Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Atlas Rehabilitation Healthcare At Daughters Of Mo during CMS and state inspections, most recent first.
Surveyors found that two residents received inappropriate incontinence care, including the use of double briefs without proper documentation or care plan updates, and that meal trays were not delivered in a timely manner due to insufficient staffing and lack of clear policy. Staff interviews revealed inconsistent practices and a lack of awareness regarding resident preferences and care plan requirements.
Surveyors identified that two residents had incomplete CNA documentation logs and care plans that were not updated to reflect their current incontinence status and care preferences. One resident's ADL records had multiple blank entries, and another resident's care plan was only updated to include the use of double briefs after surveyor inquiry, despite the resident being observed with double briefs. The DON confirmed the missing documentation and the need for care plan updates.
The facility failed to complete and transmit MDS assessments within the required 14 days for multiple residents, as identified by surveyors through interviews and record reviews. The MDSC/RN confirmed the delays, citing workload issues, and the facility relied on the RAI manual for guidelines without a separate policy. Meetings with the LNHA and DON did not yield additional information or corrective actions.
The facility failed to ensure physicians reviewed residents' care, including medications and treatments, and documented progress notes at each visit. This deficiency affected 14 residents, with overdue physician orders and missing progress notes. Interviews confirmed ongoing issues with physician services, despite facility policies requiring regular visits and documentation.
A facility failed to ensure a resident's privacy and dignity during medication administration. An LPN administered medications and checked a resident's blood pressure in the dining area, contrary to the facility's Resident Rights Policy. The resident's preference for this setting was not documented in their care plan, leading to a deficiency.
A facility failed to verify the credentials of a newly hired Social Worker (SW) upon hire. The SW's license was found to be inactive with reinstatement pending, and this was only verified after a surveyor's inquiry. The LNHA acknowledged a user error during the license renewal process and stated that HR should have verified the license upon hire, as per the facility's Hiring Policy.
A facility failed to provide written bed hold notices to a resident or their representative during multiple hospitalizations. The resident, with a complex medical history including dementia and COPD, was hospitalized for issues like catheter malfunction and ESBL. Despite policy requirements, no bed hold notifications were documented for the specified dates, as confirmed by facility staff.
A resident experienced significant cognitive decline and weight gain, but the facility failed to complete a Significant Change in Status Assessment (SCSA) as required. The MDS Coordinator acknowledged the oversight but could not provide documentation or justification for the decision not to conduct the assessment, resulting in a deficiency.
The facility inaccurately coded the MDS for two residents, leading to discrepancies in assessments. One resident's weight was incorrectly recorded, and another's discharge location was misreported. The errors were acknowledged by staff but highlighted the absence of a specific MDS policy.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in addressing their medical and psychosocial needs. A resident with a history of falls did not have an individualized care plan, another with multiple diagnoses had an incomplete plan for ADLs, and a third with a left arm splint lacked documented interventions. Additionally, a resident at risk for skin breakdown had a care plan missing necessary interventions. These oversights highlight the need for improved care planning processes.
A facility failed to conduct routine and accurate monthly Psychoactive Reviews for a cognitively impaired resident on psychotropic medications. The behavior monitoring records showed inconsistencies, and the PR did not account for all medications or documented behaviors. The facility's policy required comprehensive reviews, which were not adhered to, leading to incomplete monitoring.
A facility failed to update a resident's care plan with necessary interventions after falls and did not conduct quarterly fall risk assessments as required. The resident experienced several falls, and the care plan lacked previous interventions. Staff interviews revealed confusion about responsibilities for updating care plans and conducting assessments, contributing to inadequate supervision and increased accident risk.
A facility failed to administer the correct total volume of enteral tube feeding for a resident with a gastrostomy, as per physician's orders. The resident, with a history of stroke, dementia, and diabetes, was prescribed a specific volume of Diabetisource 1.2, but documentation showed significantly lower volumes were infused over several days. Interviews revealed confusion among nursing staff regarding documentation, leading to discrepancies in the Medication Administration Record.
A resident with a history of pneumonia was found with improperly stored nebulizer equipment, and the facility lacked an individualized care plan and necessary orders for equipment maintenance. The Unit Manager confirmed the absence of a care plan and order for weekly nebulizer changes, contrary to facility policy.
