Inspection Reports for
Beth Haven Nursing Home
2500 PLEASANT ST, HANNIBAL, MO, 63401-2600
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
20.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
273% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
36
27
18
9
0
Census
Latest occupancy rate
69 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Abbreviated Survey
Census: 69
Deficiencies: 3
Date: Jun 30, 2025
Visit Reason
The inspection was conducted due to failure to maintain indoor air temperatures within a safe and comfortable range in resident rooms on the East wing, resulting in immediate jeopardy to resident health and safety.
Findings
The facility failed to maintain indoor air temperatures between 71°F and 81°F in 19 sampled resident rooms, with temperatures ranging from 82°F to 92°F. Portable air conditioning units were installed but staff did not monitor temperatures or residents adequately, and the emergency cooling plan was not properly implemented. Immediate jeopardy was identified but later removed after corrective actions.
Deficiencies (3)
Failure to maintain indoor air temperatures of resident rooms between 71°F and 81°F, with temperatures ranging from 82°F to 92°F in 19 sampled residents' rooms on the East wing.
Failure to have a comprehensive monitoring system including documentation of resident room temperatures and each resident's condition.
Failure to follow the emergency cooling plan to monitor temperatures hourly and assess residents appropriately.
Report Facts
Residents affected: 19
Facility census: 69
Room temperature range: 82
Room temperature range: 92
Heat index: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E | Certified Medication Technician (CMT) | Interviewed regarding lack of temperature monitoring and resident discomfort |
| Director of Nursing (DON) | Interviewed about air conditioning failure, emergency plan, and monitoring failures | |
| Administrator | Interviewed about air conditioning failure, emergency plan, and monitoring failures | |
| Medical Director | Interviewed about expectations for monitoring residents during excessive heat |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 1
Date: Jun 5, 2025
Visit Reason
The inspection was conducted following a complaint alleging verbal abuse by Licensed Practical Nurse (LPN) A towards Resident #1 regarding refusal to provide a cup of coffee.
Complaint Details
The complaint was substantiated. LPN A verbally abused Resident #1 by yelling and pointing a finger in the resident's face after refusing to provide a cup of coffee. The facility suspended LPN A on 05/28/25, conducted an investigation, provided staff in-servicing on abuse, and terminated LPN A on 06/02/25.
Findings
The facility failed to ensure Resident #1 was free from verbal abuse when LPN A yelled at the resident, pointed a finger in the resident's face, and refused to provide coffee. The facility investigated, suspended, and ultimately terminated LPN A for staff-to-resident abuse. The deficiency was corrected with staff in-servicing on abuse prevention.
Deficiencies (1)
Failure to protect Resident #1 from verbal abuse by LPN A who yelled at the resident and pointed a finger in the resident's face.
Report Facts
Residents present: 64
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Alleged perpetrator of verbal abuse towards Resident #1 |
| Director of Nursing | Director of Nursing | Suspended LPN A pending investigation and oversaw corrective actions |
| Administrator | Administrator | Notified of noncompliance and confirmed verbal abuse as form of abuse |
| CNA B | Certified Nursing Assistant | Witnessed and reported LPN A's verbal abuse |
| CNA C | Certified Nursing Assistant | Witnessed and reported LPN A's verbal abuse |
| GPN D | Graduate Practical Nurse | Provided coffee to resident after LPN A refused and witnessed verbal abuse |
Inspection Report
Routine
Census: 65
Deficiencies: 2
Date: Apr 10, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding resident care, specifically focusing on ensuring residents have proper fitting wheelchairs and that outpatient therapy services are properly coordinated.
Findings
The facility failed to ensure one resident had a properly fitting wheelchair that did not cause pain, and failed to ensure residents received coordinated outpatient therapy services, resulting in lack of communication and inadequate care for residents receiving therapy.
Deficiencies (2)
Failed to ensure one resident had a proper fitting wheelchair that did not cause pain.
Failed to ensure residents received physical, occupational, and speech therapy services under an agreed arrangement, resulting in lack of communication and coordination of care.
