Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Amberwood Estates Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to maintain a homelike environment by allowing extremely loud door alarms to sound repeatedly throughout the building, including during meals, without prompt staff response, which residents described as constant and annoying. The facility also did not maintain adequate hot water in several rooms and bathing areas; cognitively intact residents dependent on staff for ADLs reported cold or non-functioning water, and CNAs confirmed that some rooms lacked hot water, that water was sometimes taken from an eye wash station for care, and that residents were not receiving regular showers or bed baths due to cold water. In addition, a resident’s room and bathroom were not thoroughly cleaned, with repeated observations of dark pellet-like debris, accumulated dirt along wall perimeters, and a visibly stained, soiled toilet and surrounding flooring, while the resident reported only brief, inadequate mopping by housekeeping.
Surveyors found that the facility failed to designate and communicate a grievance official and did not make grievance forms or instructions readily accessible. The written policy required 24/7 availability of grievance forms in unsecured common areas, posted information on residents’ rights to file grievances orally, in writing, or anonymously, and clear identification of a grievance official, typically the Social Services Director. However, alert and oriented residents reported they did not know where forms were located, how to file a grievance, or who the grievance official was. Observations showed forms were kept in an unmarked folder in a locked receptionist’s office and only provided on request, with no posted signage about the grievance process. Staff interviews revealed confusion about who served as grievance official after the Social Worker position became vacant, with grievances routed informally through the receptionist, HR, the Activity Director, the Administrator, or the DON without a clearly identified responsible grievance official.
Surveyors found that the facility did not provide or document required bed-hold policy information when residents were transferred to the hospital, despite the Administrator stating that floor nurses were responsible for giving this information at the time of transfer. Review of records showed multiple transfers and discharges with no corresponding bed-hold documentation. In addition, the facility failed to send required copies of discharge notices to the State LTC Ombudsman, even though its written policy required Ombudsman notification for facility-initiated discharges, planned discharges and transfers, and discharges decided while a resident was hospitalized. The last documented Ombudsman notification and transfer log were several months old, and the facility lacked copies of discharge notices for more recent discharges.
The facility failed to provide required showers or baths and to honor resident bathing preferences, resulting in multiple residents not receiving at least two showers or bed baths weekly as required by policy. One resident with mobility impairment and dementia, care planned for twice-weekly assisted showers, had very limited documented bathing and was repeatedly observed with greasy hair, body odor, and unchanged clothing, while reporting infrequent showers due to limited shower room access. Another resident with paraplegia and renal failure, who preferred daily bed baths and required maximal assistance, reported that nonfunctioning or cold water on the unit led to not being offered showers or bed baths, and described an aide refusing to take them to another unit or obtain hot water, then documenting a refusal. A third dependent resident reported avoiding showers because of cold water and resorting to sink bathing, with records showing only one shower, several bed baths, and multiple refusals over many opportunities. Facility leadership acknowledged that residents should have been offered showers or bed baths at least twice weekly and that resident choices, including daily bathing, should have been honored despite water temperature issues.
The facility failed to maintain safe and appetizing food temperatures during tray service, resulting in multiple meals being served either lukewarm, cold, or partially melted. Several cognitively intact residents, including individuals with conditions such as anemia, inflammatory bowel disease, heart failure, malnutrition, renal disease, and diabetes, reported that the food tasted bad, was often cold, or that they avoided eating it. During observed meal services, surveyors and an LPN recorded hot items such as lasagna, chicken bites, and corn at temperatures well below expected hot-holding levels, and cold items such as salad, coleslaw, fruit cups, and sherbet at temperatures that were warm, wilted, or melted, contrary to the facility’s stated expectations for food service.
Surveyors found that staff repeatedly failed to follow the facility’s infection control and EBP policies during high-contact care for multiple residents who were dependent for toileting and personal hygiene and had conditions such as stroke, multiple sclerosis, hemiplegia, cerebral palsy, chronic wounds, and g-tube status. Despite EBP signage and available PPE at room doors, CNAs provided incontinence and peri-care without wearing required gowns, used improper peri-care technique, double gloved, and placed soiled pads and blankets directly on the floor or on another resident’s bed before reusing them. One resident’s care plan called for EBP for a g-tube without a corresponding physician order, and staff interviews confirmed that expected practices—front-to-back peri-care, no double gloving, proper linen handling, and gown and glove use for high-contact care—were not consistently followed in practice.
Unauthorized Use of Resident Funds: Two residents had personal funds deducted without written authorization on the facility’s Withdraw Receipt forms. One resident with quadriplegia and impaired cognition was linked to purchases from Dollar General and a restaurant, but said he/she was unaware of the family making them. Another resident with dysphagia and severe cognitive impairment had a clothing purchase from Wal-Mart, but said he/she did not remember authorizing it or receiving the items; the POA was unsure about signing paperwork, and the ADM said a resident or responsible party was expected to sign before trust account funds were deducted.
Resident trust fund accounting was not properly maintained, with missing monthly reconciliations, unexplained balance variances, and no documentation that quarterly statements were provided to residents or their representatives. A resident with ESRD, DM, and a financial POA and another resident with Parkinson’s, Alzheimer’s, and severe cognitive impairment both had trust account balance changes that were not explained to them or their families, and the BOM and Administrator could not produce the required records.
The facility failed to ensure timely physician response to monthly pharmacy drug regimen review recommendations for multiple residents. One resident with schizoaffective disorder had blank, unsigned review forms for psychotropic medication recommendations and no chart documentation that the physician was made aware of them. Another resident with anxiety and PTSD had PRN lorazepam reviews that lacked required duration and rationale documentation, including one blank, unsigned form. A third resident on hospice had pharmacy recommendations to clarify morphine strength and address duplicate ophthalmic therapy, but one review was blank and unsigned and the chart lacked documentation of physician response.
QAPI meetings were not documented as attended by the required committee members. The facility’s policy required quarterly QAA meetings with the DON, Medical Director or designee, an Administrator or other leadership member, and the IP. Review of sign-in sheets showed meetings where the IP, Administrator, and/or Medical Director were absent, and the Administrator stated she could not locate some meeting minutes and that the facility did not currently have an IP nurse.
The facility failed to designate a qualified IP for its IPCP. The policy required one or more trained infection preventionists, but the Administrator stated the part-time IP was no longer responding to calls, the ADON was still obtaining specialized training, and the facility currently did not have an IP.
Incomplete CNA Annual In-Service Tracking: The facility failed to maintain a system to track required CNA annual education for CNAs who had worked at least one year. In-service records for multiple CNAs had blank time start and end fields, and there were no individual records showing each CNA completed 12 hours of annual in-services. The DON stated the education duration was not included and that the duration and education material should be documented with the sign-in sheet.
The facility failed to follow its own policy requiring that nourishing bedtime snacks be offered to all residents unless contraindicated by a physician’s diet order. The policy specified that dietary would stock snacks such as milk, 100% fruit juice, cookies, crackers, and fruit at each nursing station and that nursing staff would pass snacks room to room rather than announcing them from the nurse’s station. Resident Council minutes documented that residents were told there were no snacks at the nurse’s desk and that dietary was not passing out snacks. In a group interview, most alert and oriented residents reported they were not offered bedtime snacks, and one noted that only residents able to walk to the nurse’s station sometimes received snacks. Observations over multiple days showed no snacks at several nursing stations, and the Dietary Manager stated that snacks had not been provided to nursing staff for delivery, affecting all residents who ate at the facility.
Failure to Honor Resident Bathing Preferences: A cognitively intact resident who required substantial to maximal assistance with bathing had a documented preference for a daily bed bath, but bathing was provided inconsistently and not in line with that preference. The resident reported that hot water was unavailable on the unit and that staff did not offer showers or bed baths as expected; staff confirmed residents on the unit were not receiving bathing at least twice weekly because of cold water, and that the resident’s choice for daily bathing should have been honored.
Failure to Complete Final Accounting for Resident Trust Funds After Death. A resident expired with $5,175.22 remaining in the resident trust account, but the required TPL form had not been completed within the required timeframe. The BOM said she was waiting for a corporate check to close the account before sending the TPL letter, and the Administrator stated TPL forms were expected within 30 days of a resident’s death.
Survey results, certifications, complaint investigations, and any POC were not made readily accessible for resident and family review. The Resident Rights policy did not address the right to examine the most recent survey and POC, and observations showed the survey binder was not posted in an accessible location. During a resident group interview, alert and oriented residents said they were unsure where to find the prior survey results and complaint findings; staff reported the binder was kept behind the receptionist desk or in the ADM’s office.
The facility failed to issue required Medicare coverage and non-coverage notices when skilled Part A services ended for three residents. Two residents remained in the facility after Part A services ended, and one resident discharged to the community, but no NOMNC was issued and no SNFABN or denial letter was provided. The Administrator stated the facility had not issued any SNFABN or NOMNC forms upon discharge from Medicare Part A services.
Failure to establish and implement policies to prevent sexual abuse for two residents identified as a couple and sexually active. The facility’s abuse policy did not include protocols for supporting consensual sexual relationships or determining capacity to consent, and the DON and ADON stated staff allowed the residents privacy during intimate encounters. One resident was cognitively intact, while the other had moderate cognitive impairment; both had sexuality assessments, but the Administrator confirmed the facility had no policies or protocols for sexually active residents.
A resident with anemia, anxiety, and depression had a physician order for weekly Zepbound injections for weight management, but staff repeatedly documented the medication as unavailable or left MAR entries incomplete instead of documenting administration. The MAR and progress notes showed multiple missed or unclear entries, while the pharmacist confirmed the medication had been filled and a nurse later found six Zepbound pens in the medication refrigerator. The DON stated staff were expected to accurately document medications and treatments as ordered.
Failure to Provide Ordered Nutrition Support and RD Monitoring: A resident with renal disease and DM did not receive ordered double portions, a divided plate, or a sack lunch for dialysis days, and observations showed regular meals served without the ordered modifications. Two other residents had significant weight fluctuations, but there was no RD assessment or documentation that the DM/RD was notified. The DON and Administrator stated dietary assessments were to occur on admission, quarterly, annually, and with significant change, yet no dietary notes or assessments were in the record since 2024.
A resident with a g-tube, dysphagia, weight loss, CP, and malnutrition had tube feeding orders for Glucerna 1.5 at 60 ml/hr with water flushes every 6 hours, but staff repeatedly found the pump set incorrectly for flush timing and duration. The resident was also observed lying flat while TF continued during personal care, and the TF was not held or stopped during repositioning. An LPN later stated the pump had been restarted without checking the ordered rate and duration, and the DON said staff were expected to follow the physician’s TF orders.
