Citations in Missouri
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Missouri.
Statistics for Missouri (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Missouri
A resident with dementia and anxiety, who was his/her own responsible party, was moved to a different room, including a locked memory care unit, without documented written notice or a signed agreement for the room change. The care plan indicated the room move had been discussed and agreed to, but the resident later reported not agreeing, becoming very upset and tearful, and feeling trapped in the locked unit. Staff, including CNAs and an agency LPN, stated that residents were supposed to receive written notice and that all parties should agree before a room change, but they were unsure if this occurred for this resident. EMR review showed no guardian or DPOA and no uploaded agreement related to the move, and the DON confirmed the resident had not been notified in writing and acknowledged unawareness of the regulatory requirement.
Two residents were affected when staff failed to follow and document physician orders for diagnostic testing. One resident with urinary retention, neuromuscular bladder dysfunction, and an indwelling catheter had multiple UAs ordered and marked as completed in the system, but the EMR contained no notes of urine collection attempts, refusals, or any UA results, despite care plan notes that the resident sometimes refused catheter care. Another resident with C. diff enterocolitis and morbid obesity fell while rising from a commode; after an X-ray could not be obtained, a CT of the back and right side was ordered, but the resident reported not being informed of the CT or a scheduled date, and the hospital scheduler stated the CT order was not received until days later and was initially invalid, preventing scheduling. Facility leadership and staff acknowledged that all MD orders should be followed and that attempts, refusals, and fax confirmations should be documented, but such documentation was absent in these cases.
The facility failed to manage finances and operations in a way that ensured timely payment to key vendors and adequate supplies and staffing for resident care. After a change in ownership, staff reported chronic shortages of wipes, towels, plates, gloves, and incontinence products, with downgraded product quality and no clear departmental budgets. Housekeeping used substitute cleaning chemicals with uncertain dilution, and dietary staff reported the dish machine lacked soap and rinse chemicals for an extended period, leading to hand-washing dishes and serving meals on Styrofoam plates and foam cups despite resident council requests for regular dishware. Corporate-controlled ordering resulted in reduced quantities and substitutions of cheaper food items, while the RD reported not being paid and difficulty working with corporate. Multiple vendors, including primary food suppliers, a staffing agency, an oxygen supplier, pest control, and other service providers, confirmed large unpaid, past-due balances with no payments made under new management. CNAs and LPNs described bounced or incorrect paychecks, missing hours, and unresolved payroll issues, along with frequent short staffing, extended shifts, and nurse turnover, while maintenance and housekeeping staff were reduced and multiple vendors remained unpaid, affecting services throughout the facility.
Surveyors found that the facility failed to complete a thorough facility-wide assessment, leaving all sections documenting monthly average ADL assistance needs (bed mobility, transfers, bathing, eating, toileting, and mobility) blank, despite a census of 91 residents. The assessment contained only general statements about staffing assignments and infection prevention practices and did not quantify resident care needs. During the survey, additional issues were identified, including lack of required 12-hour CNA training in abuse/neglect and dementia care for sampled CNAs, insufficient nursing staff resulting in missed treatments and ADL care, absence of a restorative program and speech therapy, incomplete TB testing for sampled residents, missing EBP signage and PPE for residents on enhanced barrier precautions, and housekeeping staff not using an EPA-registered hospital disinfectant. The administrator acknowledged responsibility and stated the assessment was expected to be fully completed with total numbers of residents requiring assistance.
Surveyors found that staff repeatedly failed to follow infection prevention and control policies, including not implementing Enhanced Barrier Precautions for residents with catheters, wounds, and nephrostomy tubes, not posting EBP signage, and not using gowns during high-contact care. Perineal care was performed on multiple residents with improper glove use and without required hand hygiene, and catheter care was omitted after bowel movements. A shared Hoyer lift was used on two residents consecutively without disinfection between uses. Several newly admitted residents and newly hired employees lacked required two-step TB testing or TB screening documentation. Housekeeping staff used a non–EPA-registered all-purpose cleaner on floors instead of a hospital-grade disinfectant and were unsure of correct dilution, while supply limitations and lack of a housekeeping leader contributed to inconsistent cleaning practices.