The facility failed to adjust medication schedules for two residents requiring dialysis, leading to missed doses and duplicate orders. One resident had duplicate blood sugar check orders, while another had eye drops scheduled during dialysis sessions. The facility's Hemodialysis Policy was not followed, resulting in deficiencies in care.
The facility failed to post accurate daily staffing information on two occasions, with outdated and incorrect Nursing Home Resident Care Staffing Reports observed by surveyors. Staff interviews and policy reviews confirmed the deficiencies, as the reports were not updated at the beginning of each shift as required.
A resident with dietary restrictions due to hypertension and diabetes did not receive meals according to their preferences, despite selecting items from a menu. The resident, who was cognitively intact, frequently received incorrect meals, such as turkey meatloaf instead of roasted chicken. The Food Service Director confirmed the resident's selections were not honored, and the facility's investigation cited unclear writing as the cause, despite clear indications on the menu.
The facility failed to maintain complete and accurate medical records, with late entries for physician visits, missing consent documentation for vaccinations and psychoactive medications, and incomplete bowel and bladder management records. These deficiencies were identified for several residents, highlighting significant oversights in care documentation and consent processes.
The facility failed to follow proper infection control practices, including hand hygiene and PPE use, as observed with a CNA and RN/UM. An LPN left a disinfecting wipes container open, compromising its effectiveness. Additionally, a resident on transmission-based precautions for COVID-19 lacked proper signage and documentation, indicating a failure to adhere to facility policies.
A resident with multiple serious health conditions was observed to be dehydrated, but the LPN on duty failed to promptly notify the physician or escalate the issue according to facility policy. Despite an initial attempt to contact the physician, no further action was taken until after the resident's death, and the required communication with supervisory staff and the Medical Director did not occur.
Deficient Incontinence Care and Delayed Meal Delivery
Penalty
Summary
Surveyors identified deficiencies related to the provision of incontinence care and timely meal delivery for residents. On the observed unit, there was only one CNA present to distribute breakfast trays, resulting in meal trays being left unattended and not delivered to residents within the expected timeframe. The DON confirmed that meal trays should be delivered within 5 to 10 minutes of arrival to keep food warm, but observations showed that the last tray was not delivered until significantly later. Staff interviews revealed that the lack of a written policy and reliance on verbal communication contributed to inconsistent meal delivery practices. Incontinence care deficiencies were also observed for two residents. One resident, who was cognitively impaired and required extensive assistance with ADLs, was found to be wearing double incontinence briefs, a practice not documented in the care plan and not in line with facility expectations unless specifically requested and documented. The CNA responsible stated that the double briefs were applied at the resident's request, but the RN and LPNS were unaware of this and confirmed it was not standard practice. The resident's care plan did not reflect this preference, and the DON stated that such preferences should be documented, especially for residents who are cognitively intact. A second resident was also found with double incontinence briefs, with staff unable to confirm who applied them and the care plan not reflecting this intervention until after surveyor inquiry. The resident was moderately cognitively impaired and had a history of urinary incontinence. The DON stated that double briefs should only be used if requested by the resident and documented in the care plan, and that this practice increases the risk of skin impairment and urinary tract infection. Facility policies reviewed did not provide clear guidance on the use of double incontinence briefs or the process for meal tray distribution, contributing to the observed deficiencies.
Incomplete Medical Records and Inaccurate Care Plans Identified
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as evidenced by missing documentation in the Certified Nursing Aide (CNA) accountability logs and care plans that were not updated to reflect current resident needs. For one resident with moderate cognitive impairment and incontinence, the CNA documentation logs for activities of daily living (ADLs) had multiple blank entries for specific dates in October, despite the expectation that CNAs document every shift. The Director of Nursing (DON) confirmed that the ADL log was the required care log for CNAs and acknowledged the missing documentation when notified by surveyors. For another resident with a history of stroke, hemiplegia, and urinary incontinence, the care plan was not revised to accurately reflect the resident's incontinence status and preference for extra protection until after surveyor inquiry. The CNA documentation for this resident also had blank entries for several shifts in October. Additionally, the resident was observed wearing double incontinent briefs, a preference that was only added to the care plan on the day of the survey after being brought to the attention of the DON. The DON confirmed that the care plan had not been updated to reflect the resident's current needs prior to the surveyor's inquiry.
