Wellsville Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wellsville, Missouri.
- Location
- 250 E Locust, Wellsville, Missouri 63384
- CMS Provider Number
- 265398
- Inspections on file
- 20
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Wellsville Health Care Center during CMS and state inspections, most recent first.
Facility staff did not provide a full-time DON as required for facilities with a census over 60, with the DON frequently working as a charge nurse due to staffing shortages. Staff and administrator interviews confirmed that the DON was responsible for administrative duties but also covered nursing shifts to maintain coverage, and the facility lacked a policy for DON coverage.
The facility failed to protect a resident from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. This indicates a lapse in ensuring resident safety and well-being.
Staff did not report a revised allegation of sexual abuse between two residents to DHSS within the required two-hour window, as mandated by facility policy. Although the initial incident of inappropriate contact was reported, the subsequent, more serious allegation was not, and facility leadership could not provide a reason for this failure.
Staff failed to investigate and document an allegation of sexual abuse between two residents, as required by facility policy. A resident reported being inappropriately touched by another resident at night, but staff did not notify the physician or family, did not document the incident, and did not initiate an investigation. Leadership interviews confirmed that the required actions were not taken and the incident was not addressed according to policy.
A former administrator misappropriated $800 from a resident's digital wallet, intended for a facility bill, into their personal account. The resident, who was cognitively intact, provided evidence of the transaction, but the funds were not applied to their account, and no receipt was issued. The former administrator admitted to receiving the funds but could not provide documentation of its application. Facility records confirmed the payment was not received, and staff interviews revealed no recollection of cash being applied to the resident's bill.
The facility failed to maintain a clean and homelike environment, with observations of sticky floors, debris, and stained toilets in resident rooms. Residents expressed dissatisfaction with the cleanliness, and interviews revealed a shortage of housekeeping staff, often leaving only one housekeeper for the entire building. The facility's administrator and housekeeping staff acknowledged the challenges in maintaining cleanliness due to insufficient personnel.
The facility failed to employ a qualified Director of Food and Nutrition Services, as the Dietary Manager (DM) lacked certification and formal food service training. The DM, initially hired as a part-time cook, assumed the DM role without documented food service experience or management certification. The administrator, new to the facility, had not yet addressed the issue.
Facility staff failed to serve food according to nutritionally calculated recipes and menus, with multiple instances of unapproved meal substitutions and missing items. The Dietary Manager admitted to not consulting the dietician for meal substitutions and not maintaining the substitutions log. The administrator confirmed that the dietician had not been seen since March 2024, and food delivery issues had recently been resolved.
Facility staff failed to maintain kitchen cleanliness, properly sanitize kitchen wares, and serve food at safe temperatures. Observations revealed food debris, dust, and grease accumulation, improper sanitizer use, and food served at unsafe temperatures. The ice machine's drain line was also improperly connected, risking cross-contamination.
The facility administration failed to develop or maintain an operational policy to guide daily operations. The administrator became aware of the absence of a policy in March 2024, and the DON confirmed that the facility should not be operated without a guiding policy. The facility census was 38.
Facility staff failed to implement an Antibiotic Stewardship Program with a system to monitor antibiotic use. The new Infection Preventionist confirmed that there was no program in place and that the previous Infection Preventionist had removed all records and programs upon leaving suddenly. The DON and administrator corroborated the loss of records and the absence of the program.
Facility staff failed to maintain the privacy and confidentiality of residents' personal and medical records by leaving computer screens unattended and visible to others. Observations showed exposed resident information on computer screens in areas accessible to staff and residents. Interviews confirmed staff awareness of the requirement to close screens, but they failed to comply.
Facility staff failed to maintain a sanitary and homelike environment, with observations of a cluttered bathtub, loose baseboards, strong odors, and damaged walls and floors. Staff interviews revealed a lack of a full-time maintenance department and an absence of a clear process for reporting and addressing repairs.
Facility staff failed to prime insulin pens before administration for three residents and did not ensure a resident's PT/INR and digoxin levels were obtained as ordered. Staff were unaware of the need to prime insulin pens and had not received training. Additionally, necessary blood test orders were not transcribed into the medical record, potentially leading to incorrect medication dosing.