Failure to Provide Social Services Support: A cognitively intact resident admitted after a fall reported no help with social service needs, including transferred finances, retrieving property from a prior facility, and picking up eyeglasses. The resident said there was no family support and felt helpless. Staff and residents reported there was no social worker available, and the DON/Administrator acknowledged the facility had been without a social worker and told the resident she could not assist with the requests.
Medication Storage and Labeling Deficiencies: Surveyors found multiple medication storage failures across medication rooms and carts, including expired OTC medications left in CMT carts, an unlabeled capsule in a nurse cart, and an unlocked medication refrigerator containing sealed lorazepam liquid and insulin pens. An LPN stated the unlabeled medication would not be administered, and the ADON and DON stated expired medications should be disposed and the medication refrigerator should remain locked, with lorazepam double-locked.
Two residents were found living in rooms with significant pest issues, including ants, rat droppings, and water damage, with staff unaware or slow to address the problems. Maintenance logs were not properly used, and cleaning procedures were not followed, resulting in an environment that was neither clean nor homelike.
A resident with cognitive impairment and heel wounds did not receive six ordered doses of Tramadol for pain due to delays in prescription processing and lack of timely physician contact. Staff were unable to access the emergency stock of the medication because the required prescription was not provided to the pharmacy, and documentation inaccurately reflected medication administration when it had not occurred.
The facility did not maintain appropriate hot water temperatures in multiple resident rooms and shower areas, with observed water temperatures consistently below standard levels. Staff interviews revealed that residents had complained about the lack of hot water for months, and CNAs had to take extra measures to provide warm water for bathing. The facility lacked clear policy parameters and regular monitoring, and administrative staff were unaware of the full extent of the issue due to missing documentation and recent changes in management.
The facility failed to monitor and maintain safe water temperatures, resulting in excessively hot water in two resident rooms, and did not conduct a thorough investigation after a resident fall, with missing documentation such as witness statements and neuro checks. Leadership and staff interviews revealed a lack of access to necessary policies and procedures, and required post-fall assessments were not completed.
A resident's personal and medical information was exposed when a medication card was left visible in an unlocked shred bin accessible to staff, residents, and the public. Additionally, an LPN used a personal phone and email to send a photo of the resident's prescription to the pharmacy due to lack of access to secure communication systems. Facility staff and management confirmed that secure procedures and policies for handling confidential information were lacking, and shred bins containing sensitive documents were often unlocked, overflowing, and located in unsecured areas.
A resident with psychiatric and cardiac conditions was slapped by another resident with neurological impairments. Although the incident was witnessed and reported internally, there was no documentation or confirmation that the required report was made to state authorities, and no investigation records were found. Staff interviews indicated uncertainty about whether the abuse was properly reported, resulting in a failure to follow mandated abuse reporting procedures.
The facility did not thoroughly investigate allegations of narcotic misappropriation by an LPN and resident-to-resident physical abuse involving two residents. In both cases, required investigative steps such as obtaining statements, conducting interviews, and documenting findings were not completed, and there was no evidence of a comprehensive investigation as mandated by facility policy.
A resident with multiple pressure ulcers did not receive consistent wound care or weekly wound assessments as ordered, with numerous missed treatments documented. The resident was found with maggots in a wound, and staff confirmed inconsistent dressing changes and lack of wound care policies. The facility lacked a designated wound nurse, and leadership was unaware of the incident and did not investigate.
The facility failed to promote self-determination for residents dependent on staff for transfer assistance by not ensuring they were out of bed daily and did not provide showers per resident preferences. A resident reported being out of bed only twice since admission, and multiple observations confirmed this. Staff interviews revealed that frequent short-staffing hindered their ability to assist residents as needed.
The facility failed to ensure functional bathroom toilets, lights, and call lights for several residents, leading to unsafe and uncomfortable conditions. One resident had to use a shower room down the hallway due to a clogged toilet, while another experienced consistently cold water and a non-functional bathroom light. Additionally, a resident's call light was unreliable, causing delays in receiving assistance. The Maintenance Director admitted to not conducting regular equipment inspections, relying on staff to report issues.
The facility failed to ensure that residents requiring assistance with ADLs received showers as per policy. Multiple residents were observed with poor hygiene and reported not receiving showers for several weeks. Staffing issues and lack of shower sheets were cited as reasons for the deficiency.
The facility failed to ensure proper bed rail assessments and fall interventions for a resident, leading to multiple falls and injuries. Additionally, the facility did not follow safe mechanical lift transfer protocols, failed to complete smoking assessments for two residents, and did not respond promptly to an exit door alarm, highlighting inadequate supervision and safety measures.
The facility failed to maintain adequate staffing levels, resulting in multiple residents not receiving necessary care. One resident, requiring extensive assistance, was repositioned by a single CNA, contrary to their care plan. Another resident had not received a shower for over a month due to staff shortages. A third resident, dependent on staff for ADLs, was found in an unkempt state and had not received scheduled showers. The Regional Nursing Consultant confirmed the facility's staffing was insufficient to meet care expectations.
The facility failed to ensure proper labeling and storage of medications, with multiple instances of opened, undated, and expired OTC medications found in medication carts and a medication room. An unsteady refrigerator storing insulin pens lacked a temperature log sheet. Staff inconsistencies in maintaining medication storage were noted.
A facility failed to maintain dignity and provide personal privacy for a resident by not covering the resident's catheter drainage bag, which was visible from the hallway. Despite the care plan's directive, the catheter bag was observed uncovered multiple times. Staff acknowledged the oversight and confirmed that the catheter should always be covered.
The facility failed to prevent a physical altercation between two residents, resulting in one resident being struck in the face with a cane and sustaining a skin tear. The incident occurred when one resident entered another's room, causing irritation and leading to the altercation. The facility's investigation confirmed the incident, and staff were instructed to monitor both residents for aggressive behavior.
A resident at risk for skin injury developed multiple open areas on the buttocks and thighs due to moisture and incontinence. The CNAs did not report these skin changes to the nurse, and the wound nurse was not informed until she conducted an assessment. The facility's wound treatment management policy was not followed, leading to a delay in appropriate wound care treatment.
The facility failed to provide consistent restorative services to two residents with limited mobility. One resident did not receive the required splint and range of motion exercises, while another did not have a knee splint applied for several weeks. Staff shortages and the reassignment of restorative aides contributed to the inconsistency.
The facility failed to ensure proper dialysis care and communication for a resident with end-stage renal disease, as there were no physician orders, dialysis provider information, or transportation details documented. Additionally, staff did not provide communication forms to the dialysis provider or assess the dialysis access site before or after treatment.
The facility failed to notify the attending physician about a pharmacy medication regimen review recommendation for a resident with diabetes, resulting in the omission of a recommended HgA1C test. Despite the facility's policy for frequent medication reconciliation, the necessary follow-up actions were not documented or completed.
The facility failed to ensure a gradual dose reduction (GDR) was attempted or documented as contraindicated for two residents receiving psychotropic medications. The necessary documentation for GDR was incomplete and unsigned by the physician, and no GDR attempts had been made, as confirmed by the Regional Nurse Consultant.
The facility failed to ensure accurate documentation and administration of medication for a resident. The LPN marked the MAR as if the medication was given, despite it not being available and not taken from the e-kit. Interviews revealed discrepancies in the medication administration process.
The facility failed to follow infection control practices during personal care for a resident requiring a Foley catheter and did not maintain proper hand hygiene during medication administration for another resident. An LPN reused a washcloth after rinsing it in the sink and handled medications with bare hands, contrary to the facility's policies.
A facility failed to provide a working call light system for a resident, preventing them from calling for assistance. The resident, who was dependent on assistance for daily activities, was observed yelling for help as the call light was not activated. Staff interviews revealed the call light system was unreliable, and the Maintenance Director did not conduct regular inspections, relying on staff to report issues.
The facility failed to post the Nurse Staffing Information daily as required. Observations revealed outdated or missing information, and the Regional Nurse Consultant was unable to provide current staffing details. The facility's policy mandates daily updates in a clear, accessible format, which was not followed.
The facility failed to provide an RN for eight consecutive hours per day, seven days a week, despite having a census of 90 residents. Staffing sheets for specific weekends showed only LPNs were present, with no RN coverage. The Administrator acknowledged the issue, noting the weekend RN was on leave.
A resident with severe cognitive impairment developed a pressure ulcer, but the facility failed to notify the responsible party as required by their policy. Despite documentation of the skin condition changes and new treatment orders by the Wound Nurse, there was no record of family notification, leading to a deficiency.
Failure to Maintain Homelike Environment, Adequate Hot Water, and Cleanliness
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment by allowing excessively loud door alarms to sound repeatedly throughout the building, including during meal service, without timely staff response. During a dining observation with approximately 30 residents present, a fire exit door alarm sounded at a very loud volume and continued intermittently for several minutes before staff silenced it. Residents in the dining room reported that the alarms sounded constantly and were annoying. The Administrator acknowledged that the alarms had been sounding continuously since she began working at the facility months earlier, and that this was not homelike. The facility also failed to maintain adequate hot water temperatures in multiple resident rooms and bathing areas, affecting residents who were dependent on staff for bathing and personal hygiene. One cognitively intact resident with heart failure and hypertension reported not taking showers lately because the water was cold; observation showed no cold water from the cold tap and hot water measuring only 58.9°F after running for two minutes. Another cognitively intact resident with anxiety, depression, and PTSD stated the facility only had hot water sometimes; observation showed no cold water from the cold tap and hot water at 52.0°F after two minutes. A third cognitively intact resident with renal failure, neurogenic bladder, and paraplegia reported that the water in the room had not worked for several months and that the unit’s shower rooms did not have hot water; observation confirmed the sink water never became warm after several minutes. CNAs reported that some rooms had no hot water since the weather turned cold, that hot water was obtained from an eye wash station for resident care, and that residents on one unit were not receiving regular showers or bed baths due to cold water. Additionally, the facility failed to thoroughly clean one resident’s room and bathroom. Over multiple observations on different days, the perimeter of the room’s walls contained multiple small, dark pellet-like substances scattered along the floor and within crevices near the walls and furniture bases, along with accumulated dirt and debris. The bathroom toilet had visible brown staining and streaking on the exterior porcelain surface, with accumulated dirt and discoloration around the base where it met the flooring, and darkened residue and debris along the perimeter of the toilet base. The flooring immediately surrounding the toilet base was soiled and discolored. The resident reported that housekeeping staff entered and mopped briefly but did not perform a thorough cleaning.