Report Facts
Residents affected: 1
Residents affected: 2
Census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Responsible for ensuring residents had proper equipment including wheelchairs | |
| Social Services Director | Responsible for scheduling occupational therapy evaluation for wheelchair fitting |
Inspection Report
Routine
Census: 71
Deficiencies: 27
Date: Feb 6, 2025
Visit Reason
The inspection visit was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, safety, medication management, infection control, and facility maintenance.
Findings
The facility had multiple deficiencies including improper wheelchair fitting causing resident discomfort, lack of access to resident funds on weekends, inadequate security of resident funds, failure to post survey results accessibly, loss and damage of resident property, unapproved use of restraints, failure to prevent abuse and neglect, incomplete care plans, medication administration errors, inadequate assistance with activities of daily living, inconsistent resident code status documentation, failure to post nurse staffing information, improper pharmaceutical services, failure to ensure food safety and sanitation, pest control issues, and incomplete infection prevention and control practices.
Deficiencies (27)
Failed to ensure one wheelchair bound resident had a proper fitting wheelchair that did not cause pain.
Failed to ensure residents had reasonable access to their personal funds on weekends.
Failed to maintain a surety bond sufficient to protect residents' personal funds.
Failed to place facility survey results in an accessible area with proper signage.
Failed to ensure reasonable care for protection of resident property from loss and damage.
Failed to ensure residents had access to their personal funds and secure handling of funds.
Failed to ensure residents were free from use of physical restraints unless medically necessary.
Failed to review Nurse Aide Registry for Federal Indicator for newly hired employees.
Failed to develop complete care plans consistent with residents' specific conditions and needs.
Failed to follow professional standards for medication administration, including lab work, documentation, and observation of medication intake.
Failed to provide necessary care and assistance for activities of daily living and oral care.
Failed to ensure accurate and consistent resident code status documentation across all records and locations.
Failed to ensure harmful chemicals were kept in locked cabinets and inaccessible to residents.
Failed to post daily nurse staffing information in a prominent and accessible location.
Failed to ensure inventories of controlled substances were reconciled by two qualified staff at shift changes.
Failed to administer insulin according to manufacturer's recommendations including priming insulin pens and holding pen for proper time during injection.
Failed to complete or properly document two-step Tuberculin Skin Tests (TST) for employees and failed to complete annual TB testing as required.
Failed to develop and implement a Legionella water management program including water flow map, water management team, and monitoring parameters.
Failed to ensure lids on outdoor garbage and grease containers remained closed or covered when not in use.
Failed to ensure food was served at safe and appetizing temperatures and according to diet orders.
Failed to store, prepare, and serve food in accordance with professional food safety standards including hand hygiene, glove use, hair restraints, and sanitation of surfaces and equipment.
Failed to ensure discontinued and discharged residents' medications were destroyed or returned timely.
Failed to ensure residents received physical, occupational, and speech therapy services as ordered and coordinated with outpatient providers.
Failed to ensure residents were free from significant medication errors including improper medication handling and administration.
Failed to ensure staff washed hands and used gloves properly during resident care and medication administration.
Failed to regularly inspect bed frames, mattresses, and bed rails for safety and entrapment hazards.
Failed to maintain an environment to deter pests from entering the facility including open windows without screens and propped open exterior doors.