Repeated Deficiency in Timely MDS Completion
Penalty
Summary
The facility failed to complete and transmit the Minimum Data Set Assessment (MDS) within the required 14 days for 14 out of 38 residents reviewed. This deficiency was identified through interviews and record reviews conducted by surveyors. The MDS Coordinator/Registered Nurse (MDSC/RN) was unable to immediately provide the facility's protocol for completing MDS assessments and later confirmed that the assessments for several residents were completed beyond the required timeframe. The facility relied on the Resident Assessment Instrument (RAI) manual for guidelines but did not have a separate policy for MDS completion. Surveyor #1 found that the comprehensive MDS (cMDS) for five residents were completed late, with completion dates highlighted in red in the electronic medical records. The MDSC/RN confirmed that these assessments were not completed within the 14-day requirement. Similarly, Surveyor #2 identified late completion of MDS for six residents, with the MDSC/RN attributing the delays to the workload and being the only one handling subacute assessments. Surveyor #3 also noted late completion of MDS for three residents, and the facility's policy was found to be based on the RAI manual's current requirements. The survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional Director of Clinical Services to discuss the findings. Despite the facility's reliance on the RAI manual, the MDS assessments were not completed within the required timeframes, leading to repeated deficiencies. The facility did not provide additional information or corrective actions during the survey team's meetings.
Deficiency in Physician Services and Documentation
Penalty
Summary
The facility failed to ensure that physicians reviewed residents' total program of care, including medications and treatments, and wrote, signed, and dated progress notes at each required visit. This deficiency was identified for 14 out of 35 residents reviewed for physician services. For instance, Resident #18's medical records showed no evidence of progress notes or assessments by Physician #1 from July 2024 through February 2025. Similarly, Resident #175's records lacked documentation from Physician #2 from November 2024 through February 2025, despite the resident being on contact precautions for ESBL in urine. The survey revealed that several residents' monthly physician orders were overdue for signing by their respective physicians. For example, Resident #10's physician had not signed the monthly physician orders for several months, and Resident #13's physician failed to conduct face-to-face visits or write progress notes for multiple months. Additionally, Resident #50's physician did not sign orders or conduct visits for several months, indicating a pattern of non-compliance with required physician services. Interviews with facility staff, including the Licensed Nursing Home Administrator and the Director of Nursing, confirmed ongoing issues with physician services, including the signing of orders and writing of visit notes. The facility's policy required physicians to visit residents monthly for the first 90 days and every 60 days thereafter, with orders to be signed off monthly. However, the survey findings highlighted significant lapses in adherence to these policies, affecting the quality of care provided to the residents.
Failure to Ensure Privacy and Dignity During Medication Administration
Penalty
Summary
The facility failed to treat a resident with respect and dignity during medication administration, as observed by a surveyor. During a medication pass, an LPN prepared and administered medications to a resident in the dining area while the resident was eating breakfast with other residents present. The LPN also checked the resident's blood pressure in the same setting. When questioned, the LPN stated that it was the resident's preference to receive medications in the dining room, but this preference was not documented in the resident's care plan. Further investigation revealed that the resident's care plan did not include any documentation of a behavior of swaying hands or a preference for taking medications in the dining room. The resident's cognitive status was assessed as intact, with no documented behaviors or mood disturbances. The facility's Resident Rights Policy emphasizes the importance of treating residents with respect and dignity, but the lack of documentation and adherence to the resident's care plan led to a deficiency in this area.
Failure to Verify Social Worker's License Upon Hire
Penalty
Summary
The facility failed to ensure that the credentials of a newly hired licensed staff member, a Social Worker (SW), were verified upon hire. During a review of ten randomly selected new employee files, it was discovered that the SW's license was not present in her employee file. Upon inquiry, the Regional Nurse indicated that the SW worked full-time and mentioned a pending status on her license. The License Nursing Home Administrator (LNHA) later provided documentation showing that the SW's license was inactive and reinstatement was pending, which was only verified after the surveyor's inquiry. The LNHA acknowledged that the SW's license had erroneously expired due to a user error during the renewal process, where the SW may have selected inactivate instead of renew. The LNHA stated that the Human Resources (HR) department should have verified and printed the license upon hire. The facility's Hiring Policy mandates that the HR Director is responsible for maintaining and ensuring the validity and current status of individual certification/licensure. However, there was no documented evidence that the SW's license was verified before her hire date, indicating a lapse in the facility's hiring procedures.