Failure to Designate Grievance Official and Provide Accessible Grievance Process
Penalty
Summary
The deficiency involves the facility’s failure to implement its grievance policy by not identifying a grievance official responsible for overseeing the grievance process and not making grievance information and forms readily accessible. The written policy, dated 4/1/2022, specified that the facility would have grievance forms available 24/7 in an unsecured common area, notify residents via postings of their right to file grievances orally, in writing, and anonymously, and identify a Grievance Official (normally the Social Services Director) with name, business address, email, and phone number posted in prominent locations. The policy also stated that staff would assist individuals who could not or chose not to write, and that grievances noted verbally would be recorded on the facility’s grievance form or in the electronic tracking system. During a group interview with eight alert and oriented residents, all residents reported they did not know where grievance forms were located, and six did not know how to file a grievance even if a form were available. All eight residents stated they did not know who the Grievance Official was. The previous Grievance Official had been the Social Worker, but the facility did not have a Social Worker at the time, and six residents reported they did not know who else to go to with grievances or concerns. These resident reports demonstrated a lack of awareness of the grievance process and the designated grievance contact. Surveyor observations over multiple days showed that grievance forms were not readily accessible in unsecured common areas and that there was no visible information posted identifying the Grievance Officer, the location of forms, or how to file grievances orally, in writing, or anonymously. Grievance forms were found in the receptionist’s office, behind a desk in an unmarked folder, and were only provided upon request; the receptionist’s office was locked at night. The front desk staff stated that residents requesting to file a grievance were directed to the receptionist desk for a form and, if assistance was needed, were referred to the Social Worker, who was not employed at that time, and then to the HR office. The HR Manager reported that grievance forms were turned in to her because there was no Social Worker, that she sometimes sought help from the Activity Director, and that unresolved grievances were forwarded to the Administrator or DON. The HR Manager stated she did not know who was designated as the grievance officer and assumed it would be the Social Worker. The Administrator stated she expected signage identifying the Grievance Officer and freely accessible grievance forms, and that the process should allow anonymous grievances, confirming that these elements were not in place during the survey period.
Failure to Provide Bed-Hold Notices and Ombudsman Discharge Notifications
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents and/or their representatives with the required bed-hold policy information at the time of transfer to the hospital or as soon as practicable. Record review showed that between 9/1/25 and 2/2/26, 31 residents were transferred to acute care hospitals, yet the facility did not have documentation that the bed-hold policy had been provided for these transfers. During interview, the Administrator stated that floor nurses were responsible for giving the bed-hold policy at the time of transfer and acknowledged that the facility did not have the bed-hold documentation for residents who were transferred to the hospital. Surveyors also found that the facility failed to send copies of discharge notices to the Office of the State LTC Ombudsman as required by the facility’s own Transfer and Discharge policy dated 4/1/22. That policy required that a copy of the discharge notice be sent to the Ombudsman for 30-day facility-initiated discharges, planned discharges and transfers to the hospital initiated by the facility, and unplanned discharges where the facility decided to discharge the resident while hospitalized. Review of Ombudsman notifications showed the last notification was in July 2025, and the Ombudsman representative reported the last transfer log received was from August 2025. The facility also lacked copies of discharge notices after July 2025, despite 15 residents being discharged home and three discharged to another facility during the review period.
Failure to Provide Required Showers and Honor Bathing Preferences
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents who required assistance with activities of daily living received showers or baths in accordance with facility policy and resident preferences. The facility’s written policy required that showers or bathing be offered at least twice weekly or per resident/resident representative preference, with schedules developed for each resident and refusals reported to licensed staff. Surveyors requested a shower schedule but none was provided. For one resident with moderate cognitive impairment, impaired mobility, and a care plan specifying limited assistance with showering twice weekly, documentation showed only one shower or bed bath in October, two in November, one in December, and a refusal in January. Observations over several days showed this resident with long, messy, greasy hair, strong body odor, and wearing the same clothes, and the resident reported receiving showers only every two weeks or once a month, citing limited shower room availability and needing staff assistance to access the shower room. Another resident, cognitively intact with renal failure, neurogenic bladder, and paraplegia, required substantial/maximal assistance with bathing and had a care plan indicating a preference for a daily bed bath. Documentation for November and December showed four showers or bed baths each month, and two in January. However, this resident reported that the water in the room had not worked for several months and that shower rooms on the unit did not have hot water, resulting in not being offered showers or bed baths and an inability to recall the last shower. The resident stated a preference for daily shower or bed bath and described an instance when an aide declined to take the resident to another unit for a shower or obtain hot water from another unit, instead documenting a refusal after the resident’s request for hot water was not accommodated. A CNA confirmed that residents on the unit, including this resident, were not being showered regularly due to cold water and were not consistently receiving at least two showers or bed baths per week. A third cognitively intact resident, dependent on staff for bathing and personal care, reported not taking showers lately because the water was cold and instead performing partial “whore baths” at the sink. Review of shower sheets over nearly three months showed 19 opportunities, with only one documented shower, nine bed baths, and nine refusals. Facility leadership, including the DON, ADON, and Administrator, acknowledged that showers or bed baths were to be offered at least twice weekly and that resident choices, including daily bathing preferences, should have been honored. They also acknowledged that some residents may not have received showers or bed baths twice weekly due to inadequate water temperatures, despite the possibility of taking residents to other units for showers or obtaining hot water from other units.
Failure to Maintain Safe and Palatable Food Temperatures During Tray Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food and drink were served at palatable, attractive, and safe temperatures during tray service. The facility’s own policy, revised 10/1/23, stated that food is to be cooked to specified temperatures and times to mitigate dangerous microorganisms and identified the danger zone for food temperatures as above 41°F and below 135°F. Multiple cognitively intact residents reported dissatisfaction with the food, including one resident with anemia, ulcerative colitis, Crohn’s disease, and inflammatory bowel disease who stated they barely ate the facility’s food and relied on their own snacks, another resident with heart failure and hypertension who said the food tasted bad, a resident with malnutrition who said the food was not good and often arrived cold, and a resident with renal disease and diabetes who said the food was sometimes served cold. Surveyor observations and temperature checks during meal service showed that hot foods were not consistently maintained at or above 120°F and that cold foods were not kept at appropriately cold or frozen temperatures. At one lunch service, lasagna on a tray from the 200 unit was lukewarm, initially 125°F but dropping to 112°F after 15 seconds, coleslaw measured 66°F and appeared wilted, and sherbet was melted. On the 100 unit at another lunch, salad with creamy dressing was warm at 76°F, lasagna was 102.6°F, and rainbow sherbet was mostly melted at 28.2°F. During an evening meal on the 100 unit, an LPN measured chicken bites at 95.4°F, corn at 109.9°F, and a fruit cup at 70.5°F. The Dietary Manager stated she expected food to be served at 135°F when it reached the resident and sherbet to be served frozen, and the Administrator stated she expected food to be served at a safe and appetizing level.
Failure to Follow Enhanced Barrier Precautions and Standard Infection Control Practices During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program, including Enhanced Barrier Precautions (EBP) and standard precautions, during high-contact care for multiple residents. The facility’s EBP policy required an order for EBP for residents with chronic wounds, indwelling medical devices, or infection/colonization with certain MDROs, clear signage on the door indicating required PPE and high-contact activities, and the use of gown and gloves for high-contact care such as dressing, transferring, providing hygiene, changing linens, and changing briefs or assisting with toileting. The standard precautions policy required assuming every person could be infected or colonized and minimally handling contaminated laundry with appropriate PPE, placing it in leak-proof bags at the location of use. Surveyors observed that these policies were not followed for several residents. One resident with severe cognitive impairment, total dependence for toileting and personal hygiene, and diagnoses including stroke, multiple sclerosis, and altered mental status had an EBP sign and PPE at the room door. A CNA provided incontinence and peri-care without wearing a gown, contrary to the EBP requirement for high-contact care. During this care, the CNA cleaned the resident’s genital area from front to back abdomen (back to front), placed a soiled pad directly on the floor without a barrier, and moved blankets from the resident’s bed to the roommate’s bed and then back to the original resident’s bed. The Assistant DON later stated that peri-care for a female resident should be performed front to back, linens should not be transferred between residents’ beds due to cross contamination, and staff should wear a gown, gloves, and mask as needed for high-contact care. Another resident, cognitively intact but dependent for toileting and personal hygiene and always incontinent of bladder with frequent bowel incontinence, had a physician order for EBP for a chronic wound, with gown and gloves required for high-contact care. An EBP sign and PPE were present on the door. A CNA entered, performed hand hygiene, donned two pairs of gloves but no gown, and provided incontinence care, including cleaning the groin and between the legs. The CNA placed a soiled blanket on the floor without a barrier, used double gloving, and later used a folded blanket as a substitute for a pad, stating the facility had run out of pads. The CNA then picked up linens from the floor and placed them in a trash bag. The ADON stated staff should not double glove, should remove gloves and perform hand hygiene, and should not place soiled linens on the floor. A third resident with moderate cognitive impairment, dependence for toileting and personal hygiene, and diagnoses including stroke and hemiplegia/hemiparesis had an order for EBP for a chronic wound with gown and gloves required for high-contact care. This resident preferred to remain in bed and was totally dependent on staff for toileting and used incontinence products. A CNA provided peri-care while wearing gloves but did not wear a gown, despite the EBP order and high-contact nature of the care. A fourth resident, rarely or never understood, totally dependent for toileting and personal hygiene, always incontinent of bladder and bowel, and with diagnoses including cerebral palsy and gastrostomy status, had a care plan indicating EBP for a g-tube with gown and gloves required for high-contact care, but there was no corresponding physician order for EBP on the physician order sheet. An EBP sign and PPE were on the door, and a CNA provided peri-care wearing gloves but no gown. Additional staff interviews confirmed expectations that conflicted with observed practices. One CNA stated that residents requiring EBP were identified by a sign and PPE at the door and that staff should wear a gown, mask, face shield, and gloves every time they entered the room, remove PPE before exiting, avoid double gloving, place soiled linens in a trash bag rather than on the floor or another resident’s bed, and perform peri-care front to back. Another CNA similarly stated that peri-care should be front to back, staff should not double glove, and soiled linens should be placed in a linen cart or trash bag, and that staff should wear gown, gloves, and mask when providing close contact care to residents. The Administrator stated she expected staff to follow the facility’s infection control policies and procedures. These statements contrasted with the observed failures to use gowns during EBP-required high-contact care, improper handling of soiled linens, improper peri-care technique, and inconsistent implementation of EBP orders and signage.
