Village Care Center Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Maryville, Missouri.
- Location
- 810 East Edwards Street, Maryville, Missouri 64468
- CMS Provider Number
- 265643
- Inspections on file
- 16
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Village Care Center Inc during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia, chronic pain, and behavioral symptoms became agitated, cried, and attempted to disrobe while staff were providing toileting and dressing care. An RN used a raised and harsh tone, grabbed the resident’s forearm, made demeaning comments including comparing the resident’s behavior to that of a baby, and threatened to tell the resident’s spouse about the disrobing. When a CMT offered to stay with the still-upset resident to calm them, the RN refused and instead took the resident to the dining room so others could see the behavior, reportedly jerking the wheelchair back and forth and making comments likening the resident to a “bucking bronc” or “ride’em cowgirl.” The facility’s investigation, supported by multiple witness statements and the RN’s own account, substantiated verbal abuse and inappropriate physical handling that did not follow the resident’s care plan for calm, reassuring approaches to dementia-related behaviors.
The facility did not ensure that the Dietary Manager had the necessary certifications or knowledge of required qualifications for the role. The DM had not completed or enrolled in any dietary manager certification courses and was unaware of the certification requirements. The facility also lacked a policy specifying the qualifications for the DM position, and the Administrator confirmed the DM was serving in an interim capacity while recruitment for a qualified candidate continued.
Staff failed to maintain food safety and sanitation standards by not recording or acting on low dishwasher and refrigeration temperatures, not washing hands between tasks, and not labeling or sealing food items. The kitchen was observed to be unclean and in disrepair, and food storage practices were inadequate, with missing dates and spoiled items present.
Staff did not consistently use PPE or follow infection control protocols during high-contact care activities, blood glucose monitoring, and insulin administration. For example, a resident with a suprapubic catheter and wound dressing received care without staff donning required gowns and gloves, and hand hygiene was not performed as per policy. In other cases, staff failed to wear gloves when obtaining blood sugar samples and did not clean insulin pen ports with alcohol wipes before attaching needles, despite being aware of the correct procedures.
Two residents, both cognitively intact and independent, were found with medications at their bedside without proper assessment, care plan documentation, or physician's orders authorizing self-administration. Staff interviews confirmed that medications should not be left in resident rooms without appropriate authorization and assessment.
The facility did not use the correct, current SNFABN form to notify two residents about Medicare coverage and potential financial liability, instead providing an outdated form. The facility also lacked a policy for ABN use, and the Administrator confirmed that the responsible Social Services staff member was new and should have used the correct forms.
Staff did not provide complete perineal care or adequate morning hygiene for two dependent residents, including not separating and cleaning all skin folds, reusing the same area of a wipe on different skin areas, and failing to offer oral care or wash the face and hands before breakfast. Interviews confirmed staff were aware of proper procedures but did not follow them.
Staff did not consistently follow proper procedures for using a mechanical lift during transfers of two residents who required maximum assistance, resulting in the lift being operated with its legs closed instead of open as required by facility policy and manufacturer guidelines. This failure was observed multiple times and confirmed by staff interviews, affecting residents with significant physical and cognitive impairments.
Staff did not follow proper procedures for oxygen administration for three residents, including leaving excess oxygen tubing on the floor, not dating tubing, and failing to fill humidifier bottles with distilled water. Interviews confirmed that these actions were not in line with facility policy or physician orders, resulting in improper respiratory care.
The facility did not properly assess, document, or obtain physician orders for bed rail use for three residents with mobility impairments and multiple diagnoses. Bed rails were installed without complete assessments, including missing bed measurements and resident size documentation, and were not consistently addressed in care plans. Staff interviews confirmed that physical therapy recommended bed rails without performing required assessments, and the administrator acknowledged the lack of necessary documentation and care planning.
The facility did not ensure that all nurse aides completed or were enrolled in a state-approved training and competency evaluation program within four months of hire, as required by policy and regulations. This was confirmed through employee record review and administrator interview.