Report Facts
Facility census: 71
Residents with regular diet: 43
Residents with consistent carbohydrate diet: 10
Residents with heart healthy diet: 7
Residents with large portion diet: 4
Residents with pureed diet: 6
Narcotic count missing signatures: 7
Days medication not documented: 7
Days medication not documented: 5
Days medication not documented: 10
Days medication not documented: 20
Mouse droppings count: 50
Mouse droppings count: 50
Temperature of pureed potato salad: 89.1
Temperature of pureed spinach: 108.7
Temperature of mechanical soft pork loin: 110.7
Temperature of pureed pork loin: 111.2
Temperature of mechanical soft potato salad: 61.2
Temperature of chopped spinach: 105.8
Temperature of mechanical soft spinach: 105.8
Temperature of mechanical soft meat: 170
Temperature of mechanical soft starch: 166
Temperature of mechanical soft vegetable: 165
Temperature of mechanical soft bread: 160
Temperature of puree meat: 170
Temperature of puree starch: 167
Temperature of puree vegetable: 166
Temperature of puree bread: 160
Temperature of puree dessert: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN P | Licensed Practical Nurse | Named in insulin administration and therapy coordination findings |
| CMT W | Certified Medication Technician | Named in insulin administration and medication handling findings |
| CNA A | Certified Nurse Assistant | Named in incontinence care and hand hygiene findings |
| Dietary Manager | Named in food safety and sanitation findings | |
| Maintenance Director | Named in water management and pest control findings | |
| Director of Nursing | Director of Nursing | Named in multiple findings including infection control, therapy, and code status |
| Administrator | Administrator | Named in multiple findings including staffing, therapy, pest control, and code status |
| SSD | Social Service Director | Named in therapy coordination and code status findings |
| LPN I | Licensed Practical Nurse | Named in TB testing findings |
| CMT BB | Certified Medication Technician | Named in TB testing findings |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Date: Oct 10, 2024
Visit Reason
The inspection was conducted due to a complaint or concern regarding the improper transfer of Resident #2, who was transferred using a gait belt instead of the required mechanical lift as specified in the resident's care plan.
Complaint Details
The visit was complaint-related due to concerns about improper transfer techniques for Resident #2. The complaint was substantiated as staff transferred the resident with a gait belt instead of a mechanical lift, contrary to the care plan and facility policy.
Findings
The facility failed to transfer Resident #2 safely according to the care plan, which required use of a mechanical lift. Staff transferred the resident with a gait belt despite the resident being non-weight bearing, resulting in multiple bruises on the resident's left upper arm. Interviews revealed staff were unaware or improperly trained on the resident's transfer needs. The Director of Nursing confirmed the expectation for mechanical lift use and linked the bruises to improper transfer.
Deficiencies (1)
Failure to provide safe transfer for Resident #2 by using a gait belt instead of the required mechanical lift as per care plan.
Report Facts
Facility census: 71
Residents affected: 1
Bruise age estimate: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nurse Aide | Involved in improper transfer of Resident #2 using a gait belt |
| CNA D | Certified Nurse Aide | Involved in improper transfer of Resident #2 using a gait belt |
| LPN F | Licensed Practical Nurse | Directed CNAs to transfer Resident #2 with gait belt despite care plan |
| Director of Nursing | Confirmed expectation for mechanical lift use and linked bruises to improper transfer |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 3
Date: Jul 18, 2024
Visit Reason
The inspection was conducted following complaints and allegations including misappropriation of narcotics by a Licensed Practical Nurse (LPN D), alleged staff abuse of a resident, and pest control issues within the facility.
Complaint Details
The complaint investigation involved allegations that LPN D misappropriated narcotics from residents #1 and #3, and that a staff member slapped Resident #2 on the hand. The facility failed to conduct thorough investigations or obtain written statements from involved parties. Resident #2 reported the abuse and had a bruise, but the investigation was not completed. The facility also failed to report investigation results to the state agency within five working days.
Findings
The facility failed to prevent misappropriation of narcotics by LPN D, who was found to have signed out and documented administration of pain medications that residents denied receiving. The facility also failed to conduct thorough investigations into allegations of abuse and misappropriation, and failed to report investigation results timely. Additionally, the facility failed to maintain effective pest control measures, with evidence of mice and roaches in the kitchen and dining areas.
Deficiencies (3)
Failure to protect residents from misappropriation of narcotics by LPN D, who removed and documented administration of medications not received by residents.
Failure to provide evidence of a thorough investigation following allegations of staff abuse and misappropriation, and failure to report investigation results to the state agency within five working days.
Failure to maintain effective pest control measures to prevent mice and roaches in the facility including the east dining room and kitchen.