Unauthorized Use of Resident Funds
Penalty
Summary
The facility failed to use the personal funds of a resident only when authorized in writing for two sampled residents. For one resident, the quarterly MDS showed quadriplegia, contracture of the right hand and both shoulders, moderate impairment, and minimal depression. The resident’s care plan stated that personal preferences should be honored as safely allowed. The facility’s Withdraw Receipt form showed a total amount of $325.54 with the resident’s signature section and witness sections blank, and included purchases from Dollar General and Tucker’s Place. During interview, the resident said he/she was unaware of anyone in the family making the purchases on the receipt. For another resident, the quarterly MDS showed dysphagia following cerebral infarction, severe cognitive impairment, and moderate depression. The care plan focused on the resident wishing to stay long-term and continuing to express satisfaction with living arrangements. The facility’s Withdraw Receipt form showed a total amount of $146.43 for clothing from Wal-Mart, with the resident’s signature section and witness sections blank. During interview, the resident said he/she did not remember authorizing the purchase or receiving the items. The resident’s financial POA said he/she made the purchase but was not sure about signing anything when the facility reimbursed him/her, and the Administrator said she expected the resident or responsible party to sign the Withdraw Receipt before money was deducted from the patient trust account.
Resident Trust Fund Accounting and Statement Deficiencies
Penalty
Summary
The facility failed to properly hold, secure, and manage resident personal funds deposited with the nursing home. Review of the Resident Trust policy showed monthly reconciliations were to be completed, quarterly statements were to be mailed to residents or their representatives, and documentation was to be maintained for resident trust fund activity. However, review of the 2025 resident trust fund records showed missing monthly reconciliations for June, July, August, and September 2025, and no documented explanation for a $26,523.24 difference between the May 2025 and October 2025 trial balances. The facility also did not provide documentation that quarterly statements were issued to residents with funds in the resident trust account. Resident #10 had a financial POA, end stage renal disease, diabetes, and was cognitively intact, with funds held in the resident trust account. The resident’s trial balance decreased from $6,613.08 in May 2025 to $3,038.69 in October 2025, and later statements showed additional balance changes. During interview, the POA said the facility had told him/her the resident needed to spend down funds, but he/she was unaware the balance was $569.07 as of early February 2026. The facility did not explain the decrease in the resident’s trust account balance and did not provide quarterly statements or inform the POA that they were available. Resident #33 was responsible for his/her own finances but had Parkinson’s disease, Alzheimer’s disease, and severe cognitive impairment, with funds held in the resident trust account. The resident’s trial balance decreased from $11,712.65 in May 2025 to $8,342.03 in October 2025, and later statements showed further balance changes. During interview, the resident said he/she was unaware of the account balance and did not know why it decreased. A family member said a nurse had previously notified him/her that the resident had excess funds, but the facility did not follow up further, and the family member was unaware how the balance changed. The Business Office Manager and Administrator were unable to provide documentation of quarterly statements for residents with trust funds and did not have the reports explaining the variance in the resident trust balances.
Failure to Document Timely Physician Response to Pharmacy Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that physician or prescriber responses to monthly pharmacy drug regimen review recommendations were documented in a timely manner for three of five sampled residents. The report states that the licensed pharmacist was to perform monthly drug regimen reviews, including review of the medical chart, and that the facility did not provide the pharmacy review policy when requested during the survey. The Director of Nursing said she did not know whether the pharmacy reviews had been addressed by the physician, and the Administrator said she expected the pharmacy reviews to be completed monthly and the physician/provider to review the recommendations. For one resident with schizoaffective disorder, the chart contained pharmacy recommendations regarding psychotropic medications, including quetiapine and ramelteon, with requests for gradual dose reduction consideration. The forms were blank and unsigned by the physician/prescriber, and the progress notes showed no documentation that the physician was made aware of the pharmacy review and recommendations. The resident’s care plan identified use of psychotropic medications and included consultation with pharmacy and the MD to consider dosage reduction at least quarterly. For a second resident with anxiety, depression, PTSD, and bipolar disorder-related psychotropic use, the pharmacy review noted PRN lorazepam orders and stated that PRN psychotropic orders cannot exceed 14 days unless the prescriber documents the rationale and duration. One review was signed by the physician, but no duration or rationale was documented for use beyond 14 days. A later review was blank and unsigned, and the progress notes showed no documentation of the physician’s duration or rationale for the medication. For a third resident with spastic quadriplegic cerebral palsy, dysphagia, depression, and hospice care, the pharmacy review requested clarification of a morphine order strength and identified duplicate therapy involving erythromycin ophthalmic ointment and TobraDex ophthalmic medication. One later review was signed with handwritten changes, but another was blank and unsigned. The MAR showed the morphine and erythromycin ophthalmic medications were administered, and the progress notes contained no documentation related to those medications during the reviewed period.
QAPI Committee Lacked Required Members and Attendance Documentation
Penalty
Summary
The facility failed to ensure that QAPI meetings were documented as attended and included the required committee members. Review of the facility’s QAA policy showed the committee was required to meet at least quarterly and include, at a minimum, the DON, the Medical Director or designee, at least three other staff members with at least one in a leadership role such as the Administrator, owner, or board member, and the infection preventionist. Review of QAPI sign-in sheets showed that at the 5/6/25 meeting no IP staff attended, at the 6/10/25 meeting no IP or Administrator attended, at the 8/27/25 meeting no Administrator, IP, or Medical Director attended, and at the 1/21/26 meeting no IP staff attended. During interview, the Administrator stated she could not locate the meeting minutes for February 2025 and October 2025, knew the meetings were held, and said the facility did not currently have an IP nurse; she also stated she would have expected all required members to attend and that proof of attendance should have been documented.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate one or more individuals with specialized training in infection prevention and control as the Infection Preventionist for its infection prevention and control program. The facility’s Infection Prevention and Control Program policy, revised 11/28/22, stated that the facility would designate one or more individual(s) as the infection preventionist(s) responsible for the IPCP and that the IP would have completed specialized training in infection prevention and control. During interview, the Administrator stated that the IP worked part time, the Assistant Director of Nursing was in the process of obtaining specialized training, and later stated that the facility currently did not have an IP because the prior IP was no longer responding to calls.
Incomplete CNA Annual In-Service Tracking
Penalty
Summary
The facility failed to ensure it had a system in place to track the required CNA 12 hours of annual education for CNAs who had worked at least one year. Review of the facility’s In-Service Training Report sheets for CNA B, CNA J, CNA K, CNA L, CNA M, CNA N, CNA O, CNA P, CNA Q, and CNA R showed the form included fields for date, subject, time start and end, type of in-service, and instructor, but the time start and end lines were blank. The records also did not include individual documentation showing that each CNA completed 12 hours of in-services in a year. The facility did not provide a policy related to CNA 12-hour training. During interview, the DON stated the education did not include the duration of the education and that there should be material showing what was discussed; she expected CNAs to receive 12 hours of required education each year and said the duration of the in-service should be documented along with the education material and sign-in sheet.
Failure to Provide and Offer Bedtime Nourishing Snacks
Penalty
Summary
The facility failed to provide and offer nourishing bedtime snacks to residents in accordance with its own policy and resident needs and preferences. The facility’s undated Between Meal Snack/Bedtime Nourishments policy required that between-meal snacks and bedtime nourishments be offered to all residents unless contraindicated by a physician’s diet order, and specified that bedtime nourishment must consist of nourishing foods such as milk, 100% fruit juice, cookies, crackers, and fruit. The policy also stated that dietary should develop a snack nourishment stock level for each nursing station and that nursing staff were to pass snacks and nourishments from room to room, with an explicit statement that it was not acceptable to simply announce snacks from the nursing station. Surveyor review of Resident Council meeting minutes showed that residents had previously reported problems with snack availability and distribution. In one meeting, residents were told by a nurse that there were no snacks at the nurse’s desk, and in another, residents reported that dietary was not passing out snacks. During a group interview with eight alert and oriented residents, six reported they were not offered snacks at bedtime, and one reported that snacks were sometimes available at the nurse’s station for residents who could ambulate there, but staff did not come to resident rooms to offer snacks. Observations over several days showed no snacks at the nursing stations on three units. The Dietary Aide confirmed the scheduled meal times, and the Dietary Manager acknowledged that snacks had not been provided to nursing staff for delivery to residents. This deficiency affected all residents who ate at the facility, with a census of 83.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination for one resident who was dependent on staff for bathing and showering by not ensuring showers or bed baths were provided in accordance with the resident’s preferences. The resident’s care plan stated a preference for a daily bed bath, and the MDS showed the resident was cognitively intact, had no rejection of care, considered bathing choice very important, and required substantial to maximal assistance with showering/bathing. The resident also had renal failure, neurogenic bladder, and paraplegia. Facility records showed showers or bed baths were documented only intermittently in November and December 2025 and twice in January 2026. During observation, the water in the resident’s room ran cool and never got warm. The resident stated the water had not worked in several months, the shower rooms on the unit did not have hot water, and as a result the resident was not offered bed baths or showers. The resident said a recent shower offer was changed to a bed bath because the aide said there was no time to take the resident to another unit and documented the resident as refusing a shower, even though the resident agreed to the bed bath and asked for hot water from another unit. Staff interviews confirmed the resident had not been showered regularly because of cold water on the unit, that residents on the unit were not receiving at least two showers or bed baths per week, and that resident preferences for daily bathing should have been honored.
Failure to Complete Final Accounting for Resident Trust Funds After Death
Penalty
Summary
The facility failed to ensure third party liability forms were completed within 30 days for the final accounting of a resident who expired and still had money in the resident trust account. Resident #9 expired with a resident trust fund balance of $5,175.22, and the required TPL had not been completed, leaving the funds in the account. The facility’s Resident Trust policy dated 2/2022 stated that no funds are released until a final audit of the account is completed and that such funds are to be provided within 30 days of the resident’s death. During interview, the Business Office Manager said she had started her position four days earlier and was aware that TPL letters were required to be sent to the Missouri Department of Social Services within 30 days of a resident’s death, but she was waiting for a check from the corporate office reflecting closure of the patient trust account to accompany the TPL letter. The Administrator stated she expected TPL forms to be sent within 30 days of a resident’s death.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to make accessible for examination the results of the most recent survey, certifications, complaint investigations, and any plan of correction in effect for the facility by residents, visitors, and resident representatives. Review of the Resident Rights policy showed it did not address residents’ rights to examine the results of the most recent federal or state survey and any plan of correction in effect. Observation from 1/29/26 through 2/4/26 showed the survey results, certifications, and complaint investigations were not posted in a place readily accessible to residents and family members or legal representatives. During a group interview on 1/30/26, eight alert and oriented residents said they were not sure where they would look to review the prior annual survey results and complaints investigated. During interviews on 2/4/26, front desk staff said the survey binder was usually kept behind the receptionist desk and provided upon request, but was currently in the administrator’s office, and the Administrator stated she would expect the statement of deficiencies and plans of correction from the prior survey, including any complaints investigated, to be available to residents and the public.