The facility did not maintain an active antibiotic stewardship program as required by its own policy. The written policy, dated 7/1/25, called for an antibiotic stewardship program integrated with infection prevention and control, led by the Medical Director, DON, IPC nurse, and consultant pharmacist, with support from the Administrator and governing officials, and intended to optimize infection treatment and reduce adverse events from antibiotic use. However, the Administrator reported that the program had not been updated for many months, the IPC nurse had recently left, and the program had only just been restarted, leaving the facility without established antibiotic use protocols or a system to monitor antibiotic use for its resident population.
The facility did not follow its own policy requiring that COVID-19 vaccines be offered, education provided, and vaccination status documented for all residents. Record review for five residents with significant conditions such as heart failure, kidney disease, asthma, diabetes, osteomyelitis, stroke, and dysphagia showed no documentation that they were offered or received the COVID-19 vaccine, nor that any education or refusals were recorded. The Infection Preventionist stated that vaccines, refusals, and related education are expected to be offered on admission or upon request and documented in the medical record, but this was not done for these residents.
The facility failed to maintain required inventories of personal belongings for two cognitively intact residents who reported missing clothing, despite a policy requiring completion and updating of inventory sheets and staff acknowledgment that such forms should be present and scanned into the medical record. A resident with anxiety, DM, and glaucoma did not receive an admission packet on the day of admission and lacked a baseline care plan, with the admission packet only signed later. The facility also used a new admission agreement that did not address prior $6,000 security deposits required under a previous management contract; one resident’s family provided documentation of having paid such a deposit, but subsequent invoices showed no record of a refund after discharge, while leadership reported unawareness of the prior deposit terms and that deposit funds were not turned over during the ownership change.
The facility failed to provide adequate ADL care, including bathing, nail care, oral hygiene, and assistance out of bed, for multiple residents. One resident with cognitive impairment and multiple comorbidities had no baseline care plan, was observed with oily hair and long, jagged fingernails, and reported not receiving a shower that week. Another cognitively intact, incontinent resident with heart failure, hip fracture, diabetes, and kidney disease, care planned for hands-on ADL assistance, was seen in stained clothing with unkempt hair and reported needing staff help with showers but receiving them infrequently, with missing shower documentation for an entire month. A third resident with muscle weakness and diabetes had no ADL needs in the care plan, was observed with overgrown toenails and caked debris on the teeth, and reported staff would not assist with nail care or toothbrushing, with a CNA citing lack of staffing. A fourth resident with heart and kidney disease, requiring extensive assistance and a Hoyer lift, had no care plan, was repeatedly observed in bed in a hospital gown, and reported wanting to get out of bed and into clothes but believing they were too much work for staff, despite therapy confirming no restrictions and a special wheelchair being available. Staff interviews confirmed expectations for twice-weekly showers or bed baths, hair washing, nail care, oral hygiene, and daily out-of-bed opportunities, which were not consistently met or documented.
The facility failed to follow physician orders for wound care and compression therapy for two residents with lower extremity wounds. One resident with multiple comorbidities had non‑pressure leg wounds with orders for specific cleansing, skin prep, xeroform, collagen powder, gauze, and Kerlix, as well as XXL knee‑high compression stockings. Observations showed saturated dressings left in place for several days, macerated surrounding skin, omission of ordered products, lack of collagen powder, and repeated failure to apply compression stockings despite an active order. Another resident with CHF, pneumonia, glaucoma, and diabetes had a skin tear on the left lower leg with orders for daily and PRN wound care, but staff did not document treatments for several days, and the dressing remained dated from the initial application. There was also no baseline care plan to guide staff on this resident’s care needs.
Failure to Provide Written Notice and Obtain Agreement for Resident Room Change
Penalty
Summary
The facility failed to honor a resident’s right to be informed and to exercise self-determination regarding a room change. A resident with unspecified dementia of unspecified severity without behavioral disturbance and an anxiety diagnosis was admitted as his/her own responsible party, with no guardian or DPOA documented. The resident’s care plan noted dementia and documented that on 1/6/26 a room move was discussed and the resident agreed, and that on 1/7/26 staff were assisting with the move when the resident became upset and stated a desire to leave the facility. A quarterly MDS dated 1/8/26 showed the resident had severely impaired cognition and no wandering behavior. During a later interview, the resident reported not agreeing to the room move, becoming very upset and tearful, not understanding why he/she had been moved to a locked unit, and feeling trapped there, and was unable to state whether written notice of the room change had been received. Record review of the EMR showed the resident had no guardian or DPOA, was his/her own responsible party, and there was no signed agreement uploaded related to the room move. Multiple staff interviews (two CNAs and an agency LPN) confirmed that all residents were supposed to receive written notice of room moves and that all parties needed to agree before a room change, but they were unsure whether this resident had received written notice; the agency LPN reported the resident was upset and refused to move while being escorted down the hall. The DON confirmed the resident had not been notified in writing about the room move, was unsure why written notification had not been provided, and stated unawareness of the regulation, while acknowledging the resident should have been notified in writing. The facility’s own Resident Rights policy stated that information about resident rights and responsibilities would be given orally and in writing, but there was no documentation that written notice of the room change had been provided to this resident.