Report Facts
Facility census: 68
Pain medication removal times: 1
Pain medication removal times: 1
Resident pain rating: 14
Resident #2 abuse report date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Named in narcotic misappropriation findings and terminated following investigation |
| CMT E | Certified Medication Technician | Reported concerns about narcotic administration and worked with LPN D on 7/7/24 |
| House Supervisor/RN F | Registered Nurse | Notified DON of narcotic concerns and sent LPN D home on 7/7/24 |
| Director of Nursing (DON) | Director of Nursing | Interviewed residents and staff, acknowledged incomplete investigations |
| Administrator | Facility Administrator | Acknowledged failures in investigation and pest control oversight |
| CNA C | Certified Nurse Assistant | Reported abuse allegation by Resident #2 to DON |
| Dietary A | Dietary Staff | Reported sightings of mice in kitchen |
| Dietary Aide B | Dietary Aide | Reported unawareness of mouse droppings in dry storage |
| Maintenance Director | Maintenance Director | New employee unaware of pest issues in kitchen and dry storage |
| Operation Manager | Pest Control Company Manager | Provided recommendations on pest control and food storage |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 3
Date: Jun 14, 2024
Visit Reason
The inspection was conducted due to complaints regarding medication administration documentation, safe resident transfers, and provision of special eating equipment for residents.
Complaint Details
The complaint investigation revealed issues with medication administration documentation for Residents #11, #13, #15, and #16; unsafe transfer techniques causing bruising and skin tears for Resident #9; and failure to provide special eating equipment for Resident #9.
Findings
The facility failed to properly document administration of controlled medications for multiple residents, failed to provide safe transfer techniques causing bruising and skin tears to a resident, and failed to provide special eating equipment and utensils as required for a resident.
Deficiencies (3)
Failed to document administration of controlled medications removed from the Nexus machine and resident medication count sheets for multiple residents.
Failed to provide safe transfers and prevent bruising and skin tears for one resident by lifting under the arms and pulling on arms during dressing.
Failed to provide special eating equipment and utensils (divided plate, large handled curved utensils, Kennedy cups) for one resident as indicated in dietary orders.
Report Facts
Facility census: 73
Bruise size: 12
Bruise size: 13
Skin tear size: 2.5
Skin tear size: 0.5
Medication doses removed: 4
Medication doses removed: 4
Medication doses removed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN I | Licensed Practical Nurse | Named in medication administration documentation deficiencies and interviews regarding medication handling |
| LPN H | Licensed Practical Nurse | Named in medication administration documentation deficiencies and interviews regarding medication handling |
| CMT F | Certified Medication Technician | Named in medication administration documentation deficiencies and interviews regarding medication handling |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided interview statements regarding medication administration expectations and safe transfer practices |
| LPN/Clinical Care Coordinator | Licensed Practical Nurse/Clinical Care Coordinator | Provided interview statements regarding medication cart audit and medication handling |
| CNA B | Certified Nurse Assistant | Observed and interviewed regarding feeding assistance and failure to provide special eating equipment |
| CNA D | Certified Nurse Assistant | Observed and interviewed regarding unsafe transfer techniques causing bruising and skin tears |
| CNA E | Certified Nurse Assistant | Observed and interviewed regarding unsafe transfer techniques causing bruising and skin tears |
| Dietary Supervisor | Dietary Supervisor | Interviewed regarding failure to provide adaptive eating equipment and dietary compliance |
| Administrator | Administrator | Interviewed regarding safe transfer practices and dietary compliance |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 2
Date: Apr 23, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report and thoroughly investigate allegations of sexual abuse involving one resident (Resident #1).
Complaint Details
The complaint involved allegations of sexual abuse by a family member (Power of Attorney A) toward Resident #1. Staff reported the incident on April 13, 2024, but the facility did not report it to the state agency until April 17, 2024. The investigation was delayed and incomplete, with no interviews of the resident's representative and other residents. The Social Services Director initiated the investigation days later and contacted law enforcement and the state agency.
Findings
The facility failed to timely report allegations of abuse to the state agency and did not thoroughly investigate the allegations of sexual abuse reported by staff. The investigation lacked interviews with the resident's representative and other residents, and documentation was incomplete. The abuse was reported to the state agency four days after staff became aware of it.
Deficiencies (2)
Failed to timely report allegations of abuse to the state agency for one resident.