Failure to Issue Medicare Coverage and Non-Coverage Notices
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A services, and failed to provide a Notice of Medicare Non-Coverage (NOMNC, CMS-10123) when Medicare-covered skilled services ended for three sampled residents. The report states that two residents remained in the facility after their Medicare Part A skilled services ended, and one resident discharged to the community after the end of Medicare Part A skilled services. Review of the records showed that Resident #3 had Medicare Part A skilled services from 5/29/25 through 9/5/25, remained in the facility, and had no NOMNC or SNFABN issued. Resident #82 had Medicare Part A skilled services from 6/6/25 through 9/12/25, remained in the facility, and had no NOMNC or SNFABN issued. Resident #95 had Medicare Part A skilled services from 6/27/25 through 8/5/25, discharged to the community, and had no NOMNC issued. The facility policy stated that the NOMNC and SNFABN would be issued no later than two days before termination of skilled services, and during interview the Administrator said the facility had not issued any SNFABN or NOMNC forms upon discharge from Medicare Part A services.
Failure to Establish Policies for Consensual Sexual Activity
Penalty
Summary
The facility failed to develop and implement comprehensive policies and procedures to prevent potential sexual abuse for two residents who were identified by staff as being in a sexual relationship. The facility’s Abuse, Neglect and Exploitation policy stated that it would provide protections for residents by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property, but the policy did not include establishing a safe environment that supports, to the extent possible, a resident’s consensual sexual relationship or protocols for preventing sexual abuse, including how capacity to consent to sexual contact would be determined, by whom, and where that documentation would be recorded. Resident #86 was documented as cognitively intact on the quarterly MDS and had a Social Services Sexuality Assessment showing he was cognitively able to complete the assessment, had no history of sexually inappropriate behavior, and did not want STI testing. Resident #80 was documented as having moderate cognitive impairment on the quarterly MDS and had a Sexuality Assessment showing she was cognitively able to complete the assessment but did not wish to participate. The DON and ADON stated the two residents were a couple and were sexually active, and staff allowed them privacy in a room when they became intimate. The DON also stated a CNA stood by the closed door during sexual activity to ensure no other residents or staff entered, and the Administrator stated the facility did not have policies or protocols in place for sexually active residents or to determine capacity to consent to sexual contact.
Failure to Administer and Document Ordered Weight Loss Medication
Penalty
Summary
The nursing facility failed to follow physician orders for a resident's weight loss medication, Zepbound, and documented the medication as unavailable when it was available. The resident was cognitively intact and had diagnoses of anemia, anxiety, and depression. The care plan included administering medications as ordered and monitoring/documenting side effects and effectiveness. The physician ordered Zepbound 2.5 mg subcutaneously once weekly on Thursday for weight management starting 12/4/25. Review of the MAR and progress notes showed multiple instances where staff documented the medication as unavailable or entered incomplete documentation instead of recording administration. In December 2025, the MAR showed two of four opportunities documented as "other, see nurse's notes" and one opportunity blank; progress notes documented "medication unavailable" on 12/4/25 and 12/18/25. In January 2026, the MAR showed two of five opportunities documented as "other, see nurse's notes," and progress notes documented "medication unavailable" on 1/1/26 and 1/22/26. The pharmacist stated the resident's Zepbound was filled on 12/4/25 and 12/28/25, with four pens in each box. A nurse later checked the medication refrigerator and found six Zepbound 2.5 mg pens present. The DON stated she expected staff to accurately document medications and treatments in residents' clinical records as ordered.
Failure to Provide Ordered Nutrition Support and Complete RD Assessments
Penalty
Summary
The facility failed to provide ordered nutrition support for a resident with renal disease and diabetes. Resident #74 had physician and RD orders for double eggs at breakfast, double meat with lunch and dinner, a divided plate, and a sack lunch or snack for dialysis days. During interviews and observations, the resident reported never receiving the sack lunch, never receiving double portions, and sometimes returning from dialysis with no food available. Observations showed the resident eating regular meals on a regular plate without the ordered divided dish or double portions, and the resident was seen leaving for dialysis without a sack lunch or snack. The resident’s record showed the nutrition assessment dated 4/11/24 with the ordered diet modifications, but no additional nutrition assessments were found after that date. The care plan included interventions to provide and serve the diet as ordered and to provide a sack lunch and/or snacks for dialysis days. The Dietary Manager stated that residents were expected to receive double portions and sack lunches as ordered, but she observed that double portions had not been served and dialysis residents were not being provided sack lunches. The resident also stated that family members brought food so there would be something available after dialysis. The facility also failed to complete RD assessments and to notify the RD or physician of significant weight changes for other residents. Resident #19 had diagnoses including anemia and ulcerative colitis/Crohn’s disease, and the record showed weight loss from 378 pounds to 362 pounds to 356 pounds, with an observed weight of 341 pounds, but no dietary evaluation or documentation that the DM/RD was informed. Resident #5 had diagnoses including anxiety, depression, PTSD, and diabetes; the record showed weights of 331.5 pounds and 340 pounds, with an observed weight of 325 pounds, but no RD note or documentation that the DM/RD was aware of the weight fluctuations. The DON and Administrator stated that dietary assessments were to be completed on admission, quarterly, annually, and with significant change, and the Administrator stated there had been no dietary notes or assessments in the medical records since 2024.
Incorrect Tube Feeding Pump Settings and Feeding Continued During Care
Penalty
Summary
Staff failed to follow acceptable standards of practice for a resident with an enteral tube feeding. Resident #9 had a significant change in status assessment showing impairment of both upper and lower extremities, diagnoses of non-traumatic spinal cord dysfunction, cerebral palsy, and malnutrition, and a nutritional approach of feeding tube. The resident’s care plan identified the need for tube feeding related to dysphagia and weight loss, with goals to remain free of tube-feeding complications and aspiration. The physician’s orders directed Glucerna 1.5 at 60 ml/hr to run 22 hours a day and to flush the tube with 200 ml of water every 6 hours. During observation, the tube feeding pump screen showed the flush set incorrectly at 160 ml every 0 hours, and staff later adjusted it after recognizing it was not set per order. On another observation, the resident was lying flat in bed while the tube feeding continued to infuse at 60 ml/hr, and CNA care was provided with the resident turned from side to side before the head of bed was raised. The tube feeding was not held or stopped during the care. Further observations showed the pump again set incorrectly with the flush at every 0 hours, and later at every 4 hours instead of every 6 hours. An LPN stated the flush should not have been on zero and said the pump had been restarted without attention to the infusion rate and duration after the tube was unclogged. The DON stated staff were expected to follow physician orders for tube feeding rates and duration, and that the nurse assigned to the resident was responsible for checking the orders and pump. The DON also stated tube feeding should be held or stopped when the resident is lying flat and receiving care or repositioning.
Failure to Provide Social Services Support
Penalty
Summary
The facility failed to provide medically related social services and person-centered care to meet the highest practicable psychosocial well-being of a recently admitted resident. Resident #93 was admitted after a fall and hospital stay, had previously been at another facility, and reported wanting to move because of problems with a roommate. The resident stated that after admission there was no assistance with social service needs, the resident’s finances had not been transferred, property remained at the prior facility without a way to retrieve it, and glasses purchased from an eye clinic were ready for pickup but not obtained. The resident also reported having no family outside the facility and feeling helpless and “dumped” there without assistance. The facility’s records showed the resident was cognitively intact, had no discharge plans initiated, and the social services evaluation noted memory was okay. During interviews, a CNA stated there was no social worker at the facility and residents, especially Resident #93, had been trying to receive services since admission. In a group interview, eight alert and oriented residents said there was no social worker available and that they were expected to figure things out on their own. The Administrator stated the social worker had left and the facility had been without a social worker since the end of November, and she told Resident #93 there was no social worker at the time and she could not assist with the resident’s requests.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted standards of practice in multiple medication storage areas, including two medication rooms, two nurse carts, two CMT carts, and one treatment cart. Surveyors found issues in all three medication carts and one medication room. In the Hall 200 CMT cart, multiple OTC medications were found expired, including calcium, aspirin, Colace, Mucus Relief Expectorant, magnesium oxide, sodium chloride, vitamin B6, oyster shell calcium plus vitamin D, Optimum Dairy Rescue, vitamin B12, and vitamin D. An LPN stated the expired medications should not be used and should be disposed immediately. Surveyors also found an unlabeled medication cup containing a blue capsule in the top drawer of the Hall 100/200 nurse cart, and the LPN stated he/she did not know what the medication was, whose it was, or who prepared it. In the locked medication room, the medication refrigerator was observed unlocked with the padlock placed on top of it, and two sealed bottles of lorazepam liquid were stored inside along with insulin pens. The ADON stated the refrigerator should be locked at all times, and lorazepam should be placed in a double-locking system. In the Hall 400/500 CMT cart, additional expired OTC medications were found, including vitamin C and aspirin, and the ADON stated expired medications should not be used and should be disposed immediately.
Failure to Maintain Clean, Pest-Free, and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as evidenced by multiple pest control and maintenance issues in resident rooms. In one instance, a resident with moderately impaired cognition, quadriplegia, and other significant health conditions was found in a room with multiple ants on the floor, in the sink, and on the wall by the sink. The resident's room also had a can of pesticide on the sink, a steadily dripping faucet, dust and debris around storage bins, and a black, fuzzy, wet, and spongy spot on the wall under the air conditioning unit, which transferred residue when touched. Staff interviews revealed a lack of awareness about the ant infestation and uncertainty about the timing of recent pest control visits. The maintenance log at the nurse's station was found to be empty, with no current work orders or requests documented at the time of review. Another resident, who had severely impaired cognition and required substantial assistance with daily activities, was found in a room with several small brown pellets on the floor behind the bed, identified by a family member as rat feces. Observations confirmed the presence of these droppings during multiple visits. Staff interviews indicated that pest control and maintenance issues were not consistently reported or addressed in a timely manner. The housekeeping manager acknowledged awareness of some issues, such as a leaking faucet, but was unaware of the extent of the pest problem and the water damage to the wall. The pest control company was reported to visit frequently, but the last visit could not be recalled. Review of facility policies and procedures for floor care outlined steps for cleaning and maintaining vinyl plank flooring, but observations indicated that these procedures were not being followed, particularly in high-traffic and problem areas. The maintenance log, intended for staff to report issues, was not being utilized effectively, and completed and incomplete work orders were not readily available for review. Interviews with nursing and housekeeping leadership confirmed that cleaning and pest control should be prioritized, but acknowledged delays and lapses in reporting and addressing these deficiencies.
