Tiffany Springs Rehabilitation & Health Care Cente
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Missouri.
- Location
- 9191 N Ambassador Drive, Kansas City, Missouri 64154
- CMS Provider Number
- 265863
- Inspections on file
- 34
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Tiffany Springs Rehabilitation & Health Care Cente during CMS and state inspections, most recent first.
A resident admitted with a left ankle fracture and a soft cast, and identified as at risk for pressure ulcers, later had a CAM boot applied with orders to keep it on except for hygiene. Nursing documentation repeatedly noted no skin issues other than a Stage I pressure injury on the right great toe, and staff (including an RN, LPN, and CNA) reported they never removed the boot to assess skin or provide hygiene, despite the resident’s ongoing complaints of significant foot pain. The resident stated the boot and underlying sock were never removed for more than two weeks and that staff told them they could not take the boot off. When the resident finally returned to the orthopedic physician after more than three weeks, a large medial ankle/foot ulcer was found, and wound clinic evaluation documented a large unstageable wound with eschar under the CAM boot, which was attributed to the boot not being removed for three weeks. Subsequent surgery revealed a full-thickness ulcer with eschar, partial tendon exposure, and associated hardware infection requiring debridement and hardware removal.
A resident with a signed DNR order did not have their code status accurately updated in the physician orders or medical record banner. When the resident was found unresponsive, staff could not verify the DNR status and performed CPR, with EMS continuing life-saving measures. The failure to update and communicate the resident's code status led to the deficiency.
The facility failed to provide timely lab testing and results for three residents, leading to significant health issues. Two residents were hospitalized with septic shock due to untreated UTIs, as the facility did not carry out lab orders despite repeated communications from hospice staff. Another resident was without psychotropic medication for fourteen days because the pharmacy required lab results, which the facility failed to obtain. This resulted in increased stress and sleep disturbances for the resident.
The facility failed to provide timely laboratory services, resulting in a resident being without psychotropic medication for two weeks due to missing lab results. Several residents with UTI symptoms did not receive timely urine cultures, leading to one resident's hospitalization for sepsis. The facility also lacked necessary lab supplies, further delaying care.
The facility failed to maintain safe food handling practices and a sanitary kitchen environment. Observations showed staff using the same gloves for multiple tasks, leading to potential contamination. The kitchen had significant cleanliness issues, including greasy surfaces and food debris. Staff interviews revealed a lack of training in food safety practices, and the Dietary Manager acknowledged the unsanitary conditions.
The facility failed to provide properly prepared pureed food to residents on a pureed diet. Observations revealed that the pureed sausage served was dry and crumbly, requiring chewing, contrary to the required smooth, mashed potato consistency. Cook1 admitted to not blending the sausage long enough, leading to the deficiency.
The facility failed to provide adequate pain management for three residents, leading to significant deficiencies in care. A resident with severe pain did not receive timely medication, despite clear communication of her pain. Another resident experienced a five-day delay in receiving effective pain management due to an expired prescription and lack of follow-up. A third resident with chronic pain syndrome did not receive scheduled pain medication consistently, affecting her daily activities. Interviews revealed a lack of communication and failure to ensure medication availability.
A resident with chronic pain conditions did not receive prescribed pain medications due to unavailability, and the facility failed to notify the physician. The resident's Norco and lidocaine patch were not administered on several occasions, and there was insufficient documentation of physician notification. Interviews with staff revealed a lack of communication and adherence to protocol, resulting in inadequate pain management for the resident.
A facility failed to conduct a timely PASARR Level II screening for a resident who returned from a psychiatric facility with a new diagnosis of major depressive disorder with severe psychotic symptoms. Despite receiving psychiatric services, the necessary screenings were not initiated, as confirmed by the Social Services Designee and the DON, highlighting a lapse in the facility's process for handling significant changes in residents' conditions.