Failed to thoroughly investigate allegations of sexual abuse, including lack of interviews with resident's representative and other residents, and incomplete documentation.
Report Facts
Facility census: 79
Date of incident: Apr 13, 2024
Date of report to state agency: Apr 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant A | CNA | Reported the suspected abuse and provided a written statement |
| Licensed Practical Nurse B | LPN | Received report of suspected abuse from CNA and involved in the incident |
| Licensed Practical Nurse C | LPN | Received report of suspected abuse from CNA and involved in the incident |
| Registered Nurse D | RN | Supervisor who investigated the incident but did not find reason to further investigate |
| Social Services Director | SSD | Initiated investigation days later, contacted law enforcement and state agency |
| Administrator | ADMIN | Notified late about the incident and involved in the investigation process |
| Director of Nursing | DON | Notified late about the incident and involved in the investigation process |
Inspection Report
Routine
Census: 76
Deficiencies: 4
Date: May 2, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations related to fall prevention and infection control practices.
Findings
The facility failed to consistently evaluate and modify fall prevention interventions for residents at risk, resulting in falls and injuries. Additionally, infection control deficiencies were noted, including improper glove use, hand hygiene, and inadequate sanitization of glucometers and respiratory care supplies.
Deficiencies (4)
Failure to consistently evaluate, implement, and modify fall prevention interventions for residents at risk of falls.
Failure to ensure staff changed gloves and washed hands as indicated during care provision.
Failure to ensure infection control measures were followed when sanitizing glucometers between uses.
Failure to ensure proper infection control for respiratory care supplies, including uncovered CPAP masks.
Report Facts
Residents sampled: 22
Facility census: 76
Falls documented: 4
Accu-check frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT C | Certified Medication Technician | Named in infection control deficiencies related to glove use, hand hygiene, and glucometer sanitization |
| CNA D | Certified Nurse Aide | Named in infection control deficiency related to improper glove use and hand hygiene during resident care |
| LPN P | Licensed Practical Nurse | Interviewed regarding fall intervention documentation and care plan updates |
| RN F | Registered Nurse / Supervisor Admissions | Interviewed regarding fall intervention processes and care plan updates |
| ADON | Assistant Director of Nursing | Interviewed regarding fall prevention responsibilities and infection control practices |
| CNA I | Certified Nurse Aide | Interviewed regarding CPAP machine use and care |
| CNA J | Certified Nurse Aide | Interviewed regarding CPAP mask care and storage |
| LPN G | Licensed Practical Nurse | Interviewed regarding CPAP mask care and storage |
| LPN H | Licensed Practical Nurse | Interviewed regarding CPAP mask care and storage |
Inspection Report
Census: 76
Deficiencies: 22
Date: Apr 25, 2023
Visit Reason
The inspection was conducted to investigate multiple deficiencies including failure to notify resident representatives of falls, failure to maintain a clean and homelike environment, failure to protect residents from abuse, failure to report abuse allegations, failure to update care plans, medication administration errors, infection control issues, fall prevention deficiencies, staffing issues, and food service concerns.
Findings
The facility was found deficient in multiple areas including failure to notify family of resident falls, inadequate maintenance and repair of the facility environment, failure to protect residents from verbal and sexual abuse by another resident, failure to report abuse to the state agency, failure to update care plans to reflect current needs, medication administration errors including failure to check blood glucose and administer insulin properly, infection control lapses including improper glove use and equipment sanitation, failure to evaluate and document bed rail use and obtain consent, failure to provide adequate RN coverage, failure to conduct nurse aide performance reviews, failure to post nurse staffing information, failure to follow dietary recipes and serve proper food portions, failure to maintain kitchen sanitation, and failure to provide required nurse aide education.
Deficiencies (22)
Failure to notify resident representative of resident falls.
Failure to maintain a clean, comfortable, and homelike environment with facility repairs and maintenance.
Failure to protect residents from verbal and sexual abuse by another resident, including failure to investigate and report abuse allegations.
Failure to update care plans to reflect current resident needs and behaviors.