Failure to Timely Process and Administer Ordered Narcotic Pain Medication
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality when staff did not process an ordered narcotic pain medication, Tramadol 50 mg, in a timely manner for a resident with moderate cognitive impairment and heel wounds. The resident was re-admitted with a care plan indicating a risk for pain related to stroke, and interventions included administering pain medication as ordered. Despite a physician order for Tramadol to be given twice daily, the medication was not delivered promptly by the pharmacy, and staff did not promptly contact the physician to ensure the prescription was processed. Documentation in the medical record and Medication Administration Record (MAR) showed that the resident missed a total of six doses of Tramadol over several days. Progress notes indicated that the medication was unavailable and that the pharmacy was waiting for a signed prescription. Staff administered acetaminophen as needed in place of the ordered Tramadol. The facility's emergency stock (e-kit) contained Tramadol, but staff were unable to access it because the pharmacy required a signed prescription before providing the access code. Interviews with staff revealed that the nurse practitioner (NP) who wrote the order did not have a DEA number, which prevented the pharmacy from filling the prescription. The process for obtaining the necessary prescription signatures was not clearly defined, and staff did not have a protocol to ensure timely processing of narcotic orders. The Director of Nursing confirmed that the resident did not receive any Tramadol until several days after the order was written, and that staff had documented administration of the medication when it was not actually available.
Failure to Maintain Adequate Hot Water Temperatures in Resident Areas
Penalty
Summary
The facility failed to maintain appropriate water temperatures throughout multiple resident areas, including hallway shower rooms and individual resident rooms. Observations with a calibrated digital thermometer revealed that hot water temperatures in various sinks and shower stalls ranged from 72.4°F to 97.1°F, which is below typical standards for hot water in such settings. Several rooms and shower areas consistently provided water that was not sufficiently warm, and in some cases, shower stalls lacked proper fixtures such as showerheads. The facility's water temperature policy did not specify recommended temperature parameters, and there was no evidence of regular monitoring or documentation of water temperatures. Interviews with staff, including CNAs and the Maintenance Director, indicated ongoing issues with water temperature, with some staff reporting that residents had complained about the lack of hot water for several months. Staff described having to take extra steps, such as running water for extended periods or transporting warm water in bags, to accommodate residents' needs for bathing and personal care. Some staff noted that only a few rooms had access to warm water, and that the problem had persisted for an extended period, affecting both residents who required assistance and those who bathed themselves. Administrative staff, including the Administrator and DON, were not fully aware of the extent of the water temperature issues or the specifics of the facility's water temperature policy. The Maintenance Director was unable to locate maintenance or water temperature logs, and there was confusion regarding policy documentation due to changes in facility ownership and staff turnover. The lack of clear policy parameters, regular monitoring, and documentation contributed to the ongoing deficiency in providing a safe, comfortable, and homelike environment for residents.
Failure to Monitor Water Temperatures and Incomplete Fall Investigation
Penalty
Summary
The facility failed to monitor and maintain safe water temperatures throughout the building, resulting in hot water in two resident rooms measuring significantly above the required range, with temperatures recorded at 136.5°F and 141.0°F. The maintenance director, who was new to the position, was unable to locate any water temperature logs or maintenance records, and there was no clear policy in place specifying acceptable water temperature parameters. Interviews with staff and residents confirmed that the water in these rooms was very hot, and the maintenance director acknowledged that water temperature checks had not been performed as required. Additionally, the facility did not conduct a complete and thorough investigation following a resident fall. One resident, who was moderately cognitively impaired and had a history of falls, experienced an unwitnessed fall and was subsequently sent to the emergency room for evaluation. Documentation related to the incident was incomplete, as the facility was unable to provide witness statements or neurological check records for the resident. The care plan for this resident indicated multiple previous falls, but no new interventions were added after the most recent incident, and required post-fall assessments and documentation were not completed. Interviews with facility leadership, including the administrator and DON, revealed that they did not have access to the previous company's policies and procedures, including those related to water temperature monitoring and fall investigations. The DON stated that a full and thorough investigation should be completed after every fall, including head-to-toe assessments, pain evaluations, and neuro checks, but these were not documented for the resident in question. The lack of policies, procedures, and documentation contributed to the deficiencies identified during the survey.
Failure to Protect Resident Confidentiality and Secure Medical Records
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal and medical records in multiple ways. Identifying information, including a medication card with the resident's name, room number, medication name, and dose, was observed sticking out of an unlocked shred bin located in an area accessible to residents, staff, and the public. The shred bin was not locked, and the area was not secured, allowing anyone to access confidential information. Additional observations revealed that other shred bins in the facility were also full, overflowing, and located in unsecured areas, with confidential resident information visible and accessible. Staff practices further compromised resident confidentiality. An LPN, lacking access to the facility's e-fax system and a work email, used a personal device to take a photo of a resident's medication prescription and then sent it to the pharmacy using a personal email address. This process exposed the resident's name, date of birth, and prescription details. Interviews with facility staff and management confirmed that floor nurses did not have access to secure communication methods for transmitting sensitive information, and there was confusion about proper procedures for sending prescriptions to the pharmacy. The facility did not have a current policy on maintaining the confidentiality of resident medical records available when requested. The administrator and DON acknowledged that the use of personal devices and unsecured email for transmitting resident information, as well as the exposure of confidential documents in unlocked and overflowing shred bins, constituted privacy violations. The facility was also in the process of changing shred companies, and there was uncertainty about when confidential materials were last securely disposed of.
Failure to Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving one resident who was slapped by another resident. According to the facility's policy, any suspicion or allegation of abuse must be immediately reported to the charge nurse, who is then responsible for notifying the Administrator or Director of Nursing and making the required notifications to state authorities. In this case, documentation showed that a restorative aide informed a nurse that a resident had slapped their roommate. The incident was acknowledged by the resident who was slapped, and the Director of Nursing was notified. The involved residents were separated, and one was sent for psychiatric evaluation. Despite these actions, there was no documentation of a formal investigation or a report being made to the Missouri Department of Health and Senior Services (DHSS) as required by policy. Staff interviews revealed uncertainty about whether the incident was reported to authorities. The Social Services Director and Human Resources Manager both stated they had no direct knowledge of the notification being sent, and there was no evidence or confirmation of a report being filed. The previous Administrator, who was terminated, claimed to have reported the incident but left no documentation or investigation records. The lack of documentation and confirmation of reporting the abuse incident constitutes a failure to follow the facility's abuse investigation and reporting policy. The incident involved residents with significant medical and psychiatric histories, including schizophrenia and stroke-related disabilities. The absence of a documented investigation and notification to authorities represents a deficiency in the facility's response to suspected abuse.
Failure to Investigate Alleged Misappropriation and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate two separate allegations: one involving misappropriation of property (narcotics) by an LPN, and another involving resident-to-resident physical abuse between two residents. In the case of the alleged misappropriation, the facility's records lacked documentation of a statement from the accused LPN, resident interviews, staff interviews, a summary or conclusion of the incident, or any witness statements. The initial allegation was made by the LPN's significant other, who claimed the LPN possessed prescription bottles and medication cards without names, and the facility administrator notified the police and state authorities. However, there was no evidence that a comprehensive investigation was conducted, as required by facility policy. For the resident-to-resident abuse allegation, the facility failed to document a thorough investigation into an altercation between two residents. The care plans and progress notes indicated a history of physical altercations and behavioral issues, but there was no documentation of a completed investigation, witness interviews, or a summary of findings. Staff interviews revealed that the previous administrator claimed to have notified the state, but there was no confirmation or supporting documentation. Staff members were generally unaware of the details of the incident, and the file related to the incident was found empty after the administrator's departure. Both deficiencies were compounded by a lack of proper documentation and follow-through on required investigative steps, as outlined in the facility's own policies. The absence of statements, interviews, and investigative summaries for both the misappropriation and abuse allegations demonstrates a failure to respond appropriately to alleged violations, as required by federal and state regulations.
Failure to Provide Consistent Wound Care and Assessments Resulting in Maggot Infestation
Penalty
Summary
The facility failed to ensure that weekly wound assessments and ordered wound treatments were performed as prescribed for a resident with multiple complex medical conditions, including paraplegia, severe malnutrition, and several pressure ulcers. Documentation revealed that wound care orders, such as the application of Collagenase Ointment and Vashe Wound Solution, were not consistently signed out or completed as required, with numerous missed opportunities recorded on the Medication Administration Record (MAR) and Treatment Administration Record (TAR). Only two weekly wound assessments were documented for the entire month of August, despite expectations for weekly assessments. The lack of consistent wound care and assessment was confirmed by staff interviews, with nurses and the DON acknowledging that if treatments were not signed out on the TAR, they were not done. A significant event occurred when a resident was found with small, white, legless, worm-like organisms (maggots) in their wound and brief during a routine care episode. The CNA and nurse responded by cleaning the wound, changing the dressing, and cleaning the resident and their environment. The resident reported that staff did not change dressings daily as ordered and expressed embarrassment about the incident. Staff interviews confirmed the presence of maggots and noted environmental factors such as food crumbs and flies in the resident's room. The incident was not reported to all relevant nursing staff, and no investigation was initiated by facility leadership. Additionally, the facility did not have wound care or pressure ulcer policies and procedures available to staff. The DON and Administrator both stated they did not have access to such policies, and the DON had not been provided with any. The absence of these policies, combined with the lack of a designated wound nurse and inconsistent documentation and performance of wound care, contributed to the deficiency. The failure to provide appropriate pressure ulcer care and prevent new ulcers had the potential to affect all residents with wounds in the facility.
Failure to Promote Resident Self-Determination and Provide Adequate Care
Penalty
Summary
The facility failed to promote and facilitate self-determination for residents dependent on staff for transfer assistance by not ensuring residents were out of bed daily according to their preferences. Resident #71, who had no cognitive impairment and required extensive assistance for mobility and personal hygiene, reported being out of bed only twice since admission. Multiple observations confirmed the resident remained in bed despite expressing a desire to get up. Staff interviews revealed that the facility was often short-staffed, which hindered their ability to assist residents in getting out of bed as per their preferences. Additionally, the facility did not provide showers or baths according to resident preferences. During a group meeting, five alert and oriented residents reported not being offered at least two showers per week and being told it was not their shower day when they requested one. One resident, who required a mechanical lift for transfers, stated they were often unable to get out of bed due to staff shortages. Staff interviews corroborated that residents did not always receive the required number of showers per week and were not always able to get out of bed daily due to insufficient staffing. The facility's policy on Resident Rights emphasized the importance of promoting self-determination and accommodating resident preferences. However, interviews with the Director of Rehab, LPNs, CNAs, and the Regional Nurse Consultant indicated that the facility's staffing issues frequently prevented them from meeting these standards. The Administrator, DON, and RNC acknowledged that residents should receive at least two showers per week and be up and out of bed daily, but this was not consistently achieved due to staffing constraints.