Staff failed to maintain a medication error rate below 5%, with three errors out of 25 opportunities involving two residents. Errors included not measuring topical medication doses, improper hand hygiene, incorrect administration of nasal spray, use of the wrong eye drops, and failure to follow proper eye drop technique, as confirmed by both the CMT and DON.
The facility failed to maintain a safe, clean, and comfortable environment, with multiple areas showing chipped paint, exposed wood, and damaged sheetrock. Additionally, the only drinking fountain was non-functional, and the staff was unaware of the requirement to maintain it.
The facility failed to maintain accurate and individualized care plans for three residents, leading to multiple falls, improper medication management, and dietary non-compliance. Staff were unaware of necessary care plan updates, resulting in inadequate resident care.
A resident with a history of falls, severe cognitive impairment, and medication use for anxiety and pain sustained three falls within a week, resulting in a hematoma. The resident's care plan was not updated to include new interventions, and the resident's room was far from the nurses' station, increasing the risk of further falls.
Verbal Abuse and Rough Handling of Cognitively Impaired Resident During Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from mental and physical abuse during the provision of care. The resident had dementia, chronic kidney disease, anemia, diabetes, anxiety disorder, chronic back pain that could worsen with movement, and a history of recent hospitalization for altered mental status. The resident’s care plan directed staff to approach slowly and calmly with clear instructions, to give space and perform cares later if the resident became overwhelmed or upset, to use gentle reassurance, reduce noise and distractions, and to keep the resident’s routine consistent. The care plan also instructed staff to monitor for nonverbal signs of pain and for acute changes from baseline dementia behaviors. On the day of the incident, the resident was observed in a common area attempting to disrobe and refusing medications. RN A and another nurse placed the resident in a wheelchair and transported the resident to the room, where RN A, a CNA, and a CMT were involved in toileting and dressing. Witness accounts and the facility’s investigation documented that the resident was yelling, crying, and repeatedly attempting to remove clothing while staff were providing care in the bathroom. During this time, RN A used a raised, harsh, or firm tone, grabbed the resident’s forearm while telling the resident to stop and “knock it off,” and made demeaning statements, including calling or referring to the resident as a baby in response to crying and biting behavior. RN A also verbally threatened to call the resident’s spouse to report that the resident was trying to be naked in front of everyone, which a witness described as causing the resident to cry more. After toileting and dressing, the resident remained visibly upset and continued trying to disrobe. A CMT offered to stay with the resident to help calm the resident, but RN A declined and stated that the resident needed to go to the dining room so others, including management, could see the behaviors RN A had to deal with. While transporting the resident in the wheelchair, a witness reported that RN A shook or jerked the wheelchair forward and backward several times and made a comment likening the resident to a “bucking bronc,” while RN A acknowledged making a similar “ride’em cowgirl” remark during wheelchair maneuvering. The facility’s investigation, based on multiple consistent witness statements and RN A’s own statements, concluded that RN A used demeaning and humiliating language, raised and harsh tones, threats of public shaming, and physical handling inconsistent with safe and respectful standards, including jerking the wheelchair and grabbing the resident’s forearm, which caused emotional distress to the resident even though no physical injury was identified on assessment. The facility’s abuse policy defined abuse as willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and included mental abuse such as humiliation, harassment, threats of punishment, or deprivation. The policy required immediate removal of a resident from a harmful environment and prompt reporting of suspected abuse. In this incident, the actions attributed to RN A—demeaning language, threats to involve the resident’s spouse to shame the resident for disrobing, refusal to allow a staff member to remain with the resident to calm them, and intentional public exposure of the resident’s distressed behavior in the dining room—were determined by the facility’s investigation to constitute verbal abuse and inappropriate physical handling. These actions did not follow the resident’s individualized care plan strategies for managing behavioral symptoms and dementia-related distress and resulted in the substantiated finding of abuse.