Failure to administer insulin as ordered and failure to check blood glucose levels as ordered.
Failure to obtain urine samples and labs as ordered.
Failure to provide adequate personal hygiene care to residents requiring assistance.
Failure to provide 8 consecutive hours of RN coverage 7 days a week.
Failure to complete nurse aide performance reviews and provide in-service education.
Failure to post nurse staffing information daily including facility name, census, and hours worked.
Failure to respond timely to pharmacist recommendations for medication dose reductions.
Failure to prime insulin pens prior to administration as per manufacturer instructions.
Failure to remove expired medications and medications of discharged residents from the medication room.
Failure to follow recipes and serve proper portion sizes for pureed diets; food served was bland and portions incorrect.
Failure to maintain kitchen sanitation including grease buildup, dirty ceiling tiles, damaged cove base, leaking pipes, and improper glove use by dietary staff.
Failure to follow proper infection control practices including hand hygiene, glove changes, and sanitizing glucometers between residents.
Failure to properly store and clean CPAP/BiPAP equipment including uncovered masks and unlabeled tubing.
Failure to assess residents for bed rail use, obtain informed consent, and conduct regular inspections for entrapment risks; use of assist bars without proper documentation or consent.
Failure to ensure timely physician response to pharmacist recommendations regarding psychotropic medication dose reductions.
Failure to ensure food was palatable, served at proper temperature, and served in correct portion sizes according to recipes.
Failure to ensure sanitary food handling practices including glove use, hand hygiene, and beard/hair restraints in the kitchen.
Failure to maintain an effective pest control program resulting in roach infestation in the kitchen and dishwashing areas.
Report Facts
Resident census: 76
Expired medication counts: 20
Bed rail use: 11
RN coverage days missed: 40
Nurse aide in-service hours: 0
Food temperature: 104
Food temperature: 100
Blood sugar: 797
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN N | Licensed Practical Nurse | Administered Tylenol to Resident #32 and failed to check blood sugar when resident showed signs of hyperglycemia |
| CMT C | Certified Medication Technician | Failed to prime insulin pens and failed to sanitize glucometer between residents |
| Dietary Supervisor | Reported roach sightings in kitchen and issues with food temperature | |
| Administrator | Acknowledged lack of RN coverage and nurse aide training | |
| Assistant Director of Nursing | Provided multiple interviews regarding facility policies and deficiencies |
Inspection Report
Routine
Census: 99
Deficiencies: 14
Date: Sep 12, 2019
Visit Reason
Routine inspection of Beth Haven Nursing Home to assess compliance with regulatory requirements including resident rights, abuse prevention, medication administration, infection control, dietary services, pressure ulcer care, fall prevention, and other care standards.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity with urinary catheter care, failure to prevent verbal abuse, failure to follow physician orders and standards for medication and tube feeding administration, failure to ensure staff transporting residents were CPR certified, failure to provide adequate personal hygiene care, failure to properly stage and manage pressure ulcers, failure to implement fall prevention interventions and safe transfer techniques, failure to provide appropriate catheter care, failure to comprehensively assess and manage resident pain, failure to monitor dialysis access sites, failure to ensure psychotropic medications were used appropriately with required dose reductions and PRN limits, failure to prepare and serve food according to dietary orders and recipes, failure to maintain kitchen sanitation and staff hygiene, and failure to follow infection control practices including hand hygiene and tracheostomy care.
Deficiencies (14)
Failure to maintain resident dignity by not covering urinary catheter drainage bags with privacy bags and allowing catheter bags to be visible from hallways.
Failure to prevent verbal abuse by Licensed Practical Nurse threatening to duct tape resident to bed and other threats.
Failure to follow physician orders and standards for gastrostomy tube medication administration and failure to obtain apical pulse prior to digoxin administration.
Failure to ensure staff transporting residents were CPR certified and facility lacked transportation policy.
Failure to provide adequate personal hygiene care including oral care, nail care, shaving, and peri-care for multiple residents.
Failure to properly stage pressure ulcers, notify physician of wound deterioration, and use air mattresses according to manufacturer instructions resulting in wound progression to Stage IV.