A facility failed to create a comprehensive care plan for a resident with an ICD, despite the resident's cognitive intactness and specific health needs. The care plan lacked focus on ICD-related interventions, and facility leaders believed no specific plan was needed, assuming staff would call 911 if necessary. This oversight was identified during a review of the resident's EMR.
A resident with Parkinson's and dementia experienced a decline in ADL abilities, which the facility failed to address. Despite being assessed as needing minimal assistance, observations showed the resident struggled with personal hygiene and grooming. Staff interviews confirmed the resident required more help than previously assessed, indicating a need for reassessment of care needs.
A resident with emphysema was observed with an oxygen e-tank standing unsupported against the wall, while connected to an oxygen concentrator. The MDSC confirmed the e-tank should have been secured in its carrier, and the DON stated that e-tanks are to be secured.
A resident with a PICC line for IV antibiotics had their dressing unchanged for 15 days, contrary to the facility's policy of changing it every seven days. The dressing was observed to be partially detached, increasing infection risk. The ADON confirmed the oversight.
A resident with rheumatoid arthritis, chronic pain syndrome, and anxiety did not receive timely administration of medications due to prescription changes, pharmacy delays, and lack of communication with the physician. The facility staff, including the DON and NP, were not adequately informed of the missed doses, leading to a failure in ensuring the resident received her necessary medications.
A facility failed to document the death of a resident and did not include a physician order to release the body. The resident, who had a history of lumbar fracture, congestive heart failure, and COVID-19, experienced respiratory distress and stabilized after oxygen intervention. Despite the family's decision to avoid hospitalization, there was no further documentation after 4:00 AM. Interviews revealed the resident's rapid decline and the absence of hospice care before death. The Medical Director acknowledged the lack of documentation and the missing release order.
A CNA at a LTC facility recorded two videos of a resident without consent, violating the resident's right to privacy. The resident, who had severe cognitive impairment, was filmed in undignified situations. The facility lacked clear policies and training on resident rights and cell phone use, contributing to the incident.
A resident in a long-term care facility was found unresponsive and without a pulse, but CPR was not initiated immediately due to an LPN's incorrect assumption about the resident's code status. Despite being informed by CNAs that the resident was a full code, the LPN delayed CPR until the DON arrived and confirmed the status. The LPN, an agency nurse, had not received proper orientation on emergency procedures, contributing to the delay in life-saving measures.
Failure to Monitor Skin Under CAM Boot Resulting in Unstageable Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to prevent the development of an unstageable pressure injury under a removable medical device for one resident. The facility’s own skin policy required licensed nurses to evaluate skin integrity on admission, weekly, and with significant changes, and required CNAs to observe skin during ADLs and report changes so that licensed nurses could initiate preventive or treatment interventions. On admission from the hospital, the resident had a left ankle fracture, a soft cast/splint applied by the orthopedic surgeon, and no documented skin lesions other than a Stage I pressure injury on the right great toe that was present on admission. The admission MDS identified the resident as at risk for pressure ulcers, with partial to moderate assistance needs for ADLs and diagnoses including ankle fracture, muscle weakness, anxiety, stroke, and dementia. Early nursing documentation repeatedly stated there were no other skin issues besides the right great toe. The resident initially had a soft cast that was not to be removed until an orthopedic follow-up. At the follow-up, the orthopedic physician removed the soft cast and placed a CAM boot on the left ankle, with orders that the boot be left on at all times except for hygiene. Despite this order, multiple nursing staff, including an RN and an LPN, reported they never removed or opened the boot to assess the skin or provide hygiene, stating they believed