Dietary Manager Lacks Required Certification and Competency
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the appropriate competencies and skill sets required to carry out the functions of the food and nutrition service. The DM, who had worked at the facility for ten years and served as the DM for one year, reported not having any dietary manager certifications, was unaware of the required certifications for the position, and was not currently enrolled in any certification courses. The DM also indicated a need to coordinate with the facility's contracted dietician, who visits once a month, to make a plan for enrolling in dietary certification classes. The facility did not provide a policy outlining the qualifications for the DM position. The Administrator confirmed that the DM was serving in an interim capacity, acknowledged the need for the DM to complete the required dietary management course, and stated that efforts to fill the position with a qualified candidate had been ongoing.
Failure to Maintain Food Safety and Sanitation Standards in Dietary Services
Penalty
Summary
The facility failed to prepare and serve food in accordance with professional standards for food service safety. Staff did not consistently keep records of dishwasher temperatures and chemical tests, nor did they cease using the dishwasher when temperatures did not meet required levels. There were also missing daily records of refrigerator and freezer temperatures. Observations revealed that staff did not wash hands between tasks or glove changes, and food items were not consistently labeled or dated upon receiving or opening. The kitchen environment was not maintained in a clean and sanitary condition, with visible grime on equipment and areas in disrepair. Multiple observations showed staff using gloved hands to perform various tasks without washing hands in between, such as turning on faucets, handling food, and using oven mitts. Staff also failed to wash hands before donning new gloves or after cleaning workstations. Food storage practices were inadequate, with numerous items in refrigerators and freezers lacking received or opened dates, and some opened items were unsealed, wilted, or browning. Temperature logs for refrigeration units were incomplete for several days, and food items were not properly rotated or discarded when spoiled. Dishwasher temperature logs were missing for multiple days, and recorded temperatures were consistently below required levels for both wash and rinse cycles. Despite these low temperatures, the dishwasher continued to be used, and staff did not consistently switch to hand washing dishes as required by policy. The facility did not provide the requested dishwasher user manual, and there was confusion among staff regarding the correct temperature standards for the dishwasher. Maintenance issues with the hot water heater were noted, but the problem persisted, and the facility's policies for food safety and sanitation were not followed.
Failure to Follow Infection Control Protocols and Proper PPE Use
Penalty
Summary
Staff failed to consistently follow infection prevention and control protocols, including the use of personal protective equipment (PPE), hand hygiene, and proper procedures for blood glucose monitoring and insulin administration. Certified Medication Technicians (CMTs) and Certified Nurse Aides (CNAs) did not wear gowns and gloves as required during high-contact care activities for a resident with a suprapubic catheter and a wound dressing. Observations showed that staff did not wash or sanitize their hands before donning gloves, between glove changes, or after providing care, and did not always use PPE when handling bodily fluids or medical devices. Interviews revealed confusion among staff regarding when to use Enhanced Barrier Precautions (EBP) and what PPE was required, with some staff believing gowns and gloves were only necessary for wound or catheter care. In another instance, a CMT failed to wear gloves while obtaining a blood sugar sample from a resident, contrary to facility policy. The CMT also did not wash hands before the procedure. The resident did not have a physician's order for blood sugar monitoring, but the focus of the deficiency was on the lack of glove use and hand hygiene during the procedure. The DON confirmed that gloves should be worn when obtaining blood sugars, but the CMT reported not being taught this requirement. Additionally, staff did not follow proper protocol for insulin pen use for three residents. CMTs were observed attaching needles to insulin pens without first cleaning the rubber port with an alcohol wipe, as required by facility policy. This occurred during insulin administration for residents with diabetes. Interviews with staff confirmed awareness of the correct procedure, but it was not followed during the observed events. The DON also stated that insulin ports should be cleaned with an alcohol wipe before needle attachment.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that staff obtained physician's orders and properly assessed residents for the safe self-administration of medications to be kept at the bedside for two of twelve sampled residents. For one resident, who was cognitively intact and independent with activities of daily living, diclofenac sodium topical gel and Latanoprost eye drops were found on the bedside table. The resident reported being told by staff that these medications could be kept in the room for self-administration. However, the care plan did not reflect the resident's ability to self-administer these medications, and there were no physician's orders authorizing the medications to be kept at bedside for self-administration. For another cognitively intact and independent resident, three pills and Scalpicin cream were observed on the bedside table. The resident stated that the nurse left the items there but was unsure of the reason. The care plan did not address the resident's ability to self-administer these medications, and there were no physician's orders for the medications or for keeping them at bedside. Staff interviews confirmed that medications should not be left in resident rooms without proper orders and assessment, and that any such medications found should be reported and removed unless authorized.