Failure to Provide Bed Hold Notices for Hospitalized Resident
Penalty
Summary
The facility failed to provide written notification of bed hold policies to a resident or their representative during instances of hospitalization. This deficiency was identified for a resident who had multiple unplanned discharges to the hospital on three separate occasions. Despite the facility's policy requiring that bed hold notices be provided within 24 hours of an emergency transfer, there was no documented evidence that such notifications were given for the dates in question. The absence of these notifications was confirmed through a review of the facility's bed hold notification binders for the years 2024 and 2025, which did not contain any notices for the specified dates. The resident involved had a complex medical history, including diagnoses of urinary tract infection, ESBL resistance, dementia, anxiety disorders, malnutrition, and chronic obstructive pulmonary disease. The resident experienced unplanned discharges to the hospital due to issues such as suprapubic catheter malfunction and ESBL of the urine. Despite these hospitalizations, the facility did not provide the required written bed hold notices, as confirmed by the Licensed Nursing Home Administrator and the Director of Nursing during the survey process.
Failure to Complete SCSA for Resident with Significant Changes
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced significant changes in cognitive status and weight. According to the CMS's RAI Version 3.0 Manual, an SCSA must be completed within 14 days of determining a significant change from baseline, especially when the resident's condition is not expected to return to baseline within two weeks. The resident in question had a cognitive decline from a BIMS score of 13 to 5 over two quarterly MDS assessments and experienced an 11% weight gain over three months, which met the criteria for an SCSA. The surveyor's review of the resident's medical records revealed no documented evidence that the Interdisciplinary Team (IDT) met and decided that an SCSA was unnecessary despite the significant changes in the resident's status. The MDS Coordinator/Registered Nurse acknowledged that an SCSA should have been completed but was unable to provide documentation supporting the decision not to proceed with it. The facility's failure to document the IDT's decision and the lack of an SCSA for the resident's significant changes in cognitive status and weight gain constituted a deficiency. During interviews, the MDS Coordinator stated that the team believed the resident's cognitive status fluctuated and did not warrant a significant change assessment. However, there was no documentation to support this claim, and the MDS Coordinator admitted that the BIMS scores for the two quarters might not have been accurate. The facility's inability to provide documentation or a valid explanation for not conducting an SCSA highlighted a lapse in following the required assessment protocols.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to discrepancies in their assessments. For one resident, the quarterly MDS indicated a weight of 163 lbs, which did not match the dietary assessment documentation that recorded a weight of 180 lbs on the same date. This resident had a history of significant weight gain, which was unplanned and considered significant. The MDS Coordinator/Registered Nurse acknowledged the discrepancy but did not provide a separate policy for MDS coding. The Licensed Nursing Home Administrator and Director of Nursing were informed of the findings but did not provide additional information. For another resident, the discharge return not anticipated (drna) MDS was incorrectly coded, indicating the resident was discharged to a short-term general hospital, while the progress notes and unit manager confirmed the resident was discharged home with family. The MDS Coordinator/Registered Nurse confirmed the coding error upon review. The Director of Nursing acknowledged the error and stated it was corrected after the surveyor's inquiry. The facility lacked a policy regarding MDS, contributing to these inaccuracies.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their medical and psychosocial needs. Resident #111, who had a history of falls and was at risk due to conditions like diabetes and hypertension, did not have an individualized care plan that included all relevant focus areas and interventions. The care plan was mistakenly canceled when the resident was hospitalized, and upon return, a new care plan was not properly initiated, leaving out important interventions that were previously in place. Resident #172, who had multiple diagnoses including stroke, dementia, and diabetes, was found to have an incomplete and non-individualized care plan for activities of daily living (ADLs). The care plan lacked specific interventions tailored to the resident's needs, despite the resident being dependent on staff for all ADLs and having significant cognitive impairments. This oversight was acknowledged by the facility's Director of Nursing (DON), who noted the need for re-education of staff to ensure care plans are completed. Resident #180, admitted for rehabilitation with a left arm splint, did not have documented evidence of the splint in their care plan, nor were there any interventions for its care. This omission was only addressed after the surveyor's inquiry. Similarly, Resident #442, who had severe cognitive impairment and was at risk for skin breakdown due to incontinence, had a care plan that lacked interventions related to their risk factors and diabetes management. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables, but these were not adequately implemented for the residents reviewed.