Failure to Follow and Document Physician Orders for UA and CT Imaging
Penalty
Summary
The deficiency involves the facility’s failure to ensure physician orders were followed and appropriately documented for two residents. One resident with urinary retention, neuromuscular bladder dysfunction, severely impaired cognition, and an indwelling catheter had physician orders for urinalyses in December 2025, with the electronic order status showing both tests as completed. However, review of the electronic medical record revealed no nursing notes related to collection of the ordered urine specimens and no laboratory results for any urinalysis in December. The resident’s care plan included monitoring and reporting signs and symptoms of UTI and noted that the resident had a fixation with the genital area and sometimes refused catheter care, but there was still no documentation that staff attempted to obtain the ordered UAs, that the resident refused, or that collection was otherwise unsuccessful. For the second resident, who had diagnoses including enterocolitis due to C. difficile and morbid obesity, an unwitnessed fall occurred while the resident was attempting to stand from a commode. An X-ray was ordered but could not be obtained due to the resident’s abdominal size, and the physician then ordered a CT scan of the back and right side. The facility’s order summary showed the CT scan order, and staff interviews indicated that the order was to be faxed to a local hospital. The resident later reported being unaware that a CT scan had been ordered and not being given a scheduled date for the procedure. A hospital scheduling manager reported not seeing a CT order for the resident until several days after the order date and stated that the CT had not been scheduled because the facility sent an invalid order that required correction before scheduling. The administrator, CNAs, LPNs, and the DON all stated that physician orders were expected to be followed as written and that failed attempts to collect UAs or send out imaging orders should be documented in the EMR, MAR, or TAR, including confirmation of fax receipt when applicable. The DON confirmed there was no documentation that the UAs for the first resident could not be collected and no documentation confirming that the CT order for the second resident had been sent or received before the date identified by the hospital scheduler.
Failure to Pay Vendors and Maintain Adequate Supplies and Staffing for Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a way that ensured timely payment to key vendors and adequate procurement of supplies and services necessary for resident care. Staff interviews revealed that after a change in ownership, the facility experienced significant budget and payment issues, resulting in limited supplies such as wipes, towels, plates, gloves, and incontinence products. Central Supply staff reported that prior to the ownership change there were no supply problems, but afterward corporate imposed strict limits on quantities, downgraded product quality, and removed departmental budgets. Staff described gloves that ripped when donned and a switch from higher-quality briefs to lower-quality ones that did not contain urine effectively, with residents complaining about the briefs and staff reporting increased odors and residents being soiled. Housekeeping staff reported that the facility stopped purchasing the usual floor-cleaning chemicals and that they were using an all-purpose cleaner instead, with uncertainty about correct dilution and the last bottle nearly gone. The facility also failed to ensure timely payment to multiple critical vendors, including food suppliers, a dietician, staffing agencies, oxygen suppliers, pest control, and other service providers, placing residents at risk for interruption of services and inadequate care as stated in the report. The dietary department reported that the dish machine had been without soap and rinse chemicals for over a month, leading staff to wash dishes by hand and serve meals on Styrofoam plates and foam cups instead of regular dishware, despite resident council requests for regular plates and bowls. The Dietary Manager stated that corporate controlled ordering, frequently pushed back on quantities, and substituted cheaper or different food items than those ordered, including lower-quality ground beef and reduced quantities of produce such as bananas and grapes. The Registered Dietician reported difficulty communicating with corporate, uncertainty about the food-ordering staff’s food service experience, and that he or she had not been paid for services since the new ownership took over. Vendor records and interviews confirmed large unpaid balances to primary food vendors and other suppliers over several months with no payments made under the new management. In addition, the facility’s