Failure to Use Correct SNFABN Form and Lack of ABN Policy
Penalty
Summary
The facility failed to provide residents with the correct Skilled Nursing Facility Advance Beneficiary Notice of non-coverage (SNFABN) form, which is required to inform residents about their Medicare coverage and potential financial liability for services not covered. Specifically, for two of the twelve sampled residents, the facility used an outdated ABN form (CMS-R-131) that had expired, and this form was signed by the residents. Additionally, the facility did not have a policy in place for the use of ABNs. The Notice of Medicare Non-coverage (NOMNC) was provided and signed, but the correct and current SNFABN form was not utilized. During an interview, the Administrator acknowledged that the Social Services staff member responsible was new to the position and confirmed that the correct forms should have been used.
Failure to Provide Complete Perineal and Morning Care for Dependent Residents
Penalty
Summary
Staff failed to provide complete perineal care and adequate assistance with activities of daily living (ADLs) for two dependent residents. For one resident with severe cognitive impairment, upper and lower extremity limitations, bowel incontinence, and a suprapubic catheter, staff did not wash their hands before donning gloves, did not separate and clean all skin folds during perineal care, and used the same area of a wipe to clean different areas of the buttocks. Additionally, the resident was not offered or provided oral care, nor were their face and hands washed before being taken to breakfast. For another resident with intact cognition but impaired lower extremities, bowel and bladder incontinence, and multiple chronic conditions, staff did not separate and clean all areas of the skin where urine had touched during a bed bath after the resident urinated. The resident required substantial assistance with all ADLs and was dependent on staff for transfers and hygiene, but the care provided did not meet the facility's policy requirements for thorough perineal care. Interviews with the involved staff confirmed that they did not follow proper procedures for perineal care, including separating and cleaning all skin folds and not reusing the same area of a wipe. The DON also confirmed that staff should have provided oral care, washed the residents' face and hands before breakfast, and ensured all areas exposed to urine or feces were properly cleaned.
Improper Mechanical Lift Use During Resident Transfers
Penalty
Summary
Staff failed to follow proper procedures for using a mechanical lift when transferring two residents, as observed during multiple instances. According to the facility's policy and the manufacturer's guidelines, the legs of the mechanical lift should be in the maximum open position for stability when raising or lowering a resident, and at least two nursing assistants are required for safe operation. However, staff were repeatedly observed raising and lowering residents with the lift's legs in the closed position, contrary to both facility policy and manufacturer instructions. One resident involved had severe cognitive impairment, upper and lower extremity impairments, was dependent on staff for all activities of daily living, and had a suprapubic catheter. The other resident had intact cognitive skills but was dependent on staff for transfers and toileting due to bilateral lower extremity impairment and multiple chronic conditions, including CHF, COPD, diabetes, and renal insufficiency. Both residents required maximum assistance and the use of a mechanical lift for transfers, as documented in their care plans. Interviews with staff confirmed inconsistent understanding and application of the correct procedure for operating the mechanical lift, with some staff stating the legs should be closed during raising or lowering, while others correctly identified that the legs should be open. The Director of Nursing also confirmed that the legs should be open during these operations. These actions and inactions resulted in a failure to ensure the area was free from accident hazards and that adequate supervision and proper techniques were used to prevent accidents during resident transfers.