Deficient Psychoactive Review and Behavior Monitoring
Penalty
Summary
The facility failed to ensure that the monthly Psychoactive Review (PR) for behavior monitoring was conducted routinely and accurately for a resident, as required by professional standards and facility policy. The resident, who was cognitively impaired with a BIMS score of 3 out of 15, was on psychotropic medications including Quetiapine and Trazodone. However, the behavior monitoring records for December 2024 and January 2025 showed inconsistencies, with several shifts either left blank or not accurately reflecting the resident's behaviors. The PR dated February 1, 2025, only reviewed Trazodone and did not account for other psychotropic medications or documented behaviors from previous months. The facility's policy required a comprehensive review of psychotropic medication use, including evaluation of the resident's signs and symptoms. Despite this, the PR did not reflect the documented behaviors in the electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR), nor was there evidence of routine PRs being conducted. During meetings with the survey team, the facility's Regional Director of Clinical Services acknowledged the deficiency, noting that only one PR summary was completed. The facility's policy on psychotropic medication use, which mandates monthly reviews, was not adhered to, leading to incomplete and inaccurate behavior monitoring for the resident. The surveyor's findings highlighted a failure to meet the standards of clinical practice and facility policy in monitoring and reviewing psychotropic medication use.
Failure to Update Care Plan and Conduct Fall Risk Assessments
Penalty
Summary
The facility failed to ensure that a resident's current active care plan contained the necessary interventions implemented after each fall to prevent additional falls. This deficiency was identified for a resident who had experienced several falls, including an unwitnessed fall in October 2024. The resident's care plan, initiated in November 2024, only included one intervention to maintain a clutter-free environment, despite previous falls and interventions being documented in a completed care plan that was not transferred to the current active care plan. Additionally, the facility did not conduct fall risk assessments quarterly as required by their policy. The resident's fall risk assessments were not completed for several quarters, including April 2024, July 2024, and January 2025. The assessments that were conducted were either incomplete or not done quarterly, as evidenced by assessments being dated on the same day as the resident's falls. This lack of consistent assessment and documentation contributed to the failure to update the resident's care plan with appropriate interventions. Interviews with facility staff, including the LPN, Unit Manager, and MDS Coordinator, revealed confusion and inconsistency in the process of updating care plans and conducting fall risk assessments. The MDS Coordinator admitted to canceling the care plan by accident when the resident was hospitalized, and there was uncertainty about who was responsible for initiating and updating assessments. The facility's policies on fall prevention and care plans were not followed, leading to inadequate supervision and increased risk of accidents for the resident.
Failure to Administer Correct Enteral Feeding Volume
Penalty
Summary
The facility failed to monitor and administer the correct total volume of enteral tube feeding as per the physician's orders for a resident with a gastrostomy. The resident, who had a history of cerebral infarction, dementia, type 2 diabetes mellitus, and was NPO, was prescribed Diabetisource 1.2 to be administered via feeding tube at 55 ml/hr, with a total volume of 1100 ml to be infused. However, documentation in the Medication Administration Record (MAR) revealed that for six out of eleven days, the total volume infused was significantly less than the prescribed amount, with volumes ranging from 450 ml to 500 ml. The deficiency was identified through observation, interviews, and record reviews. The Licensed Practical Nurse (LPN) and Registered Nurse Unit Manager (RN/UM) confirmed that the enteral feeding should be administered according to the physician's orders and documented in the MAR. However, the RN/UM could not explain the discrepancy in the documented volumes. The Director of Nursing (DON) later stated that some nurses were confused about the volume to document, leading to incorrect entries. The facility's policy required verification of physician orders and accurate documentation of the amount and type of enteral feeding administered, which was not adhered to in this case.