they should not open it if the order was to leave it in place. A CNA reported the resident complained of a lot of pain in the left foot and that she loosened the boot strap once to assist with pain relief but did not remove the boot. The resident stated that after arriving at the facility, the CAM boot was never removed until the return visit to the physician, that a sock under the boot was left in place for more than two weeks, and that facility staff told the resident they could not take the boot off. The resident reported significant ankle pain but could not distinguish whether it was from the skin or the surgery. When the resident eventually returned to the orthopedic physician after more than three weeks instead of the ordered two-week follow-up, the physician found a medial foot/ankle ulceration measuring approximately 3–6 cm with a fibrous base and mildly erythematous edges. The orthopedic surgeon and wound clinic RN attributed the open wound to the CAM boot not being removed for three weeks, and the wound clinic RN documented a large unstageable wound with eschar on the left ankle/foot measuring 3.3 cm by 3.1 cm by 0.1 cm. The DON acknowledged that, with an order to remove the boot for hygiene, staff should have opened the boot and checked the skin every shift and admitted that the facility did not check the resident’s skin and that this was wrong. The orthopedic surgeon stated it was unacceptable that the boot was not removed and the skin was not checked for three weeks. Subsequent operative documentation showed the resident developed a full-thickness ulcer to the fat layer with large eschar and partial tendon exposure, associated with a hardware infection in the left ankle that required irrigation, debridement, hardware removal, and preparation of the wound bed for a skin graft. The sequence of events shows that, despite the resident’s identified risk for pressure ulcers, the presence of a removable CAM boot, and ongoing complaints of pain, facility staff did not perform periodic skin checks under the device for more than 20 days. Nursing notes during this period continued to document no skin issues other than the right great toe, and staff interviews confirmed that the boot was not removed for skin assessment or hygiene. The NP and Unit Manager both stated they would have expected staff to open the boot and check the skin and pulses, and the Unit Manager stated that an order to check the skin under the boot was not necessary. The failure to follow the facility’s skin monitoring policy and to assess the skin under the CAM boot as ordered for hygiene led to the development of an unstageable pressure injury and subsequent complications documented in the medical record and operative reports.
Failure to Honor Resident's DNR Due to Incomplete Medical Record Update
Penalty
Summary
Facility staff failed to honor a resident's Do Not Resuscitate (DNR) advanced directive when they performed Cardiopulmonary Resuscitation (CPR) and notified Emergency Medical Services (EMS) to complete all life-saving measures. This occurred because the DNR order, although signed by the resident and uploaded to the miscellaneous section of the medical record, was not accurately entered into the physician orders or reflected in the resident's medical record banner. As a result, staff were unable to quickly verify the resident's code status during the emergency. The resident involved was on hospice services, had a diagnosis of lung cancer and depression, and was dependent on staff for all activities of daily living. The resident had intact cognitive skills and had signed a DNR order prior to the incident. However, the admission record did not list an advance directive, and the electronic medical record did not indicate the DNR status. When the resident was found unresponsive, staff checked the available records and, not finding the DNR status, initiated CPR and called EMS, who continued resuscitation efforts until the resident was pronounced deceased. Interviews with staff revealed that the process for updating code status was not consistently followed. Social services had uploaded the DNR and notified nursing to change the code status, but the nurse responsible was interrupted and did not complete the entry. The code status was not updated in the physician orders or on the code status roster, leading to confusion during the emergency. Staff relied on the code status report and the medical record banner, both of which did not reflect the resident's DNR status, resulting in the failure to honor the resident's documented wishes.