Facility staff failed to inspect bed frames, mattresses, and bed rails regularly and did not obtain consents or complete assessments for the use of bed rails for three residents. Additionally, a physician's order was not obtained for one resident. Interviews with staff revealed a lack of clarity and adherence to the facility's policy on side rail assessments.
Facility staff failed to ensure nursing staff had the appropriate skills and competencies to meet the care needs of the residents by not providing in-services, re-evaluating, and documenting skills and competencies on a regular basis. The new DON and the administrator revealed that the previous DON, who was responsible for maintaining the in-service binder and ensuring education completion, is no longer with the facility, and no one has been identified to replace them.
A resident with dementia did not receive food in the proper form as per physician's orders. The resident was served regular consistency food instead of a prescribed puree diet due to errors in the diet roster and lack of staff awareness.
Facility staff failed to conduct, document, or create a thorough facility-wide assessment to determine necessary resources for resident care during both day-to-day operations and emergencies. The administrator and DON admitted to the absence of such an assessment and were unaware of its requirement.
Facility staff failed to implement complete policies for water system maintenance to prevent Legionnaire's Disease and did not follow proper hand hygiene and infection control protocols during blood glucose monitoring and insulin administration for two residents. The administrator acknowledged the absence of a water management program, and the LPN admitted to not following proper procedures due to nervousness.
Facility staff failed to document the administration of the pneumococcal vaccine for two residents and the influenza vaccine for two residents. The facility's policies did not include guidelines for these vaccinations, and the DON acknowledged that the vaccination program was not up-to-date in the residents' medical records.
Facility staff failed to develop and implement policies to ensure residents were offered the COVID-19 vaccine and did not document education, offer, or refusal of the vaccine for three residents. The previous Infection Preventionist left, taking all policies and records, and the resident immunization program was not currently underway.
The facility staff failed to maintain an accurate accounting system for resident funds, with missing bank statements for February and March 2023 and incomplete reconciliation for May 2023. The Business Office Manager and new administrator acknowledged issues in managing the resident trust and bond sufficiency.
Facility staff failed to provide timely pain management for a resident with a leg wound, despite the resident's repeated complaints and a documented pain assessment. The facility lacked a specific pain management policy and did not follow protocols for obtaining standing orders for pain control upon admission.
Facility staff failed to assist two residents with transportation to medical appointments. One resident missed neurology consults due to a non-operational transportation van, while another resident missed cancer treatment appointments due to scheduling and transportation issues. The administrator and transportation technicians acknowledged the problems.
Failure to Provide Full-Time Director of Nursing Coverage
Penalty
Summary
Facility staff failed to provide the services of a full-time Director of Nursing (DON) as required for facilities with an average daily occupancy of 60 or more residents. The facility census consistently exceeded 60, with an average daily census of 62. Review of facility records showed that the DON frequently worked as the charge nurse on multiple shifts, including both day and night shifts, instead of fulfilling the full-time administrative responsibilities of the DON role. The facility did not provide a policy for DON coverage, and the Facility Assessment documented the census but did not address the DON's administrative coverage. Interviews with staff and the administrator confirmed that the DON was responsible for scheduling and staffing of nurses, as well as hiring and terminating staff, but was also required to work as a charge nurse due to inadequate staffing levels. The administrator acknowledged ongoing staffing shortages and stated that the DON worked on the floor to ensure nurse coverage. The DON confirmed awareness of the requirement not to serve as a charge nurse when the census is over 60, but stated that staffing shortages necessitated this practice despite ongoing recruitment efforts.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all forms of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded against these types of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Timely Report Sexual Abuse Allegation to State Agency
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse between two residents to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe, as mandated by the facility's Abuse and Neglect policy. The policy specifies that any alleged violation involving abuse or resulting in serious bodily injury must be reported immediately, but no later than two hours. The initial allegation involved one resident entering another's room and rubbing lotion on the legs and abdomen, which was reported to the state agency. However, when the allegation changed to include inappropriate touching of the peri area, staff did not report this new information to DHSS. Interviews with facility leadership, including the DON, administrator in training, regional nurse, and interim administrator, revealed that the change in the nature of the allegation was not reported as required. The DON stated that the new allegation was not believed and therefore not reported. Other interviewed staff acknowledged that the policy was not followed and could not explain why the updated allegation was not reported to DHSS within the mandated timeframe.