Failure to implement fall prevention interventions after resident falls and failure to safely transfer resident without bearing weight and improper gait belt use.
Failure to provide appropriate catheter care including maintaining catheter bag below bladder level and off the floor.
Failure to comprehensively assess and manage pain including failure to provide PRN pain medication and failure to intervene when resident exhibited pain behaviors.
Failure to develop dialysis care policy and failure to monitor dialysis access sites before and after dialysis treatments.
Failure to ensure psychotropic medications were used appropriately including lack of gradual dose reductions and unlimited PRN orders.
Failure to prepare and serve food items according to dietary orders and recipes resulting in residents not receiving ordered items and poor food quality.
Failure to maintain kitchen sanitation including expired foods, unclean refrigerators, and failure of staff to wear proper hair and beard restraints.
Failure to follow infection control practices including hand hygiene, glove use, medication handling, and tracheostomy care.
Report Facts
Facility census: 99
Resident #81 urinary catheter bag urine volume: 250
Resident #6 weight: 138
Resident #6 pressure ulcer measurements: 2.3
Resident #6 pressure ulcer measurements: 2.2
Resident #6 pressure ulcer measurements: 0.6
Resident #6 pressure ulcer measurements: 0.5
Resident #6 pressure ulcer measurements: 2.6
Resident #6 pressure ulcer measurements: 1.3
Resident #6 pressure ulcer measurements: 5.2
Resident #6 pressure ulcer measurements: 3.1
Resident #6 pressure ulcer measurements: 0.1
Resident #6 pressure ulcer measurements: 5.5
Resident #6 pressure ulcer measurements: 2.7
Resident #6 pressure ulcer measurements: 0.1
Resident #6 sacrum pressure ulcer measurements: 6.9
Resident #6 sacrum pressure ulcer measurements: 4.9
Resident #6 sacrum pressure ulcer measurements: 0.2
Resident #6 sacrum Stage III pressure ulcer measurements: 6.9
Resident #6 sacrum Stage III pressure ulcer measurements: 7.2
Resident #6 sacrum Stage III pressure ulcer measurements: 1.3
Resident #6 air mattress weight setting: 450
Resident #6 wound hospital assessment measurements: 7
Resident #6 wound hospital assessment measurements: 7
Resident #6 wound hospital assessment measurements: 2.5
Resident #6 wound hospital discharge assessment measurements: 7
Resident #6 wound hospital discharge assessment measurements: 6.4
Resident #6 wound hospital discharge assessment measurements: 2.8
Resident #6 wound hospital discharge assessment measurements: 0.5
Resident #6 weight: 130
Resident #96 fall risk score: 12
Resident #96 fall risk score: 17
Resident #30 catheter urine volume: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Named in verbal abuse finding and medication administration deficiencies |
| Certified Nurse Assistant F | Certified Nurse Assistant | Named in catheter care and personal hygiene deficiencies |
| Certified Nurse Assistant K | Certified Nurse Assistant | Named in catheter care and personal hygiene deficiencies |
| Licensed Practical Nurse O | Licensed Practical Nurse | Named in catheter care, medication administration, dialysis care, and pain management findings |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding facility policies and expectations |
| Certified Nurse Assistant P | Certified Nurse Assistant | Named in personal hygiene and pain management findings |
| Certified Nurse Assistant Q | Certified Nurse Assistant | Named in fall prevention and transfer findings |
| Registered Nurse N | Registered Nurse | Named in tracheostomy care and medication administration findings |
| Dietary Manager | Dietary Manager | Named in dietary and food preparation findings |
| Dietary Staff V | Dietary Staff | Named in dietary and food preparation findings |
| Dietary Staff W | Dietary Staff | Named in dietary and food preparation findings |
| Licensed Practical Nurse C | Licensed Practical Nurse | Named in pressure ulcer care findings |
| Licensed Practical Nurse K | Licensed Practical Nurse | Named in pressure ulcer care findings |
| Restorative Aide KK | Restorative Aide | Named in pain management findings |
| Registered Nurse CC | Registered Nurse | Named in dialysis care findings |
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