Failure to Provide Timely Lab Testing and Results
Penalty
Summary
The facility failed to provide timely lab testing and results for three residents, leading to significant health issues. Two residents were admitted to the hospital with septic shock due to untreated urinary tract infections (UTIs). The facility did not carry out lab orders for one resident, despite the hospice nurse providing new orders for tests such as TSH and C-diff. The resident's condition deteriorated, resulting in hospitalization for sepsis, pneumonia, and a UTI. The resident's representative and hospice staff had repeatedly communicated concerns about the resident's condition and the lack of lab results, but the facility did not act promptly. Another resident experienced a delay in receiving lab results for a UA, which was crucial for monitoring their condition due to a history of UTIs and sepsis. Despite the resident and their spouse requesting a UA to check for a bladder infection, the lab specimen was mishandled, and results were delayed. This resident was also hospitalized for a UTI with sepsis, highlighting the facility's failure to ensure timely lab testing and results. A third resident was without their psychotropic medication for fourteen days because the pharmacy required lab results before dispensing the medication. The facility failed to obtain the necessary lab tests, leaving the resident without essential medication. The resident experienced increased stress and sleep disturbances due to the lack of medication. The facility's inability to coordinate lab services and ensure timely testing and results significantly impacted the residents' health and well-being.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide necessary laboratory services for its residents, resulting in significant delays in obtaining and reporting lab results. This deficiency was evident in the case of a resident who was without their psychotropic medication, clozapine, for fourteen days because the pharmacy required lab results before dispensing the medication. Despite multiple orders for weekly complete blood count with differential (CBCD) labs, the facility did not ensure these were completed, leading to the resident experiencing increased stress, insomnia, and physical discomfort due to the lack of medication. Additionally, the facility did not ensure timely collection and reporting of urine cultures for several residents showing signs and symptoms of urinary tract infections (UTIs). Multiple residents, including those with severe cognitive impairments and those receiving end-of-life hospice care, were affected by the facility's failure to obtain necessary lab tests. In one instance, a resident's condition deteriorated to the point of hospitalization for sepsis and pneumonia, with the hospital identifying a severe infection that had not been addressed due to the lack of timely lab results. The facility also failed to maintain adequate laboratory testing supplies, such as urine specimen containers, which further hindered the ability to collect necessary samples. This lack of supplies, combined with the failure to follow up on lab orders and results, contributed to the facility's inability to meet the residents' healthcare needs effectively. The deficiency in laboratory services was compounded by poor communication and coordination between the facility, the laboratory, and the pharmacy, leading to significant delays in treatment and care for the residents involved.
Deficiencies in Food Handling and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure safe food handling practices, proper labeling, dating, and sealing of food in cold storage, and maintaining a clean and sanitary kitchen environment. Observations revealed that Cook1 was preparing food while wearing the same pair of gloves, touching various surfaces and utensils, and handling food without changing gloves. This practice was observed multiple times, indicating a lack of adherence to proper hand hygiene and glove usage policies. Further observations of the kitchen environment showed significant cleanliness issues. The two-compartment vegetable prep sink had romaine lettuce in one side and dirty blender parts in the other. The standing mixer was uncovered and had dried food on the splash guard. Bulk food tubs were greasy and had food debris, and the walk-in refrigerator and freezer had food debris, cardboard pieces, and ice build-up. The kitchen floor was greasy, with stained grout and food debris pushed against the baseboards. Appliances and shelves were also found to be greasy and covered in food debris. Interviews with kitchen staff revealed a lack of awareness and training regarding safe food handling practices. Cook3 and Cook2 admitted to using gloved hands to handle food without changing gloves or using utensils, and they could not recall receiving food safety education. The newly hired Dietary Manager acknowledged the unsanitary conditions and was in the process of creating new cleaning schedules, but the issues persisted at the time of the survey.