Failure to Investigate Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
Facility staff failed to follow their Abuse and Neglect Policy when they did not investigate an allegation of resident-to-resident sexual abuse. The policy required immediate reporting, investigation, notification of the physician and family, monitoring and documentation of the resident's condition, and revision of the care plan. However, there was no documentation in the medical records of either resident involved regarding the allegation or any actions taken by staff. The resident who made the allegation reported that another resident entered their room at night and engaged in inappropriate touching, and stated that staff did not take the complaint seriously, did not notify their family or physician, and did not initiate an investigation. The resident ultimately contacted law enforcement due to feeling unsafe and unsupported by the facility. Interviews with facility leadership, including the DON, administrator in training, regional nurse, and interim administrator, confirmed that no investigation was conducted after the allegation changed from inappropriate application of soap to sexual assault. The DON admitted to not investigating because they did not believe the allegation, and other leaders acknowledged that the policy was not followed and could not explain why required actions were not taken. Both residents' medical records lacked documentation of the incident or any follow-up, despite the facility's policy outlining specific steps to be taken in such cases.
Misappropriation of Resident Funds by Former Administrator
Penalty
Summary
Facility staff failed to prevent the misappropriation of funds for a resident when the former administrator requested and accepted $800 from the resident's digital wallet service application account into the administrator's personal digital wallet service application account. The resident, who was cognitively intact and did not exhibit behaviors of inattention or disorganized thinking, reported that the money was intended to pay a bill owed to the facility. However, the funds were not applied to the resident's account, and no receipt or statement was provided to the resident. The resident showed evidence of the transaction on their cell phone, indicating that the transfer occurred when the previous owners managed the facility. The former administrator admitted to receiving the funds into their personal account and claimed to have withdrawn the money from a bank, but could not recall which bank or how the cash was applied. The former administrator suggested that the money was given to one of three people in the business office, but no records or receipts were found to confirm this. The facility's former owner's Director of Revenue confirmed that the facility did not receive the money, and the resident was in a Medicaid pending status. The resident's account statements did not reflect the $800 payment, and interviews with the Activity Director and other staff indicated that they did not recall any cash being brought in to pay the resident's bill. The current administrator stated that digital wallet service applications are not appropriate for accepting resident payments and emphasized the need for proper accounting records and receipts.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unclean floors, windows, and equipment in resident rooms. The report highlights that the facility did not have a policy for staff to report environmental concerns, which contributed to the ongoing issues. Observations on different dates revealed that the floors in various halls and resident rooms were sticky, contained debris, dead bugs, and had black and brown stains. Additionally, some toilets were stained and in disrepair, with residents reporting that their rooms had not been cleaned for extended periods. Interviews with residents revealed dissatisfaction with the cleanliness of their living spaces, with some residents unable to recall the last time their rooms were cleaned. Residents expressed feelings of dirtiness and discomfort due to the lack of regular cleaning. The report also noted that there was often only one housekeeper for the entire building, and on some days, no housekeeper was available. This staffing shortage was confirmed by interviews with housekeeping staff and the facility administrator, who acknowledged the difficulty in maintaining cleanliness due to insufficient staff. The facility's administrator and housekeeping staff admitted to the challenges faced in keeping the environment clean, citing a lack of personnel and the need for additional hiring. The newly appointed Housekeeping Supervisor also acknowledged the poor condition of the facility and expressed a commitment to improving cleanliness once more staff were hired. Despite these acknowledgments, the report indicates that the facility's current state did not meet the standards expected for a safe and homelike environment for residents.
Failure to Employ Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to designate a qualified Director of Food and Nutrition Services, as they did not employ a full-time qualified dietitian or other clinically qualified nutrition professional. The Dietary Manager (DM) was initially hired as a part-time cook in February 2023 and assumed the DM role in March 2024. However, the DM's personnel record lacked documentation of previous food service experience or food service management certification. The DM admitted to not being a Certified Dietary Manager and having no formal food service training. Additionally, the DM did not receive assistance or consultation from other facility staff. Interviews with the Business Office Manager (BOM) and the administrator revealed that the responsibility for ensuring staff qualifications fell on the administrator. The BOM was unaware of any food service-related training completed by the DM. The administrator acknowledged that the DM should be certified and had instructed the DM to look into certification courses but was unaware of any progress. The administrator, who had only recently started at the facility, admitted to not having had time to address all issues, including the lack of qualified staff in the food and nutrition services department.