Facility Fails to Maintain Functional Equipment and Safe Environment
Penalty
Summary
The facility failed to ensure a functional bathroom toilet for one resident, resulting in the resident having to use a shower room down the hallway for four out of five days of the survey. The resident reported the issue to staff, but the toilet remained clogged with a dark brown substance and toilet paper floating on the surface. Additionally, the facility failed to ensure functional bathroom lights and comfortable water sink temperature and pressure for two other residents, with one resident's bathroom light not working and the water temperature being consistently cold at 77.5 degrees Fahrenheit. Another resident experienced low water pressure in their sink, causing a very small stream of water to come from the faucet. The facility also failed to ensure a functional call light for one resident, who repeatedly yelled for help but received no response due to the call light not being activated. The resident reported the issue, and a CNA confirmed that the call lights were unreliable. The Maintenance Director admitted to not conducting regular equipment inspections and was unaware of the clogged toilet and other issues. He relied on staff to report broken equipment through a maintenance log binder, which he checked multiple times a week. The Regional Nurse Consultant expected resident room lights to be in working condition and water temperatures to be appropriate. The Maintenance Director was expected to keep a maintenance log to inspect and maintain all resident rooms and patient care equipment in functional condition. However, the lack of regular inspections and immediate repairs led to multiple deficiencies in the facility's environment, impacting the residents' safety, comfort, and dignity.
Failure to Provide Adequate Shower Care
Penalty
Summary
The facility failed to ensure that residents who required assistance with activities of daily living (ADL) care received showers in accordance with their personal needs. Eight residents were identified as not receiving showers as per the facility's policy. The facility's Resident Showers Policy mandates that residents be provided showers as per request or facility schedule protocols, and partial baths may be given between regular showers. However, observations and interviews revealed that residents were not receiving the required three showers per week due to staffing issues, and there were no shower sheets available for documentation. Resident #19, who had severe cognitive impairment and was dependent on staff for ADLs, was observed multiple times with dirty and long nails, disheveled hair, and a strong urine odor. The resident's fitted sheet had dried blood stains, and the incontinence brief was wet and soiled. Despite these conditions, the resident had not received a shower recently, and staff failed to provide timely care. Similar observations were made for Resident #17, who was cognitively intact but required substantial assistance with ADLs. The resident had long and dirty nails and emitted a strong scent of urine, indicating a lack of proper hygiene care. Other residents, including Resident #15, Resident #51, Resident #35, Resident #78, Resident #39, and Resident #50, also reported not receiving showers for several weeks. These residents expressed their desire for showers and dissatisfaction with the bed baths or wipe-downs provided by the staff. The Regional Nurse Consultant (RNC) confirmed the lack of shower sheets for these residents, further highlighting the facility's failure to adhere to its shower policy. The Administrator and RNC acknowledged that each resident should receive a shower twice a week and that bed baths with wipes are not considered adequate substitutes for showers.
Failure to Ensure Resident Safety and Proper Supervision
Penalty
Summary
The facility failed to ensure proper bed rail assessments and fall interventions for a resident, leading to multiple falls and injuries. Resident #71, who was cognitively intact and required full staff care for ADLs, experienced several falls due to inadequate bed rail maintenance and insufficient staff assistance. Despite having a physician's order for bed rails, the resident's bed rail was broken and not repaired, resulting in the resident falling out of bed multiple times. Additionally, the facility was frequently short-staffed, which contributed to the lack of timely assistance and supervision for the resident, further exacerbating the risk of falls and injuries. The facility also failed to ensure safe mechanical lift transfers for three residents. Observations revealed that staff did not follow the policy requiring two staff members to assist with mechanical lift transfers. In several instances, residents were left suspended in the air without proper support, and the mechanical lift equipment was not inspected for functionality before use. This negligence in following safe transfer protocols put the residents at risk of injury during transfers. Furthermore, the facility did not complete smoking assessments for two residents, allowing them to keep smoking materials in their rooms unsupervised. This was against the facility's policy, which required smoking materials to be stored by nursing staff and only provided to residents as needed. Additionally, staff failed to respond promptly to an exit door alarm, which had been malfunctioning for a month. The lack of timely response and proper headcount procedures during the alarm further highlighted the facility's inadequate supervision and safety measures for residents at risk of elopement.
Inadequate Staffing Leading to Deficient Resident Care
Penalty
Summary
The facility failed to maintain appropriate and competent staffing to adequately provide resident care and meet resident needs. This deficiency was observed through various instances involving multiple residents. For example, Resident #71, who required extensive assistance for bed mobility and personal hygiene, was observed being repositioned in bed by a single CNA, contrary to the care plan that required two staff members. The resident and their family expressed concerns about insufficient staffing and lack of timely assistance, including an incident where the resident fell out of bed and had to rely on a family member to get help before staff arrived. Additionally, the facility was noted to be short-staffed, with one LPN covering multiple halls and having to find additional staff to assist with mechanical lifts, further indicating inadequate staffing levels to meet resident needs effectively. Resident #39, who required moderate assistance with bathing, reported not having had a shower for over a month due to staff shortages. The resident's hair appeared unkempt, and staff confirmed that there were not enough personnel to provide showers regularly. Similarly, Resident #50, who also required moderate assistance with bathing, had not received a shower in over a month and was only given wipe-downs with wet wipes or washcloths due to the lack of staff. These observations highlight the facility's failure to provide basic hygiene care as per the residents' needs and care plans. Resident #19, who was severely cognitively impaired and dependent on staff for ADLs, was found in an unkempt state, emitting a scent of urine, and had not received a shower recently. The CNA responsible for the resident confirmed that residents were not receiving the scheduled three showers per week due to staffing issues. The Regional Nursing Consultant acknowledged the expectation for two staff to provide care for residents requiring it and for showers to be given as scheduled. However, the facility's staffing levels were insufficient to meet these expectations, leading to the observed deficiencies in resident care.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored in accordance with acceptable standards of practice. During observations, multiple medication carts and a medication room were found with opened, undated, and expired over-the-counter (OTC) medications. Additionally, a refrigerator storing unopened insulin pens was found unsteady and leaning sideways, with a thermometer stuck in the freezer and no temperature log sheet observed. The facility's Medication Storage Policy mandates proper labeling, storage, and temperature control of medications, which was not adhered to in these instances. On Hall 300, opened OTC medication bottles were found with expired dates, and some were undated. Similar issues were observed on Hall 100, where multiple opened OTC medication bottles were also expired or undated. The treatment cart on Hall 400-500 contained opened tubes of medications that were either expired or undated. Additionally, the medication cart on Hall 400-500 had multiple opened OTC medication bottles that were undated but within the current expiration date. Interviews with staff revealed inconsistencies in maintaining and organizing medication carts and rooms. A Certified Medication Technician (CMT) admitted to using undated medications as long as they were not expired and acknowledged the lack of consistency due to staff changes. The Assistant Director of Nursing (ADON) confirmed that the night shift nurse was responsible for maintaining the refrigerator temperature record, which was missing in the Hall 400-500 medication room. The Regional Nurse Consultant expected staff to date medications when opened and check expiration dates before administration, which was not consistently practiced.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain dignity and provide personal privacy for a resident when staff did not place a cover over the resident's half-full catheter drainage bag, which was visible from the hallway through the resident's open room door. This deficiency was observed multiple times over several days. The resident, who was cognitively intact and used a wheelchair, had a suprapubic catheter due to a neurogenic bladder and required dependent assistance for toileting hygiene. The resident's care plan specifically included an intervention to ensure the catheter bag was covered to maintain the resident's dignity. Despite the care plan's directive, observations on four separate occasions showed the catheter bag was not covered. Interviews with multiple Licensed Practical Nurses (LPNs) and the Regional Nursing Consultant confirmed that the catheter should have been covered and that staff were expected to follow the resident's care plan. The failure to cover the catheter bag was acknowledged by the staff, who admitted that the catheter should always be covered to respect the resident's dignity and privacy.
Resident-to-Resident Altercation Resulting in Injury
Penalty
Summary
The facility failed to ensure a resident's right to be free from abuse was not violated when two residents were involved in a physical altercation. Resident #3, who has severe cognitive impairment and uses a wheelchair independently, was struck in the face with a cane by Resident #76, resulting in a skin tear to the forehead. Resident #76, who has moderate cognitive impairment and ambulates independently, admitted to twirling the cane when Resident #3 got too close, leading to the injury. The incident occurred when Resident #3 entered Resident #76's room, causing irritation to Resident #76, who then struck Resident #3 with the cane. The facility's investigation revealed that the charge nurse observed Resident #3 with blood on the forehead and immediately separated the residents. The physician, Administrator, resident representatives, and DON were notified, and both residents were sent to the emergency room for evaluation. Resident #3's hospital visit summary showed no intracranial injury. Interviews with staff indicated that Resident #76 had a history of verbal aggression, but there were no prior conflicts between the two residents. The Social Services Director confirmed that staff were instructed to monitor both residents for aggressive behavior following the incident. The facility's policy on abuse, neglect, and exploitation mandates the protection of residents from all types of abuse and requires immediate intervention in situations where abuse is likely to occur. Despite these policies, the facility failed to prevent the altercation between the two residents, resulting in physical harm to Resident #3. The incident was substantiated, and the facility's response included monitoring both residents and updating their care plans to prevent future occurrences.
Failure to Report and Address Skin Impairment
Penalty
Summary
The facility failed to ensure a resident at risk for skin injury did not develop skin impairment. The staff did not report the skin impairment to the nurse when it was discovered. The resident, who had multiple diagnoses including diabetes, asthma, and morbid obesity, was found to have open areas on the buttocks and thighs due to moisture and incontinence. Despite having orders for barrier cream and wound consults, the resident's skin issues were not documented or reported in a timely manner. During observations and interviews, it was revealed that the resident had open areas on the buttocks and thighs, which were not reported to the nurse by the CNAs. The wound nurse, who had been in the position for two weeks, was not informed of the resident's skin issues until she conducted an assessment. The resident's skin condition included multiple areas of shearing and a Stage II wound with serosanguineous drainage. Additionally, the resident had an ingrown toenail that was not previously addressed. The facility's wound treatment management policy required that wound treatments be provided according to physician orders and that any changes in skin condition be reported immediately to the nurse. However, the CNAs did not report the resident's skin changes, and the weekly skin assessments did not reflect the resident's current condition. The LPN confirmed that aides are expected to report changes immediately, but this protocol was not followed, leading to a delay in appropriate wound care treatment for the resident.