Deficient Respiratory Care and Incomplete Care Plan
Penalty
Summary
The facility failed to provide adequate respiratory care and services for a resident, as evidenced by the lack of an individualized care plan and necessary orders for nebulizer equipment maintenance. During an observation, a resident was found with a nebulizer machine on the bedside table, but the mask was improperly stored in a drawer instead of a plastic bag. The resident, who had a history of pneumonia and was on antibiotics, confirmed that they had not placed the mask back in the bag. The facility's records showed no orders for changing the nebulizer mask or tubing, and the care plan lacked specific goals or interventions for respiratory care. Interviews with the Unit Manager and Licensed Practical Nurse revealed that the facility's practice was to change nebulizer tubing and masks weekly, but there was no documented order for this procedure for the resident in question. The Unit Manager acknowledged the absence of a care plan and order for the nebulizer equipment change, admitting that the care plan was incomplete. The Director of Nursing and the Licensed Nursing Home Administrator were informed of these deficiencies, which were not in compliance with the facility's nebulizer therapy policy and comprehensive person-centered care plan requirements.
Failure to Adjust Medication Schedules for Dialysis Residents
Penalty
Summary
The facility failed to ensure that the medication administration and blood sugar monitoring for two residents requiring dialysis were adjusted to accommodate their dialysis schedules. Resident #77, who has diabetes mellitus and end-stage renal disease, had duplicate orders for blood sugar checks, with one scheduled early in the morning and another before meals and at bedtime. The electronic Medication Administration Record (eMAR) showed inconsistencies in the documentation of blood sugar checks, with some entries marked as 'X' or 'NA' without explanation. The Registered Nurse (RN) and Unit Manager acknowledged the issue but did not address it until after the surveyor's inquiry. Resident #121, also diagnosed with end-stage renal disease, had a physician's order to adjust medication and treatment timing to accommodate dialysis sessions. However, the Brimonidine Tartrate eye drops were scheduled for administration at times when the resident was at dialysis, leading to missed doses. The Licensed Practical Nurse (LPN) confirmed that medication schedules should be adjusted around dialysis sessions, but this was not done for Resident #121. The Director of Nursing (DON) acknowledged the oversight and stated that the order should have been clarified by the nursing staff. The facility's Hemodialysis Policy requires that care and treatment be consistent with professional standards, physician orders, and the resident's care plan. However, the facility did not adhere to this policy, resulting in deficiencies in the care provided to residents requiring dialysis. The survey team discussed these concerns with the facility's administration, but no additional information was provided to address the deficiencies at the time of the survey.
Failure to Post Accurate Daily Staffing Information
Penalty
Summary
The facility failed to post the accurate Nursing Home Resident Care Staffing Report (NHRCSR) daily in a prominent place within the facility, as required. On two separate occasions, surveyors observed that the NHRCSR was not updated correctly. On the first occasion, the report dated 2/6/25 was still posted on 2/7/25, and the receptionist admitted to waiting for the Staffing Coordinator to provide the updated numbers. The Staffing Coordinator confirmed that the report was not printed correctly for 2/7/25. The facility's policy requires the staffing sheet to be posted at the beginning of each shift, which was not adhered to in this instance. On another occasion, the NHRCSR posted on 2/10/25 was for the previous day, 2/9/25, and contained incorrect census information. The Staffing Coordinator provided a Nursing Daily Staffing Sheet with handwritten notes indicating discrepancies in the census for the days leading up to 2/9/25. The facility's policy mandates that the staffing sheet be posted at the beginning of each shift, but this was not followed, resulting in outdated and incorrect information being displayed. These deficiencies were confirmed through interviews with staff and a review of the facility's policy.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to honor a resident's dietary preferences, as evidenced by the case of a resident who consistently did not receive the meals they requested. The resident, who was cognitively intact with a BIMS score of 15 out of 15, expressed concerns about not receiving the food items they selected from the menu. Despite discussing these issues with the kitchen staff and the registered dietician, the problem persisted. The resident, who had a no concentrated sweets diet due to hypertension and type 2 diabetes, often received meals that did not match their selections, such as receiving turkey meatloaf instead of the requested roasted chicken. During the survey, it was observed that the resident was served a meal that did not include the requested items, and there was no meal ticket on the table to verify the order. The Food Service Director confirmed that the resident had selected roasted chicken on their menu, but the meal ticket listed turkey meatloaf instead. The director could not explain why the resident received the incorrect meal and acknowledged that the resident's food preferences should be honored. The facility's policy on nutritional management indicated that residents' goals and preferences should be reflected in their care plans, but this was not adhered to in this case. The issue was brought to the attention of the Licensed Nursing Home Administrator, Director of Nursing, and Regional Director of Clinical Services, who were informed of the resident's unmet food preferences. The facility's investigation revealed that unclear writing on the menu led to the dietary staff's confusion. However, the surveyor noted that the resident's menu clearly showed the crossed-out item, indicating the resident's choice. The facility's policy emphasized the importance of interviewing residents to ensure their preferences are met, which was not effectively implemented in this instance.