financial and administrative failures extended to payroll and contracted services, affecting staffing and resident care. CNAs and LPNs reported bounced paychecks, incorrect pay rates, missing hours, and unresolved payroll discrepancies, with explanations referencing time clock issues and processing from an out-of-state corporate office. A staffing agency representative reported that after ownership changed, the facility used agency staff without making any payments on multiple invoices totaling approximately $179,000, leading the agency to stop providing staff. The Plant Operations Manager and other staff reported cuts to housekeeping and maintenance staff, unpaid pest control and snow removal vendors, and multiple vendors not being paid. A beautician reported not being fully paid and receiving no assistance from the facility in contacting private-pay residents’ families for payment. An oxygen vendor, an additional food vendor, and a pest control company each confirmed that no payments had been made since before the new management took over, with balances significantly past due. The report notes that the Department of Health and Senior Services attempted to contact the corporate business office manager without returned calls, while the facility census was 91 and the deficient practice was described as having the potential to affect all residents by placing them at risk for interruption of services and inadequate care. Staff also described how these financial and operational issues contributed to staffing instability and workload problems. CNAs and LPNs reported frequent short staffing, difficulty obtaining agency staff, and situations where nurses were unsure when they would be relieved, with some working extended hours such as 23 hours on a shift. The DON was reported to be working the floor extensively, contributing to burnout, and multiple nurses reportedly left due to uncertainty about relief and staffing. The Plant Operations Manager stated that staffing and supplies were an issue and that he was pulled in different directions, including filling in for housekeeping, while the transition in ownership had been hard on residents and families. The Administrator acknowledged that there had been multiple Administrators and DONs since the ownership change, that regulatory duties were not handed off between Administrators, and that agency staffing was used to meet minimum staffing requirements, while also indicating that a system for continuity of care was still being developed. These combined actions and inactions in financial management, vendor payment, supply procurement, and staffing administration led to the cited deficiency for failure to administer the facility in a manner that enabled effective and efficient use of resources to meet residents’ needs.
Incomplete Facility-Wide Assessment and Related Care Resource Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a complete and thorough facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. The written Facility Assessment, last updated on 12/18/25, included basic operational data such as licensed bed count, average daily census, and average admissions and discharges by shift, but left all sections for monthly average assistance with activities of daily living (ADLs) blank. Specifically, no data were recorded for residents’ needs in bed mobility (sit to lying), mobility (sit to stand), bathing, transfers, eating, toileting, or other care, and there were no entries for levels of assistance such as set up, supervision/partial/moderate assistance, or dependent/max assistance. The assessment also contained only general narrative descriptions of how staff assignments are determined and how the infection prevention and control program is evaluated, without tying these to quantified resident care needs. During the survey, additional problems were identified that related to staffing, training, and infection control, which were not reflected in or supported by the incomplete facility assessment. These included the absence of required 12-hour CNA competencies in abuse/neglect and/or dementia care for all sampled CNAs employed more than one year, insufficient nursing staff to meet resident needs as evidenced by staff interviews and reports of missed treatments and missed ADL care, and the lack of a restorative program or speech therapy. Infection control issues were also found, including missing tuberculosis testing for all sampled residents, residents on enhanced barrier precautions without appropriate signage or PPE supplies, and housekeeping staff not using an EPA-registered hospital disinfectant for floor cleaning. In an interview, the Administrator stated an expectation that the facility assessment be fully completed with total numbers of residents requiring assistance and acknowledged responsibility for ensuring the assessment’s completion.
