Atrium Place Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 2600 Redman Road, Saint Louis, Missouri 63136
- CMS Provider Number
- 265586
- Inspections on file
- 29
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Atrium Place Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to accurately transcribe and timely implement wound care provider orders and off‑loading interventions for multiple residents with pressure injuries. For a quadriplegic resident with impaired cognition and a sacral/right buttock pressure injury, the wound care physician’s order to change from calcium alginate to calcium alginate with silver was never updated on the POS/TAR, and the care plan did not reflect the current pressure injury. The same resident also received Bactrim DS instead of the amoxicillin‑clavulanate documented in the wound care physician’s notes, with no contemporaneous explanation in the record. Two other residents with severe cognitive and mobility impairments and incontinence had new Stage 3 pressure injuries for which calcium alginate with silver dressings were ordered, but these orders were not entered into the POS/TAR for several days, during which staff continued prior skin prep or zinc oxide treatments. One of these residents also had an order for off‑loading boots to be worn at all times, yet was observed without the boots in place, and staff reported the boots were in the laundry.
Staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy by not wearing gowns during high-contact care activities for multiple residents who had wounds, feeding tubes, or tracheostomies and were posted for EBP. In several observed instances, an LPN, the Treatment Nurse, and CNAs performed skin assessments, wound treatments, personal care, bed baths, and incontinence care while wearing gloves only, despite EBP signage on room doors and gowns and gloves being readily available. Some staff later acknowledged they should have worn gowns, while others reported they were unaware gowns were required, even though the facility’s policy and physician orders specified gown and glove use for high-contact care under EBP.
Staff did not follow physician orders to obtain and document a resident's vital signs, despite the resident having complex medical needs including quadriplegia, malnutrition, multiple pressure ulcers, a suprapubic catheter, and an ostomy. Records showed missing or incomplete documentation of vital signs over several months. Interviews revealed inconsistent practices and lack of awareness among staff regarding the required monitoring.
A resident with multiple pressure ulcers and complex medical needs had numerous wound treatments and refusals that were not documented on the Treatment Administration Record as required. Despite facility policy and electronic prompts for documentation, staff left several entries blank, and interviews with the LPN, wound nurse, DON, and nurse practitioner confirmed that treatments and refusals should have been clearly recorded.
Staff failed to provide CPR to a resident with full code status after the resident was found unresponsive and not breathing following a transfer to bed. Despite the LPN informing the Nurse Manager of the resident's full code status, no resuscitation efforts were made, and the resident was pronounced dead without CPR, contrary to facility policy and physician orders.
A resident with a seizure disorder had critically low levels of seizure medications identified in lab results, but the physician was not notified and the Medical Director did not have access to these results in the system. The resident later experienced seizures. Additionally, when the resident developed new purple discoloration of the fingertips, nursing staff delayed notifying the on-call NP until after a fall occurred, and failed to document the initial assessment. The facility also did not check g-tube residuals for another resident as required.
Two residents were involved in a physical altercation during a smoke break at an LTC facility. The incident began when one resident attempted to rush past another, leading to a verbal exchange that escalated into physical aggression. Witnesses and staff provided varying accounts, and the facility's investigation could not conclusively determine if one resident's foot was run over by the other's wheelchair. Both residents have no prior history of altercations and expressed feeling safe in the facility.
The facility failed to maintain a safe and homelike environment, as evidenced by a leaking air conditioning unit causing water puddles in a resident's room, a non-functioning call light indicator delaying staff response, and disrepair in the 300 hall with chipped tiles and a broken doorframe. Maintenance was aware of some issues but had not addressed them, and renovations were halted by the current corporation.
The facility failed to provide adequate supervision during meals and smoke breaks, leading to a resident with dysphagia experiencing a coughing episode due to improper positioning, and multiple residents engaging in unsafe smoking practices without supervision. Staff did not ensure residents were upright during meals or present during smoke breaks, contrary to facility protocols.
The facility did not maintain the required RN staffing levels, failing to have an RN on duty for at least 8 consecutive hours a day, 7 days a week. This issue was identified in the PBJ Staffing Data Report for Q2 2024, with specific dates lacking RN coverage. The administrator and Corporate Staff B confirmed the report's accuracy, and although borrowing RNs from sister facilities was suggested, it was not executed, resulting in the deficiency.