Failure to Follow Nutritionally Calculated Menus and Ensure Dietician Review
Penalty
Summary
Facility staff failed to serve food in accordance with the nutritionally calculated recipes and menus. Observations showed that residents on pureed diets did not receive the complete meal as per the menu, missing items like pureed fruit and bread. Additionally, residents on regular diets did not receive bread as specified. The cook admitted to forgetting about the pureed fruit and mentioned that breadsticks were not available, and there was not enough bread for all residents. The Dietary Manager (DM) confirmed that meal substitutions were made without consulting the dietician, and the facility vendor had been out of some items, leading to these substitutions. The DM also admitted to not keeping up with the substitutions log and not knowing when the dietician last reviewed the meals or performed kitchen inspections and staff education. The administrator confirmed that the dietician should come in monthly but had not been seen since the administrator started in March 2024. The administrator also mentioned that food delivery issues had been resolved recently after a delay due to non-payment to the vendor. The facility's Week At a Glance menu was not followed on multiple occasions. On one instance, staff served a hot dog on a bun, cheesy fries, and creamy coleslaw instead of the planned deluxe potato ham bake, mixed vegetables, frosted cake, and dinner roll. The DM signed off on the meal substitution without the dietician's review. Another instance showed that the resident's choice meal was not documented or reviewed by the dietician. The DM could not recall the sides served with the chicken and dumplings meal. On another occasion, staff served cheeseburgers, french fries, baked beans, and cookies instead of the planned roast pork, cornbread stuffing, buttered corn, glazed applesauce cake, and dinner roll. The cook mentioned that the menu was switched due to a missed food delivery. Interviews with staff revealed concerns about food portions and shortages, which were not communicated to the appropriate personnel. The DM admitted to using food from the emergency supply due to insufficient food and mentioned that there were no historical records or documents in the dietary office when they started. The administrator expected kitchen staff to follow prepared menus and the dietician to review any meal substitutions, but these expectations were not met. The administrator also noted that a resident's admission paperwork did not indicate a gluten-free diet, highlighting a lack of communication and documentation within the facility.
Kitchen Cleanliness and Food Safety Deficiencies
Penalty
Summary
Facility staff failed to maintain kitchen cleanliness, leading to potential food contamination. Observations revealed an accumulation of dried food debris on the stand mixer, dust and grease on window exhaust filters and ceiling vents, and ice accumulation in the walk-in freezer. The ice machine's drain line was improperly connected without an air gap, risking cross-contamination. The facility lacked specific cleaning policies for kitchen equipment, and the dietary manager admitted to not discussing kitchen cleaning with maintenance staff, who were responsible for high areas and the ice machine drain. Staff also failed to sanitize kitchen wares properly. Dishwasher G did not fully submerge large pots and pans in the sanitizer solution and did not check the sanitizer concentration, which was found to be less than 150 ppm. The dietary manager confirmed that items should be fully submerged and the sanitizer concentration should be between 200 and 400 ppm. Dishwasher G admitted to not being shown how to use the test strips for checking sanitizer concentration. Additionally, staff did not maintain and serve food at safe temperatures. Cook F pureed spaghetti and green beans and placed them on the steam table without checking their temperatures. The pureed spaghetti and green beans were served at 112°F and 114°F, respectively, well below the required 165°F. The dietary manager confirmed that food temperatures should be checked after pureeing and maintained at 175-180°F on the steam table. The administrator and dietary manager acknowledged their responsibility for kitchen cleanliness and staff training but were unaware of the ice machine drain air gap requirement.
Lack of Operational Policy
Penalty
Summary
The facility administration failed to develop or maintain an operational policy to guide the day-to-day operations of the facility. This deficiency was identified through record reviews and interviews. The facility records lacked a guide for daily functions, and the administrator acknowledged becoming aware of the absence of a policy in the second week of March 2024. The current owners did not leave a policy, and no new policy was developed. The Director of Nursing (DON) confirmed the absence of a policy book, stating that the facility should not be operated without a guiding policy in place. The facility census was 38 at the time of the survey.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
Facility staff failed to implement an Antibiotic Stewardship Program with a system to monitor antibiotic use. The facility, with a census of 38, did not have a policy on antibiotic stewardship, nor did it have a previous record of such a program. The new Infection Preventionist, who recently took over the position, confirmed that there was no antibiotic stewardship program in place and that the previous Infection Preventionist had removed all records and programs upon leaving suddenly. The Director of Nursing corroborated this, stating that all records for the infection prevention program, including the antibiotic stewardship program, were lost when the previous Infection Preventionist left without advance notice. The administrator also confirmed that the new Infection Preventionist had not yet started the antibiotic stewardship program as they were still working on certification.