Failure to Implement EBP, Maintain Aseptic Care Practices, Disinfect Equipment, and Complete TB Screening
Penalty
Summary
Surveyors identified multiple infection prevention and control deficiencies involving failure to implement Enhanced Barrier Precautions (EBP), improper perineal care technique, inadequate disinfection of shared equipment, and lack of required tuberculosis (TB) screening for residents and staff. Several residents with indwelling devices or open wounds did not have EBP signage or personal protective equipment (PPE) available, and staff did not use gowns during high-contact care activities as required by facility policy and CDC/CMS guidance. For example, a resident with a urinary catheter had no EBP order, no EBP signage, and no PPE available; CNAs performed incontinence and catheter care wearing only gloves, then used the same contaminated gloves to apply a clean brief, adjust bedding, and touch privacy curtains. Another resident with left leg wounds requiring dressing changes had saturated dressings and ongoing wound care performed by an LPN and the ADON without gowns, and without EBP signage or PPE supplies in or outside the room, despite the ADON acknowledging the resident was on EBP and that gowns were not available in the facility. Additional residents with indwelling urinary catheters and nephrostomy tubes also lacked EBP implementation. One cognitively intact resident with an indwelling catheter had no EBP orders and no EBP signage; a CNA entered the room, donned only gloves, and performed perineal care and catheter manipulation while leaning against the resident, without wearing a gown. Another resident with nephrostomy tubes and daily dressing changes had an EBP order, but repeated observations showed no EBP signage and no PPE at or near the room. A staff member entered, donned gloves, and changed the nephrostomy dressings without an isolation gown. A resident with pressure ulcers and a wound care order also had no EBP signage or PPE available over several days. Staff interviews revealed inconsistent understanding of EBP, with one LPN stating they were not exactly sure which residents required EBP and a CNA reporting that isolation gowns had not been seen for weeks. Surveyors also observed improper perineal care and hand hygiene practices. For one severely cognitively impaired resident, an LPN removed a soiled brief, cleaned the perineal area, then with the same gloved hands applied a clean brief, assisted the resident to dress, transferred the resident to a wheelchair, and propelled the resident to the dining room, without changing gloves or performing hand hygiene. Another resident with a catheter had perineal care performed without PPE, and catheter care was not completed after stool was cleaned from the rectal area; the CNA later stated they "guessed" they should clean the catheter and genitals. The facility’s own incontinent care policy required hand hygiene, glove changes, and use of clean surfaces of cloths for each wipe, which were not followed in these observations. The survey further documented failure to disinfect shared equipment and to complete required TB screening. A Hoyer lift was used to transfer one resident from bed to wheelchair and then immediately used to transfer another resident for weighing and back to bed, without any cleaning or sanitizing between residents. Staff, including an LPN, CNA, and the DON, acknowledged that the lift should have been wiped down between residents. Review of medical records for multiple newly admitted residents showed no documentation of two-step TB testing or TB screening, despite facility policy requiring TB screening at or before admission. Similarly, review of employee files for numerous newly hired staff showed no documentation of TB tests or chest x-rays, contrary to the facility’s Employee Tuberculosis Test policy. Environmental cleaning practices also failed to meet facility policy requiring use of an EPA-registered hospital disinfectant. Housekeeping staff reported that the facility had stopped purchasing the previous disinfectant product and were instead using Medorra Limpreza All Purpose Cleaner Lavender scent for floors, measuring it by eye into mop buckets without clear dilution instructions. The product container lacked an EPA registration number, and checks of EPA resources and the manufacturer’s website did not verify it as an EPA-registered or hospital-grade disinfectant. Housekeepers and other staff described supply limitations and lack of a Housekeeping Director, and the Regional Nurse Consultant confirmed there was no training on how much floor chemical to use, while the Administrator stated he expected housekeeping to use appropriate supplies and know correct chemical amounts.
Failure to Maintain an Active Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and maintain an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The written Antibiotic Stewardship policy, dated 7/1/25, stated that the facility would implement an antibiotic stewardship program as part of its overall infection prevention and control program, with the purpose of optimizing treatment of infections and reducing adverse events associated with antibiotic use. The policy identified the Medical Director, DON, IPC Nurse, and Consultant Pharmacist as leaders of the program, with support from the Administrator and governing officials. However, during an interview, the Administrator reported that the antibiotic stewardship program had not been updated since March 2025, that the IPC Nurse had recently quit, and that the facility had only just restarted the program on 1/22/26, despite the Administrator’s expectation that the program should have been in place for the facility’s census of 91 residents. No specific residents, their medical histories, or clinical conditions at the time of the deficiency were described in the report, and no resident-specific antibiotic use data or monitoring activities were documented. The deficiency is based on the lack of an active, updated antibiotic stewardship program and the absence of established antibiotic use protocols and a monitoring system as required by the facility’s own policy.