Improper Preparation of Pureed Diet
Penalty
Summary
The facility failed to ensure that residents on a pureed diet received food prepared in the appropriate pureed form. Observations during a kitchen tray line inspection revealed that the pureed breakfast sausage served to residents was dry, crumbly, and had a ground texture rather than the required smooth, mashed potato consistency. This inconsistency in food texture was confirmed during an evaluation of a test tray with the Dietary Manager, who acknowledged that the pureed sausage was not prepared correctly and required chewing to be swallowed. The deficiency was attributed to Cook1, who admitted to not blending the sausage long enough to achieve the desired smooth texture. The facility's recipe for pureed sausage links specified that the ingredients should be blended until a smooth, mashed potato consistency was reached, which was not adhered to in this instance. The failure to properly prepare the pureed sausage had the potential to cause issues such as choking, aspiration, malnutrition, weight loss, or dissatisfaction with meals for the residents on a pureed diet.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for three residents, leading to significant deficiencies in care. Resident 107, who was cognitively intact and experiencing severe pain, did not receive timely pain medication despite having a documented pain level of 10. The resident expressed ongoing pain and a desire for hospice care due to inadequate pain management. Interviews with the Director of Nursing (DON) and Nurse Practitioner (NP) revealed a lack of communication and failure to schedule pain medication appropriately, despite the resident's clear communication of her pain. Resident 82, who was also cognitively intact, experienced a delay in receiving effective pain management for five days. The resident's pain medication prescription had expired, and there was a lack of follow-up to obtain a new prescription. The resident reported significant pain and a lack of timely intervention, which was confirmed by staff interviews. The DON acknowledged the absence of a pain management policy and the failure to document follow-up on the resident's pain management. Resident 4, with a history of rheumatoid arthritis and chronic pain syndrome, did not receive scheduled pain medication consistently. The resident reported daily pain and missed doses of her prescribed medication, which affected her daily activities. Interviews with the DON and NP highlighted a lack of communication and failure to ensure the availability of pain medication. The NP was unaware of the missed doses and emphasized the importance of notifying him to prevent such occurrences. The facility's failure to manage pain effectively for these residents demonstrates a significant deficiency in care.
Failure to Notify Physician of Unavailable Pain Medications
Penalty
Summary
The facility failed to notify the physician when pain medications were unavailable for a resident, leading to missed doses of prescribed pain management. The resident, who was moderately cognitively impaired, suffered from chronic pain conditions including polymyalgia rheumatica, rheumatoid arthritis, and chronic pain syndrome. Despite having orders for Norco and a lidocaine patch, the medications were not administered on multiple occasions due to unavailability, and there was insufficient documentation to confirm that the physician was notified of these missed doses. Interviews with the facility's staff, including the Director of Nursing, Infection Preventionist/Assistant Director of Nursing, and Nurse Practitioner, revealed that the expected protocol of notifying the physician and documenting follow-up actions was not followed. The Nurse Practitioner was unaware of the missed doses and stated that he would have taken necessary actions to ensure the resident received the required pain medication. The lack of communication and documentation contributed to the resident not receiving adequate pain management.
Failure to Conduct Timely PASARR Level II Screening
Penalty
Summary
The facility failed to ensure a resident, who initially had a negative Preadmission Screening and Resident Review (PASARR) Level I, was accurately and timely referred for a PASARR Level II after experiencing a significant change in status with a new diagnosis of serious mental illness. The resident, identified as R29, was admitted with acute heart failure and later placed on a psychiatric hold, returning with a diagnosis of major depressive disorder with severe psychotic symptoms. Despite receiving psychiatric services upon return, a new Level I PASARR Screen was not conducted, which was necessary due to the change in the resident's mental health status. Interviews revealed that the facility lacked a policy on PASARR, and the Social Services Designee (SSD) acknowledged the oversight, stating that a new Level I and subsequent Level II screening should have been initiated upon the resident's readmission. The Director of Nurses (DON) confirmed that the resident should have been treated as a new admission following the psychiatric hospital stay, indicating a lapse in the facility's process for handling significant changes in residents' conditions.
Failure to Develop ICD Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive, patient-centered care plan for a resident with an Implantable Cardioverter Defibrillator (ICD). The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, was admitted with diagnoses including chronic heart failure and an ICD. Despite these conditions, the care plan did not include any focus area or interventions related to the ICD, which is crucial for managing the resident's health needs. The deficiency was identified during a review of the resident's electronic medical record (EMR), which showed no mention of the ICD in the care plan. The facility's cardiac nurse practitioner had seen the resident for a cardiac follow-up, and plans for ICD interrogation were discussed with the nursing staff. However, during an interview, the Medical Director and the Director of Nursing stated that the resident did not need a specific care plan for the ICD, as staff would know to call 911 if an issue arose. This oversight in care planning could potentially lead to harm, as it does not address the specific precautions and interventions necessary for residents with ICDs.