Failure to Maintain Resident Information Privacy
Penalty
Summary
Facility staff failed to maintain the privacy and confidentiality of residents' personal and medical records by leaving computer screens unattended and visible to others. Observations on multiple occasions showed computer screens with resident information exposed in areas accessible to staff and residents, including a computer kiosk near the dining room and unattended medication carts. Interviews with staff, including a Certified Medication Technician (CMT) and a Certified Nursing Assistant (CNA), confirmed that they were aware of the requirement to close computer screens but failed to do so. The Director of Nursing (DON) also acknowledged that staff are expected to close screens to protect health information privacy.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
Facility staff failed to provide a sanitary, comfortable, and homelike environment in the 200 hallway spa/shower room and the 100 hall. Observations revealed a bathtub filled with fall mats, wheelchair cushions, and wheelchair pedals, along with loose and missing baseboards on two walls. Additionally, multiple resident rooms were found with various issues such as strong odors of urine, damaged sheet rock, stained floors, missing wall trim, and debris on the floor. The facility census was 38 at the time of the survey. Interviews with staff indicated a lack of a full-time maintenance department and an absence of a clear process for reporting and addressing environmental repairs. Housekeeping staff reported continuous cleaning efforts but acknowledged the presence of debris and stains. Certified Nurse Aides confirmed the inappropriate storage of items in the spa room and the lack of a maintenance worker to address repairs. The administrator admitted to the absence of a process for ensuring facility repairs and the lack of a full-time maintenance supervisor, although efforts were being made to build a communication process for reporting issues.
Failure to Prime Insulin Pens and Ensure Blood Test Orders
Penalty
Summary
Facility staff failed to meet professional standards of quality by not priming insulin pens before administration for three residents. Observations showed that both an LPN and an RN administered insulin without priming the pens, which is necessary to remove air bubbles and ensure accurate dosing. The staff members involved were unaware of the need to prime the pens and had not received training on insulin pen usage at the facility. The Medical Director and the pharmacist confirmed that failing to prime the pens could result in incorrect insulin dosing, potentially affecting resident health. Additionally, the facility failed to ensure that a resident's Prothrombin and International Normalized Ratio (PT/INR) and digoxin levels were obtained as ordered. The resident had a diagnosis of atrial fibrillation and was prescribed warfarin and digoxin, but the Physician Order Sheet did not contain orders for the necessary blood tests. Interviews with the Medical Director and nursing staff revealed that the orders were not transcribed into the medical record, which could lead to incorrect medication dosing. The Director of Nursing acknowledged that the facility lacked policies for insulin pen usage and physician orders. The DON admitted that periodic checks of physician orders had not been conducted, as they were new to the role. The failure to prime insulin pens and ensure proper blood test orders were in place highlights significant gaps in staff training and policy implementation at the facility.
Failure to Complete Bed Rail Assessments and Obtain Consents
Penalty
Summary
Facility staff failed to complete the inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program to ensure bed rails/grab bars were properly secured. Additionally, the facility did not obtain consents for the use of bed rails for three residents and failed to obtain a physician's order for one resident. The facility also did not complete bed rail use assessments for two residents. These deficiencies were identified through observation, interview, and record review during the survey process. The facility's policy on side rails, dated 01/23/23, outlines specific procedures for the use of side rails, including assessments, consents, and entrapment assessments, which were not followed in these cases. Resident #6, who was cognitively intact and required substantial assistance for mobility, had side rail assist bars without a completed side rail assessment, consent, or entrapment assessment. Resident #12, who was moderately cognitively impaired and dependent on staff for mobility, had a U-Bar in the upright position without a completed side rail assessment, physician order, consent, or entrapment assessment. Resident #33, who was cognitively intact and required supervision for transfers, also had side rail assist bars without a signed consent or entrapment assessment. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, revealed a lack of clarity and adherence to the facility's policy on side rail assessments and entrapment assessments.