Deficiencies in Medical Record Maintenance and Consent Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for several residents, leading to deficiencies in care documentation and consent processes. For one resident, the physician's visit notes were entered late, covering a period from September 2024 to January 2025, which was not in compliance with the expected timeline for documentation. This issue was brought to the attention of the facility's administration, who acknowledged the requirement for timely documentation of physician visits. Another resident's medical records lacked documentation of consent for influenza and pneumococcal vaccinations, as well as psychoactive medication use. The facility staff were unable to locate the necessary consent forms during the survey, and it was later discovered that these documents were left in a copying machine. The absence of documented consent and education regarding vaccinations and psychoactive medications was a significant oversight in the resident's care plan. Additionally, the facility failed to document bowel and bladder management for a resident, with numerous missing entries in the CNA Intervention/Task Report sheets. This lack of documentation was confirmed by multiple staff members, who acknowledged the importance of monitoring and recording such information to prevent health complications. The facility's incontinence policy emphasized the need for appropriate treatment and services based on comprehensive assessments, which was not adhered to in this case.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple observations of staff not following hand hygiene protocols and improper use of personal protective equipment (PPE). A Certified Nursing Aide (CNA) was observed with a surgical mask not covering her nose and mouth, and she did not perform hand hygiene before and after touching her mask or donning and doffing gloves. Additionally, the CNA stored gloves in her pocket, which is against facility policy. A Registered Nurse/Unit Manager (RN/UM) also failed to perform hand hygiene before and after glove use. These actions were contrary to the guidelines set by the CDC and the facility's own policies. Further deficiencies were noted during a medication administration pass, where a Licensed Practical Nurse (LPN) left the disinfecting wipes container open, which could compromise the effectiveness of the wipes. The LPN acknowledged the oversight but did not correct it during the medication pass. This practice was not in line with the facility's Safety Data Sheet instructions, which require the container to be closed when not in use. Additionally, the facility did not properly implement transmission-based precautions (TBP) for a resident who was COVID-19 positive. There was no signage outside the resident's room to indicate TBP, and the sign was mistakenly placed inside the door. The resident's Medication Administration Record (MAR) was not signed for TBP for two shifts, and the Progress Notes did not reflect the resident's TBP status. These oversights indicate a failure to follow the facility's policy on TBP, which requires clear signage and documentation to prevent the spread of infection.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure immediate physician notification and adherence to its policy regarding changes in a resident's condition. A resident with multiple complex diagnoses, including Parkinson's Disease, Alzheimer's Disease, multiple myeloma, type 2 diabetes, aortic insufficiency, and dementia, was observed by their responsible party to appear dehydrated. The LPN on duty assessed the resident, noted poor skin turgor, and attempted to contact the resident's physician by phone but was unable to leave a message. No further attempts to reach the physician were documented until several hours later, after the resident had expired. The LPN did not escalate the issue to the Nursing Supervisor or Medical Director as required by facility policy. Interviews with staff revealed that the expectation was for nurses to report any significant changes in a resident's condition to the Nursing Supervisor and, if unable to reach the primary physician, to contact the Medical Director. The Assistant Director of Nursing confirmed that the process for physician notification was not followed in this case. Review of the facility's policy indicated that circumstances requiring a change in treatment, such as new symptoms or the need for new interventions, necessitate prompt physician notification, which did not occur for this resident.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Clifton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Chestnut Hill Llc | 1.8 mi | ★★★★★ | 0 | 0 |
| Complete Care At Hamilton, Llc | 2.3 mi | ★★★★★ | 10 | 0 |
| Doctors Subacute Healthcare, Llc | 2.5 mi | ★★★★★ | 6 | 0 |
| Complete Care At Fair Lawn Edge | 2.9 mi | ★★★★★ | 6 | 0 |
| Barnert Subacute Rehabilitation Center, Llc | 2.9 mi | ★★★★★ | 0 | 0 |
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