Failure to Provide Consistent Restorative Services
Penalty
Summary
The facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for two residents. Resident #19 had an order for occupational therapy to evaluate and treat a right-hand splint, but there was no documentation of restorative services being provided. Observations showed the resident lying in bed with a contracted right hand and no splint. Interviews with CNAs revealed that the resident was supposed to receive restorative services daily, but these services were not consistently provided due to staff being pulled to the floor to provide care. The resident confirmed that the splint was applied for the first time during the survey period. Resident #35 had contractures to both upper and lower limbs and was supposed to receive restorative therapy, including the application of a right knee extension splint. However, observations and interviews indicated that the resident had not received any restorative therapy for several weeks, and the splint had not been applied. The resident confirmed the lack of restorative services, and staff interviews corroborated that restorative aides were often reassigned to other duties due to staffing shortages. Interviews with the Director of Rehabilitation, the Regional Nurse Consultant, the Director of Nursing, and the Administrator confirmed that the facility's restorative nursing program was inconsistent. The facility had not had a stable Director of Nursing for several months, and the restorative aides were frequently pulled to work the floor, preventing them from providing consistent restorative services. The facility acknowledged the deficiency in their restorative nursing program.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure that a resident who received routine dialysis treatment had physician orders in place and consistent communication with the dialysis provider. The resident, who was cognitively intact and had diagnoses including heart failure, end-stage renal disease, and lung disease, did not have dialysis orders, dialysis provider information, or transportation details documented in the Physician Order Sheet. Additionally, the facility staff did not provide communication forms to the dialysis provider and did not assess the dialysis access site before or after treatment, as confirmed by the resident and the Regional Nurse Consultant. The facility's hemodialysis policy required ongoing assessment of the resident's condition, communication with the dialysis provider, and documentation of dialysis treatments and physician orders. However, these requirements were not met for the resident, as there were no dialysis communication forms in the medical record, and the dialysis orders were missed on the POS. The Regional Nurse Consultant acknowledged that the resident was admitted after an audit and that the dialysis orders were overlooked. The Charge Nurse was expected to catch the missing dialysis order, and communication forms should have been sent with and returned with the resident following each treatment.
Failure to Notify Physician of Pharmacy Recommendations
Penalty
Summary
The facility failed to notify the attending physician about the pharmacy medication regimen review recommendation for a resident. The resident, who had no cognitive impairment and was diagnosed with depression, anxiety disorder, and paraplegia, was on a regimen that included Novolin N FlexPen and Humalog KwikPen for diabetes management. The pharmacy review recommended a HgA1C test for baseline and subsequent monitoring every six months due to insulin therapy. However, there was no documentation in the resident's medical record indicating that the physician was notified of this recommendation, nor was the HgA1C test completed. The facility's Medication Reconciliation policy mandates frequent medication reconciliation to ensure residents are free from significant medication errors and that the facility's medication error rate remains below 5 percent. Despite this policy, the review of the resident's progress notes and medical records showed a lack of follow-through on the pharmacy's recommendations. During an interview, the Regional Nursing Consultant confirmed that nursing staff are expected to notify the physician of any pharmacy medication regimen review recommendations and follow any subsequent orders, which did not occur in this case.
Failure to Document or Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) was attempted or documented as contraindicated for two residents receiving psychotropic medications. Resident #19 had an order for Sertraline, an antidepressant, but there was no documentation indicating an attempt to reduce the dose or a justification for not doing so. The resident's care plan included the use of antidepressant medication for depression, but the necessary documentation for GDR was incomplete and unsigned by the physician. Similarly, Resident #17 had an order for Quetiapine, an antipsychotic, but the required documentation for GDR was also incomplete and unsigned. The resident's care plan included the use of psychotropic medications, but there was no follow-up on the GDR as expected. During an interview, the Regional Nurse Consultant confirmed that no GDR attempts had been made for these residents. The facility had recently hired a new Director of Nursing, who started shortly before the survey. The consultant expected that GDR should have been followed up on, but it was not done for these residents. The facility's failure to document or attempt GDR for these residents receiving psychotropic medications constitutes a deficiency in care.
Failure to Accurately Document and Administer Medication
Penalty
Summary
The facility failed to ensure medical records were accurately documented in accordance with acceptable professional standards of practice when staff documented the administration of a medication for a resident, despite the medication not being available. The resident, who was cognitively intact and had multiple diagnoses including anemia, high blood pressure, ulcerative colitis, kidney disease, diabetes, high cholesterol, stroke, seizures, and depression, was prescribed Linzess to be taken orally every Monday, Wednesday, and Friday for constipation. On the observed date, the medication was not found on the medication cart, and the LPN indicated they would reorder it from the pharmacy. However, the LPN later claimed the medication was taken from the facility's emergency kit, which was not accurate as the medication was not listed in the e-kit inventory. Despite this, the MAR was marked as if the medication had been administered at the scheduled time. Interviews with the LPN, pharmacist, ADON, and RNC revealed discrepancies in the medication administration process. The pharmacist confirmed that the medication was refilled later that night and was not part of the e-kit. The ADON and RNC both stated that if the MAR was initialed, it indicated that the medication was given, which was not the case here. This failure to accurately document and administer medication as per the facility's protocol and professional standards led to the identified deficiency.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to follow acceptable infection control practices during personal care for a resident who required a Foley catheter insertion. The Licensed Practical Nurse (LPN) used a washcloth to clean the resident's groin area but rinsed the washcloth in the sink and reused it multiple times, which is against the facility's infection control policy. The resident had a history of irregular heartbeat, diabetes, stroke, and one-sided paralysis, and required full hygiene care from the staff. The LPN acknowledged that a fresh washcloth should have been used instead of rinsing and reusing the same one in the sink. Additionally, the facility failed to maintain proper hand hygiene during medication administration for another resident. An LPN handled medications with bare hands and did not sanitize their hands before or after touching the medications. The LPN also picked up spilled tablets from the medication cart with bare hands and returned them to the container, which is against the facility's medication administration policy. The resident involved was cognitively impaired and had multiple diagnoses, including heart failure, high blood pressure, diabetes, Alzheimer's disease, and asthma. Interviews with staff, including the Regional Nurse Consultant, confirmed that the actions observed were not in compliance with the facility's infection control and medication administration policies. The staff acknowledged that washcloths should not be rinsed and reused, and spilled or dropped medications should be destroyed and replaced, not touched with bare hands. The facility's policies clearly outline the importance of hand hygiene and proper handling of medications to prevent contamination and infection.
Failure to Provide Working Call Light System
Penalty
Summary
The facility failed to provide a working call light system for a resident, which prevented the resident from calling for staff assistance. The resident, who had no cognitive impairment and was dependent on assistance for activities of daily living, was observed yelling for help because the call light was not activated. The resident's care plan emphasized the need for the call light to be within reach and for prompt response to requests for assistance. However, the call light system was found to be non-functional during the surveyor's observation. Interviews with staff revealed that the call light system was unreliable, with some lights not working properly. The Maintenance Director admitted to not conducting regular equipment inspections and relied on staff to report broken equipment through a maintenance log binder. The Regional Nursing Consultant expected the call lights to be functional and for the Maintenance Director to maintain a log and inspect the call lights regularly. The facility's policies required a safe and functional environment, including a working nurse call system in resident rooms and toilet/bathing facilities, which was not upheld in this case.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the Nurse Staffing Information on a daily basis as required by their policy. Observations on two separate dates revealed that the Nurse Staffing Information was either outdated or missing entirely. On 4/15/24, the posted information was dated 4/8 and 4/10, and it was placed in a location that was not easily accessible, being approximately 6 feet or higher from the ground. On 4/18/24, no Nurse Staffing Information was posted at the same location where it was previously observed. During an interview on 4/18/24, the Regional Nurse Consultant (RNC) stated that the Nurse Staffing Information was supposed to be updated and posted according to the facility's policy. However, the RNC was unable to show or provide the current information. The facility's policy mandates that the Daily Staffing Sheet should be posted at the beginning of each shift in a clear and readable format, in a prominent place readily accessible to residents and visitors, and should reflect any staff absences due to callouts and illness. The failure to adhere to this policy led to the deficiency noted in the report.
Failure to Provide RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, despite maintaining a census of greater than 60 residents, specifically 90 residents. This deficiency was identified through a review of the facility's staffing sheets for specific weekends, including 11/19/23, 11/20/23, 11/25/23, 11/26/23, and 12/3/23, which showed that only Licensed Practical Nurses (LPNs) were staffed, with no RN present on these days. During an interview on 12/19/23, the Administrator acknowledged the lack of RN coverage on weekends, attributing it to the weekend RN being on leave, which she realized upon returning from vacation. This oversight had the potential to affect all residents in the facility.
Failure to Notify Responsible Party of Pressure Ulcer Development
Penalty
Summary
The facility failed to notify a resident's responsible party after the development of a pressure ulcer. The resident, who had severe cognitive impairment and required total assistance for all activities of daily living, was at risk for skin integrity issues due to impaired mobility, incontinence, and other health conditions. Despite the facility's policy on pressure injury prevention and management, which included notifying the responsible party of any new skin breakdown, there was no documentation showing that the responsible party was informed of the changes in the resident's skin condition. The resident's progress notes indicated the development of a pressure ulcer and subsequent changes in skin condition, including moisture-associated skin dermatitis with eschar tissue. The Wound Nurse documented these changes and obtained new treatment orders, but failed to notify the responsible party. Interviews with facility staff, including the Wound Nurse and Director of Nurses, confirmed that it was the Wound Nurse's responsibility to notify the family of such changes, yet this was not done, leading to the deficiency.
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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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Nursing homes near Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Care Center | 1.2 mi | ★★★★★ | 32 | 1 |
| Oak Knoll Skilled Nursing & Rehabilitation Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Arbor Hills Care & Rehab Center | 2.1 mi | ★★★★★ | 28 | 0 |
| Normandy Nursing Center | 2.3 mi | ★★★★★ | 1 | 0 |
| Estates Of St Louis, Llc, The | 2.8 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.