Failure to Ensure Nursing Staff Competencies
Penalty
Summary
Facility staff failed to ensure nursing staff had the appropriate skills and competencies to meet the care needs of the residents by not providing in-services, re-evaluating, and documenting skills and competencies on a regular basis. The facility's policies did not include a policy on staff annual education or in-service requirements. The in-service annual training documentation did not contain evidence of skills and competencies to meet the care needs of the residents. During interviews, the new Director of Nursing (DON) and the administrator revealed that the previous DON, who was responsible for maintaining the in-service binder and ensuring education completion, is no longer with the facility, and no one has been identified to replace them. The facility census was 38.
Failure to Provide Proper Diet Consistency
Penalty
Summary
The facility failed to ensure that a resident received food in the proper form according to their physician's orders. Resident #13, who was cognitively impaired with a diagnosis of dementia, had a physician's order for a puree texture, regular/thin consistency diet. However, the resident's care plan did not contain direction for diet consistency, and the diet roster listed the resident's diet type as regular diet and regular texture. On observation, the resident was served regular consistency spaghetti and green beans, contrary to the prescribed puree diet. The slip of paper with the resident's diet order was crossed out and incorrectly indicated a regular diet and consistency. Interviews with staff revealed a lack of awareness and communication regarding the resident's dietary needs. The CNA assisting the resident was unaware of the puree diet until the day after the observation. The cook followed the incorrect ticket provided and was unaware of the resident's actual dietary requirements. The Dietary Manager acknowledged the error and indicated that the cook was responsible for ensuring the correct meal texture. The Dietary Manager also mentioned difficulties in managing diet orders due to recent access to the dining software and the need to print diet rosters periodically to review diets.
Failure to Conduct Facility-Wide Assessment
Penalty
Summary
Facility staff failed to conduct, document, or create a thorough facility-wide assessment to determine the necessary resources for resident care during both day-to-day operations and emergencies. The facility census was 38. Record review showed no policy or guidance for developing a facility assessment. During an interview, the administrator admitted that there was no facility assessment and was unaware of the requirement. The Director of Nursing also confirmed the absence of a facility assessment and acknowledged its importance for proper facility operation.
Inadequate Infection Control and Water Management Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for the inspection, testing, and maintenance of the facility's water system to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease. The administrator acknowledged the absence of a water management program, despite being aware of the requirement. The facility's Water Management Program policy was undated, and the administrator, who started on 03/01/24, could not locate the water management plan. Additionally, the facility did not provide policies on hand hygiene, infection control, blood glucose testing, or insulin administration. During an observation, an LPN failed to use appropriate hand hygiene during blood glucose monitoring and insulin administration for two residents. The LPN did not wear gloves during insulin administration for one resident and did not cleanse the glucometer between uses for two residents. The LPN admitted to knowing the proper procedures but failed to follow them due to nervousness. The Director of Nursing confirmed that staff are expected to wash their hands before and after performing blood glucose tests, wear gloves when administering insulin, and clean the blood glucose meter between each resident. The failure to adhere to these protocols could result in the spread of bacteria or infection to staff or other residents.
Failure to Document Vaccinations
Penalty
Summary
Facility staff failed to document the administration of the pneumococcal vaccine for two residents and the influenza vaccine for two residents out of six sampled residents. Specifically, Resident #4, aged 81, admitted on 03/12/15, did not have documentation of receiving or refusing the pneumococcal vaccine. Resident #35, aged 69, admitted on an unspecified date, did not have documentation of receiving or refusing both the pneumococcal and influenza vaccines. Resident #37, admitted on an unspecified date, did not have documentation of receiving or refusing the influenza vaccine. The facility's policies did not include guidelines for pneumococcal or influenza vaccinations. Interviews with the Infection Preventionist and the Director of Nursing (DON) revealed that both believed the immunization information for residents was up to date and that a system was in place. However, the DON, who was responsible for the vaccination program, acknowledged that the program was not up-to-date in the residents' medical records.