Failure to Maintain Safe and Appropriate Oxygen Administration Practices
Penalty
Summary
Staff failed to provide proper respiratory care for three residents by not maintaining oxygen tubing and humidifier bottles according to facility policy and physician orders. For one resident with multiple diagnoses including lung and kidney disease, observations revealed that oxygen tubing was not dated, excess tubing was left coiled on the floor, and the humidifier bottle was empty on multiple occasions. Another resident, who was independent with ADLs and had diagnoses such as heart failure and respiratory failure, was observed with excess oxygen tubing coiled on the floor. A third resident with conditions including debility, anemia, and respiratory failure also had excess oxygen tubing coiled on the floor during multiple observations. In one case, the care plan did not include information regarding oxygen use despite physician orders for regular tubing changes and dating. Interviews with staff confirmed that oxygen tubing should not be on the floor, should be stored on the concentrator, and that humidifier bottles should be filled to the appropriate level and checked daily. The facility's own policy required water in the humidifying jar and proper anchoring of tubing to prevent irritation. These failures resulted in improper respiratory care for the affected residents.
Failure to Assess, Document, and Care Plan Bed Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of bed rails for three residents, resulting in deficiencies related to resident safety and regulatory compliance. For one resident with cognitive intactness and significant lower extremity impairment, U-shaped bed rails were observed on both sides of the bed. There were no physician's orders for the use of side rails, and the positioning device assessment lacked documentation of bed measurements or the resident's height and weight. Although the care plan noted the use of positioning wands and indicated that risks and benefits were reviewed, the assessment was incomplete. Another resident, also cognitively intact and independent with ADLs but with upper extremity impairment, was observed with a U-shaped rail on the left side of the bed. The care plan reflected the resident's request for a handrail, and an assessment was performed, but again, there were no physician's orders and no documentation of bed measurements or the resident's physical dimensions. The resident reported using the rail due to inability to use one arm. A third resident with multiple diagnoses, including skin cancer and kidney disease, was observed with a U-shaped rail on the left side of the bed. The care plan did not address the use of the positioning bar, and there were no physician's orders for its use. Interviews with staff revealed that physical therapy recommended and placed bed rails but did not perform assessments or measurements, and the administrator confirmed that assessments, physician's orders, and care planning for positioning rails were required but not completed. These actions and omissions led to the cited deficiencies.
Failure to Ensure Nurse Aide Training and Competency Within Required Timeframe
Penalty
Summary
The facility failed to ensure that nurse aides met the minimum qualifications required by federal and state regulations, specifically regarding completion of a state-approved nurse aide training and competency evaluation program within four months of hire. The facility's policy, revised in May 2019, states that nurse aides must complete such training and evaluation, and that those who do not may be terminated or reassigned to non-nursing duties. Despite this policy, a review of the employee list revealed that several nurse aides had been employed for varying lengths of time, but there was no documentation provided to confirm that all had completed or were enrolled in the required training within the specified timeframe. During an interview, the Administrator acknowledged that nurse aides should be enrolled in Certified Nurse Aide (CNA) classes within four months of their hire date. However, the report did not provide evidence that this requirement was consistently met for all nurse aides listed, indicating a lapse in adherence to both facility policy and regulatory requirements. The facility census at the time was 35 residents.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
Facility staff failed to maintain a medication error rate below five percent, as required by policy, resulting in a 12% error rate with three errors out of 25 observed opportunities. The errors involved two residents and were identified through direct observation, interviews, and record reviews. The facility's policies on medication and treatment orders, administering medications, and administering topical medications outline specific procedures for safe and accurate medication administration, including hand hygiene, correct dosing, and adherence to prescriber and manufacturer instructions. For one resident, a Certified Medication Technician (CMT) did not wash hands before or after applying Diclofenac gel, did not measure the correct dose, and applied an unknown amount of the medication. The CMT admitted to not always being able to find the measuring device and acknowledged that the gel should be measured, as confirmed by the Director of Nursing (DON). For another resident, the CMT failed to follow proper procedures for administering Flonase nasal spray and artificial tears. The CMT did not close one nostril during nasal spray administration, used the wrong eye drop (Visine instead of artificial tears), and touched the tip of the dropper to the resident's eyelashes, which is against protocol. The CMT also did not apply lacrimal pressure after administering the eye drops. Both the CMT and DON confirmed these actions were not in accordance with facility policy or manufacturer guidelines.