Resident's Decline in ADL Abilities Not Addressed
Penalty
Summary
The facility failed to maintain the current abilities of a resident, identified as R80, in performing activities of daily living (ADLs). R80, who was admitted with diagnoses including Parkinson's disease, dementia, and major depressive disorder, was observed to have declined in self-care abilities. Despite being coded as independent to needing set-up assistance for ADLs in the Minimum Data Set (MDS), observations revealed that R80 struggled with personal hygiene tasks such as shaving and nail care. Interviews with staff, including a Certified Nurse Assistant (CNA) and the Assistant Director of Nursing (ADON), confirmed that R80 required more assistance than previously assessed, indicating a decline in his ability to perform ADLs independently. The resident was found with unkempt hair, long and dirty fingernails, and a soiled appearance, suggesting inadequate grooming and personal care. The ADON acknowledged that R80 needed grooming assistance and a reassessment of his care needs. Despite the resident's insistence on performing ADLs independently, staff interviews revealed that he required more help than he was receiving. The Director of Nursing (DON) and MDS Coordinators also recognized the need for a reassessment to accurately reflect R80's current abilities, as his previous assessments did not align with his present condition.
Unsafe Storage of Oxygen E-Tank
Penalty
Summary
The facility failed to safely store an oxygen emergency tank (e-tank) for a resident who was reviewed for respiratory care. The resident, who was admitted with a diagnosis of emphysema, was observed asleep in a wheelchair and connected to an oxygen concentrator via nasal cannula tubing. During the observation, the e-tank was found standing against the wall unsupported, with the oxygen carrier nearby. The Minimum Data Set Coordinator confirmed that the e-tank should have been in the carrier and was indeed unsupported. The Director of Nursing also stated that e-tanks are required to be secured.
Failure to Change PICC Line Dressing Timely
Penalty
Summary
The facility failed to ensure the timely change of an occlusive dressing on a peripherally inserted central catheter (PICC) line for a resident receiving intravenous (IV) antibiotics. The facility's policy required that the dressing be changed every seven days to prevent infection. However, for one resident, the dressing was observed to be dated 15 days prior, indicating it had not been changed as required. This oversight was confirmed by the Assistant Director of Nursing (ADON), who acknowledged that the dressing was not occlusive and should have been changed every seven days. The resident in question was admitted with a diagnosis of arthritis due to bacteria in the right knee and wrist and was receiving Ceftriaxone intravenously for septic arthritis. The resident's care plan included monitoring the PICC line site for signs of infection but did not specify the need to change the dressing every seven days. During an observation, the dressing was found to be partially detached and not adhering to the skin, increasing the risk of infection and complications. The ADON confirmed the lapse in following the facility's policy for dressing changes.
Failure to Administer Medications Timely for a Resident
Penalty
Summary
The facility failed to ensure timely administration of medications for one resident, identified as R4, which put her at risk of complications. R4, who was moderately cognitively impaired, had diagnoses including rheumatoid arthritis, chronic pain syndrome, and anxiety. She was admitted to the facility and required scheduled pain medication. However, there were multiple instances where her medications were not administered as ordered. Specifically, R4 missed doses of Hydrocodone/acetaminophen, Lidoderm Patch, and Ativan due to issues such as prescription changes, pharmacy delays, and lack of notification to the physician for new prescriptions. Interviews with facility staff, including the Director of Nursing (DON), Infection Preventionist/Assistant Director of Nursing (IP/ADON), and Nurse Practitioner (NP), revealed a breakdown in communication and procedure. The DON acknowledged that narcotic medications required a written prescription to be accessed from the emergency medication kit, and staff were expected to notify the physician of unavailable medications. However, the NP and IP/ADON were not informed of the missed doses, and there was insufficient documentation to confirm notifications were made. The NP expressed that he was unaware of the situation and emphasized that medication should have been available through the emergency kit, indicating a failure in the process to ensure R4 received her necessary medications.
