was not done, leading to the deficiency.
Lack of Back Flow Preventer on Shower Hose
Penalty
Summary
The facility staff failed to ensure the presence of a back flow preventer device on all shower hoses, which is necessary to prevent toxins from contaminating the facility's potable water supply. During an observation, it was noted that the shower hose in the shower room across from room six lacked this device. In an interview conducted at the same time, the Maintenance Supervisor admitted to being unaware of the requirement for all shower hoses to have a back flow preventer device.
Ineffective Pest Control Program and Potential Spider Bite Incident
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of gnats in the corridors and brown recluse spiders in the sprinkler riser room. The pest control logs did not show any specific treatments for spiders or gnats. During an observation, the surveyor noted at least five living spiders and a dozen dead spiders in various stages of decay in the sprinkler riser room. The Maintenance Supervisor admitted there was no specific routine for spiders in their pest control program, and the Administrator confirmed that their pest control company did not specifically target spiders, acknowledging that general sprays are ineffective against brown recluse spiders. A resident returned from a weekend with family with a red, swollen, and scabbed area on the back of their right calf. The physician assessed the area and suggested it could be an abscess or a spider bite, prescribing Doxycycline and a topical treatment. The Director of Nursing and the Administrator discussed the incident, noting the resident had been away with family, and the physician was uncertain if it was a spider bite. The Administrator acknowledged the uncertainty of the source of the bite, given the resident's time away from the facility.
Deficiency in Nurse Aide Education and Competency Training
Penalty
Summary
The facility failed to conduct at least 12 hours of nurse aide in-service education per year, as required, and did not provide the necessary annual competency training in Dementia Care and other essential areas. This deficiency affected five out of seven sampled nurse aides and had the potential to impact all staff and residents, with the facility's census being 33. The facility did not have a policy for education, and there was no tracking system in place to monitor the completion of required training hours. The facility assessment indicated that competencies should be tested every six months and at the time of hire for nursing staff, covering various critical areas such as person-centered care, activities of daily living, infection control, and caring for residents with dementia. However, a review of employee files and education records showed that several CNAs had no education tracking, and some had not completed the required competencies for 2024. The education records that were available did not indicate the length of education, start, or end times, further highlighting the lack of a structured education program. During an interview, the DON and Administrator acknowledged the absence of a tracking system for education and hours of education. The DON was unaware of the facility assessment's requirements and the lack of sufficient education hours for staff. The Administrator also admitted to not knowing that the facility assessment required competencies to be completed every six months and at the time of hire. Education was typically conducted on paydays, but there was no system to ensure that all staff received the necessary training, especially if they missed scheduled meetings.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident's Admission Minimum Data Set (MDS) indicated no cognitive loss and required setup assistance for Activities of Daily Living (ADLs). Despite having a diagnosis of PTSD, the facility did not have a policy on Trauma Informed Care, and the resident's medical record lacked behavior interventions, a psychiatric evaluation, or a care plan addressing the PTSD diagnosis. The resident expressed feelings of anxiety and distress, mentioning nightmares and a history of trauma, but reported that the facility had not provided any assistance for these issues. Interviews with facility staff revealed further deficiencies in care. The Social Service Director admitted to not arranging behavioral health appointments, relying instead on a contracted office to send a list of residents to be seen monthly. The Director of Nursing acknowledged the resident's PTSD diagnosis and stated that the care plan should have included this diagnosis. The resident was not informed about the option to see a professional for their mental health needs, contributing to their ongoing distress.
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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