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents. Observations revealed multiple areas with chipped paint, exposed wood, and damaged sheetrock in various rooms and hallways. Specific issues included scuff marks on doors, bent metal frames on fan heaters causing sharp protrusions, and exposed screws on sliding bathroom doors. Additionally, a mattress in one room had its protective coating peeling off, exposing the foam underneath. The Maintenance Supervisor acknowledged the need for repairs and mentioned working on a schedule of repairs and audits. The Administrator was also aware of the issues and had a list of needed repairs by room, along with a performance improvement plan for building repairs. The facility also failed to maintain the only drinking fountain, which was non-functional. The Administrator and Director of Nursing were unaware that the water fountain needed to be maintained and in good repair, as they believed a hydration station set up near the activity room was sufficient. They did not realize that a State tag required the water fountain to be operational and had not received or submitted approval for an exception to the regulation.
Failure to Maintain Accurate and Individualized Care Plans
Penalty
Summary
The facility failed to ensure residents had a complete, accurate, and individualized care plan to address specific needs for three of the 12 sampled residents. Resident #22, who was not cognitively intact and had a history of behaviors and wandering, experienced multiple falls. Despite these incidents, there were no updates to the care plan related to medication usage, urinary tract infection, or the implementation of personal alarms. The resident's care plan did not reflect the necessary interventions to prevent further falls, such as moving the resident closer to the nurse's station or using positioning devices and alarms, even after multiple falls were documented in the progress notes. Resident #1, who was alert and oriented with no cognitive loss, had physician orders to self-administer nasal sprays for seasonal allergic rhinitis. However, the resident's care plan did not include any information about keeping medications at the bedside. This oversight was observed when the resident was seen with the nasal sprays on the over-the-bed table, and the resident confirmed self-administration as needed. Resident #13, who had some cognitive loss and required substantial assistance with activities of daily living, had a physician order for a no-added-salt diet and a fluid restriction. The care plan did not include these dietary restrictions, leading to the resident being given a salt shaker by a CNA and liberally salting their food. Additionally, staff interviews revealed a lack of awareness about the resident's dietary restrictions and fluid limitations, indicating a communication breakdown regarding care plan updates and resident needs.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure systems and interventions were put in place for a resident with a history of falls, severely impaired cognition, and medication use for anxiety and pain. The resident sustained three falls within a week, resulting in a hematoma to the back of the head, without additional interventions being implemented. The resident's care plan did not include measures to address the increased fall risk due to a urinary tract infection, nor were there any orders for personal alarms or positioning devices to prevent further falls. Observations revealed that the resident was often found sitting alone, appearing sleepy, and with uneaten meals. The resident's room was located far from the nurses' station, and the resident was unable to use the call light due to severe cognitive impairment. Despite multiple falls, the resident's care plan was not updated to include new interventions, and the resident continued to be at risk for further falls. Interviews with staff and the resident's family indicated that there was a noticeable decline in the resident's condition, with increased sleepiness and a lack of participation in meals. The family was aware of the increased fall risk due to the resident's medications and recent infection. The Director of Nursing and the Administrator acknowledged that changes in the resident's condition should have been care planned, and they were working on other interventions, including moving the resident closer to the nurses' station.
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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