Failure to Offer and Document COVID-19 Vaccination for Multiple Residents
Penalty
Summary
The facility failed to follow its COVID-19 vaccination policy by not offering, educating about, or documenting COVID-19 vaccination for five reviewed residents. The written policy dated 7/1/25 required that COVID-19 vaccinations be offered to all residents unless medically contraindicated, that residents be educated in an understandable manner using CDC or FDA information about risks and benefits, that they be given an opportunity to ask questions, and that the facility maintain documentation of vaccination status, education, and refusals in the medical record. Record review for the sampled residents showed no documentation that any of them had been offered or received the COVID-19 vaccine, nor that any education or refusals had been recorded. The affected residents had multiple significant medical diagnoses. One resident had heart failure and kidney disease, another had asthma and kidney disease, another had diabetes and osteomyelitis of the foot, another had heart failure and a history of stroke, and another had stroke, dysphagia, and kidney disease. Despite these conditions, there was no documentation in any of their medical records regarding COVID-19 vaccination offers, administration, or refusals. In an interview, the Regional Nurse Consultant, who also serves as the facility’s Infection Preventionist, stated that he expected COVID-19 vaccinations to be offered on admission or upon resident request, and that all vaccinations, refusals, and related education should be documented in the medical record, which was not reflected in the reviewed records.
Failure to Maintain Personal Property Inventories and Provide Accurate Admission and Deposit Information
Penalty
Summary
The deficiency involves the facility’s failure to maintain and update residents’ personal belongings inventories and to follow its grievance and missing property policy, as well as failures related to admission information and financial agreements. The facility’s policy dated 7/1/25 stated that residents and representatives have the right to report missing items, that staff may resolve grievances immediately or follow the grievance procedure if unable to do so, and that supervisory personnel are responsible for notifying residents and representatives of the outcome of missing property investigations. For one cognitively intact resident admitted on 6/3/25 with diagnoses including arthritis and spinal stenosis, there was no inventory of personal belongings sheet in the medical record despite observation of multiple personal items in the room. This resident reported missing specific clothing items, stated they had informed multiple staff members, and reported that no one followed up and that they had never been provided an inventory sheet at admission or afterward. Another cognitively intact resident admitted on 4/27/25 with diagnoses including heart failure, hip fracture, diabetes, and kidney disease also had no inventory sheet in the record, despite having numerous clothing items in the room, and reported multiple tops missing after being sent to laundry, stating they had never completed an inventory of personal belongings. Staff interviews confirmed that the facility’s process required inventory sheets to be completed on admission and updated when new items were brought in, with forms to be scanned into the medical record. A CMT stated that paper inventory sheets were available on each hall and should be completed and updated, and the Laundry Supervisor stated that an inventory sheet should exist for every resident and be located either in the medical record or in the resident’s room. The Laundry Supervisor reported not having seen inventory sheets for the two residents with missing clothing and being unable to locate their missing items. The Administrator and DON stated they expected staff to complete inventory sheets on admission and update them when new items arrived, and that staff should attempt to locate missing clothing and initiate an investigation if items were not found. Additional deficiencies involved admission information and financial agreements. One resident admitted on 1/5/26 with diagnoses including anxiety, diabetes, and open angle glaucoma did not have a baseline care plan in the record and reported not receiving a welcome/admission packet on admission; the admission packet on file was signed by the resident on 1/23/26, indicating it was not provided on the day of admission as expected by the Administrator. The facility’s prior admission agreement under the previous management company required a $6,000 interest-free security deposit, refundable within 45 days after discharge, and described how it would be treated for Medicaid and room-and-board charges. The current admission agreement under new management did not address the prior contract or deposits made under it. For a resident with severe cognitive impairment and multiple diagnoses including hypertension, non-Alzheimer’s dementia, and asthma, documentation from the family showed a $6,000 deposit paid at application along with room and board charges, and progress notes documented the resident’s transfer and discharge; however, invoices reviewed later showed no documentation of a refund of the $6,000 deposit. Interviews with the Regional Nurse Consultant and Administrator revealed unawareness of the prior deposit requirement, lack of documentation addressing previous deposits in the new agreement, and that funds related to deposits were not turned over during the ownership change, while the facility was still operating under the previous management company and honoring the original contract.