Failure to Document and Offer COVID-19 Vaccination
Penalty
Summary
Facility staff failed to develop and implement policies and procedures to ensure each resident was offered the COVID-19 vaccine. The facility did not document that residents or their representatives were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. Additionally, the facility did not document each dose of the COVID-19 vaccine administered to the residents or if the residents did not receive the vaccine due to medical contraindications or refusal. This deficiency was identified for three residents out of six sampled residents, with a facility census of 38. Resident #4's medical record showed that the resident received one dose of the COVID-19 vaccine but lacked documentation of education, refusal, or offer of the second dose or an updated booster. Resident #35 and Resident #37's medical records did not contain any documentation of education, offer, or refusal of the COVID-19 vaccine. Interviews with the Infection Preventionist and the Director of Nursing confirmed that all COVID-19 vaccination documentation should be in the residents' electronic medical records, but this was not the case. The administrator mentioned that the previous Infection Preventionist had left the position and took all policies and records, and the resident immunization program was not currently underway.
Failure to Maintain Accurate Accounting System for Resident Funds
Penalty
Summary
The facility staff failed to maintain an accurate accounting system for resident funds, as evidenced by discrepancies in the reconciliation of bank statements for February 2023, March 2023, and May 2023. Specifically, the facility did not provide a policy for resident funds, reconciliation of resident funds, or a surety bond. The accounting records for February and March 2023 lacked corresponding bank statements, and the May 2023 reconciliation did not include a final total showing outstanding deposits and withdrawals. This issue had the potential to affect all residents with funds entrusted to the facility, with a census of 38 residents at the time of the survey. During interviews, the Business Office Manager (BOM) admitted to difficulties in obtaining bank statements from the prior company and acknowledged that the issue was not followed up after informing the previous administrator. The BOM also revealed a lack of awareness regarding incomplete calculations in the May 2023 reconciliation and uncertainty about how to use reconciled amounts to calculate the bond. The new administrator, who had been relying on the BOM to manage the resident trust, indicated plans to train a new staff member and provide oversight for monthly reconciliations and bond sufficiency. However, no review of the bond or its coverage of patient funds had been conducted since the prior administrator's departure.
Failure to Provide Appropriate Pain Management
Penalty
Summary
Facility staff failed to provide appropriate pain management interventions for a resident with a leg wound. The resident, who was admitted to the facility with a diagnosis of a leg wound, did not have a documented baseline care plan that included pain interventions. Despite the resident's complaints of pain and a pain assessment indicating a history of pain and a current pain level of four on a 1-10 scale, staff did not provide timely pain relief. Nurse notes from 04/01/24 to 04/04/24 showed that the resident's pain was acknowledged but not adequately addressed, with no interventions documented until new orders for Tramadol were received on 04/04/24. Interviews with the resident and staff revealed that the resident repeatedly requested pain medication but did not receive it in a timely manner. The medical director and nursing staff indicated that standing orders for pain control should be obtained upon admission, and pain complaints should prompt immediate action, including contacting the physician for further orders. However, these protocols were not followed, resulting in the resident experiencing unmanaged pain for several days. The facility also lacked a specific policy for pain management or baseline care plans, contributing to the deficiency in care.
Failure to Assist Residents with Transportation to Medical Appointments
Penalty
Summary
Facility staff failed to assist two residents with transportation arrangements to and from their medical appointments. Resident #33, who is cognitively intact and diagnosed with migraine headaches, had orders for a neurology consult dating back to August and December of the previous year. Despite these orders, the resident reported that the facility did not ensure transportation to the neurology appointments. Interviews with the transportation technicians revealed that the facility's transportation van was out of service for several months, and there were delays in setting up appointments due to authorization issues from the primary care provider. The prior transportation technician confirmed that the transportation van was non-operational for six to eight months, and the administrator was informed of the transportation needs during that period. Resident #35, also cognitively intact and diagnosed with a malignant neoplasm of the connective and soft tissue, had multiple appointments for cancer treatment that were either missed or canceled by the facility. The resident expressed significant concern about the delays in treatment. The scheduling assistant for the oncologist confirmed that appointments were missed or canceled due to transportation issues, including a lack of available transportation slots and the transportation bus being held up. The Director of Nursing was unsure why the appointments were canceled, stating that transportation priorities were decided by the administrator. The administrator acknowledged the transportation issues and cited unexpected problems that prevented planned transportation to the appointments.
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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