Failure to Document Resident Death and Release Order
Penalty
Summary
The facility failed to document the death of a resident, identified as R115, and did not include a physician order to release the body. This deficiency was identified during a review of the facility's policy on charting and documentation, which requires detailed documentation of a resident's condition, treatments, and events surrounding their death. R115 was admitted with diagnoses including a lumbar fracture, congestive heart failure, and COVID-19. On the day of the incident, a Nursing Progress Note indicated that at 4:00 AM, R115 was experiencing respiratory distress with oxygen saturation below 90%, which stabilized after increasing oxygen flow. Despite these interventions, the resident showed signs of distress, and the family was informed of the condition, opting to avoid hospitalization. There was no further documentation in the Nursing Progress Notes after 4:00 AM regarding R115's condition or subsequent death. Interviews with the Assistant Director of Nursing and the Medical Director revealed that the resident's condition was declining rapidly, and a family meeting was needed. The Medical Director had written a comfort measures order, but hospice care was not initiated before the resident's death. The Medical Director acknowledged the lack of documentation and the absence of an order to release the body to the funeral home, which was a deviation from the facility's policy.
Unauthorized Video Recording of Resident Violates Privacy
Penalty
Summary
The facility failed to maintain a resident's right to personal privacy when a Certified Nurse's Aide (CNA) used a personal cell phone to record two videos of a resident without consent. The first video showed the resident lying in bed, and the second video captured the resident with glasses on upside down. The facility did not provide the requested policy regarding resident rights or video recording of residents, and the CNA admitted to recording the videos without obtaining consent from the resident, the resident's responsible party, or the administrator. The resident involved had severe cognitive impairment and was diagnosed with Alzheimer's Disease, diabetes mellitus, and high blood pressure. The resident's care plan emphasized honoring the resident's preferences, and the admission agreement highlighted the resident's right to refuse being photographed or videotaped. Despite these stipulations, the CNA recorded the videos and shared them with siblings to demonstrate work activities, violating the resident's privacy and dignity. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed a lack of clear policies and training regarding resident rights and the use of cell phones for recording. The facility's employee handbook prohibited the use of cell phones during duty and required explicit permission for taking photographs or recordings. However, the CNA was not educated on these policies, leading to the unauthorized recording of the resident, which was deemed undignified and a violation of the resident's right to privacy.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to perform life-saving measures, including CPR, for a resident who was found unresponsive and without a pulse or respirations. The resident was identified as a full code, meaning that life-saving measures should have been initiated immediately. However, the Licensed Practical Nurse (LPN) on duty did not start CPR or instruct the Certified Nursing Assistants (CNAs) to do so, despite being informed multiple times by the CNAs that the resident was a full code. The LPN incorrectly assumed the resident was on hospice and a Do Not Resuscitate (DNR) status, leading to a delay in initiating CPR. The Director of Nursing (DON) was notified by the LPN about the resident's condition and arrived at the scene approximately five to ten minutes later. Upon arrival, the DON confirmed the resident's full code status and instructed the CNAs to begin chest compressions while preparing the crash cart. The DON had to demonstrate the use of the Ambu bag to the LPN, indicating a lack of familiarity with emergency procedures. Emergency Medical Services (EMS) arrived and took over the resuscitation efforts, but the resident was pronounced dead shortly after. Interviews with staff revealed that the LPN was an agency nurse who had not received proper orientation on the facility's emergency procedures, including the location of the crash cart and how to determine a resident's code status. The LPN admitted to having difficulty in the past with identifying residents' code statuses due to discrepancies in the medical records. The facility's failure to ensure that all staff, including agency nurses, were adequately trained and familiar with emergency protocols contributed to the delay in providing life-saving measures to the resident.
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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