Failure to Provide Adequate ADL Care, Hygiene, and Out-of-Bed Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate activities of daily living (ADL) care, including bathing, nail care, oral hygiene, and assistance out of bed, as required by facility policy and resident needs. The facility’s ADL and oral hygiene policies required staff to assist with bathing to promote cleanliness and dignity, to provide oral care per the care plan, and to notify the DON and reschedule if showers were refused. For one resident with chronic kidney disease, major depressive disorder, anxiety, and moderately impaired cognition, there was no baseline care plan in the record. This resident was observed in the dining room with oily, stringy hair and long, jagged fingernails and reported not having received a shower that week and wanting nail trimming. Another cognitively intact resident with heart failure, hip fracture, diabetes, kidney disease, and urinary incontinence was care planned for hands-on assistance with bathing and other ADLs, but was observed in stained clothing with frizzy, messy hair and reported being supposed to receive showers twice weekly, needing assistance to shower, and desiring more frequent showers due to incontinence and odor. Shower documentation showed only three showers in January and no shower records for December. A third cognitively intact resident with muscle weakness and diabetes had no ADL care needs included in the care plan. This resident was repeatedly observed in bed with toenails on both feet approximately one-eighth of an inch long and jagged, and with a whitish-yellow substance caked on the front teeth on consecutive days. The resident reported having asked staff for help with nail trimming without receiving assistance and stated that children had to come in to help with toothbrushing because staff were too busy. A CNA stated that nail care should be provided after showers and that lack of staffing was the reason the resident was not being assisted with oral hygiene, and confirmed the resident required staff assistance with showers and personal hygiene. Staff interviews, including with an LPN and the DON, confirmed expectations that residents receive at least two showers or bed baths weekly, that hair be washed during showers, that nails be kept clean and trimmed, and that staff assist with oral hygiene. Another cognitively intact resident with heart disease, kidney disease, and high blood pressure, requiring substantial to maximum assistance for bed mobility and transfers, had no care plan completed. This resident was repeatedly observed in bed on the back, wearing a hospital gown, and reported wanting to get out of bed and wear clothing but being reluctant to ask because staff left the resident up in a chair too long. The resident stated not having gotten out of bed on one observed day, believed being too much work for staff due to needing a Hoyer lift, and expressed a desire to see outside the room. The Director of Therapy reported the resident had no restrictions, should be transferred with a Hoyer lift, and had a special high-back wheelchair in the room. A CNA stated the resident was offered to get out of bed but would refuse, and the DON stated the expectation that the resident get out of bed daily and as requested, with refusals to be reported to the nurse and documented in the record and care plan. These observations and interviews demonstrate failures to provide and document ADL care, including bathing, nail care, oral hygiene, and assistance out of bed, in accordance with resident needs and facility policy.
Failure to Follow Wound Care and Compression Stocking Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care and compression therapy as ordered for two residents with lower extremity wounds. One cognitively intact resident with heart failure, hip fracture, diabetes, and kidney disease had non‑pressure wounds on the left anterior and lateral leg, caused by being struck with something. The resident’s care plan did not address wound care, despite active wound treatment orders specifying cleansing with wound cleanser or normal saline, application of skin prep, xeroform gauze, collagen powder, gauze, and Kerlix wrap secured with tape. Documentation showed wound treatments were not completed on certain ordered days. Observations revealed dressings dated several days earlier that were saturated with serous drainage, with surrounding skin macerated, and the resident reported having to change a wet sock due to drainage. During wound care observations, an LPN removed a saturated dressing that had been in place for multiple days and applied only a Mepilex dressing, omitting the ordered skin prep, xeroform, collagen powder, gauze, and Kerlix. The LPN also did not apply the resident’s ordered XXL knee‑high compression stockings, despite an active order for application in the morning and removal in the evening. On multiple subsequent observations, the resident continued to be without compression stockings, and the left leg dressing remained saturated with serous drainage and dated several days prior. The ADON later performed the wound treatment and stated the facility did not have collagen powder available, and she completed the dressing change without it. Facility leadership, including the ADON and DON, stated that nurses were responsible for completing wound treatments as ordered, ordering needed supplies, and accurately documenting treatment completion. A second resident, admitted with diagnoses including CHF, pneumonia, glaucoma, and diabetes, had no baseline care plan to direct staff on care needs. An order was in place to cleanse a skin tear on the left lower leg with normal saline, apply xeroform, and a dry dressing daily and PRN. From the date the order was initiated through several subsequent days, staff did not document completion of the ordered treatment. The resident reported having a wound on the left leg/ankle, and a CNA reported that the wound occurred when the resident’s leg became caught during a transfer with a PT. Observation later showed the dressing on the left leg still dated from the initial treatment date, indicating that ordered daily and PRN wound care had not been performed or documented during that period. The Regional Nurse Consultant confirmed that nurses were responsible for documenting completion of wound treatments and following physician orders.
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