The facility failed to maintain accurate records for controlled substances, with significant documentation gaps in narcotic books. The Controlled Substance Shift Change Count - Check Sheet showed numerous blanks for package counts and missing nurse initials. The DON acknowledged the issue, noting confusion due to shift length discrepancies, but expected adherence to policy.
A facility reported a 14.81% medication error rate due to improper administration practices. An LPN failed to prime an insulin pen before use, another crushed enteric-coated aspirin for a resident with a g-tube, and a CMT did not follow proper eye drop administration guidelines. The DON confirmed staff did not adhere to nursing practices.
The facility failed to properly label and store medications, with issues such as undated insulin pens, unidentified pre-popped medications, and expired drugs found in medication carts. The DON acknowledged these deficiencies, highlighting a lack of adherence to facility policies.
The facility failed to maintain an effective pest control program, leading to the presence of flies in the kitchen. Observations showed the backdoor left open, allowing flies into food prep areas and near the walk-in cooler. The administrator expected the kitchen to be fly-free and the door closed.
A resident with multiple diagnoses, including quadriplegia and depression, experienced a negative interaction with a CNA who used profanity and was reportedly rough while wiping the resident's face. The incident was witnessed by an LPN who heard cursing from both parties and saw the CNA toss a towel onto the resident's head. The facility's investigation could not substantiate abuse, but the CNA was terminated for policy violation.
A facility failed to obtain a physician order for a resident using a bi-pap machine and did not complete neuro check documentation for another resident who fell. The resident using the bi-pap had obstructed sleep apnea, but no physician order was documented. The resident who fell had severe cognitive impairment and a history of stroke, with incomplete neuro check documentation following the fall. Staff interviews confirmed that protocols were not fully followed.
A resident with a seizure disorder did not receive Vimpat, a seizure medication, for four and a half days due to the facility's failure to obtain it from the pharmacy in a timely manner. Despite the facility's policy requiring immediate action for unavailable medications, there was no documentation of physician notification or alternative treatment orders. Staff interviews revealed attempts to contact the pharmacy and MD, but the medication was delayed due to a lack of refills and the need for a new script.
A resident was left exposed in the hallway after a shower when a CNA refused to get a gown or blanket. The resident, who required assistance for showers and transfers, was left unclothed in a wheelchair, causing significant distress. Another CNA covered the resident and assisted them back to their room. The responsible CNA was terminated.
The facility failed to provide necessary treatment and services for residents with pressure ulcers, resulting in deficiencies. One resident with a left heel unstageable pressure ulcer did not receive timely care, and another resident with multiple pressure ulcers did not receive the prescribed wound treatment due to missing supplies. The staff did not follow physician orders or take immediate action to address open and draining wounds.
The facility failed to maintain acceptable nutritional status for a severely underweight resident with severe protein-calorie malnutrition and a wound. Staff did not accurately monitor or document the resident's weights and nutritional supplement administration, leading to the use of inaccurate information by the dietician. The facility also did not provide the ordered nutritional supplements, resulting in significant weight loss.
A resident with multiple diagnoses, including diabetes and arthritis, experienced unmanaged pain due to the facility's failure to administer prescribed pain medications in a timely manner. The facility did not follow its Medication Reordering and Physician's Orders policies, leading to a delay in receiving Oxycodone and a lack of alternative pain relief. Communication issues between the facility, pharmacy, and physician further exacerbated the problem.
The facility failed to provide necessary wound care for a resident with a foot wound, as per physician's orders. The resident, who had diabetes and neuropathy, reported that wound care was not being completed, and observations confirmed lapses in the treatment schedule. The LPN acknowledged the resident's ongoing issues with peeling skin and pain, and the administrator emphasized the importance of following physician's orders.
The facility failed to ensure that meals were served at safe temperatures, as evidenced by two residents receiving cold food. Despite initial food temperatures being correct, the lack of a heated cart and timely distribution led to meals being served below the required temperature standards.
Failure to Implement Wound Care Orders and Off‑Loading Interventions for Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate transcription and implementation of wound care provider orders, timely initiation of new pressure injury treatments, and inclusion of a resident’s pressure injury in the care plan. For one quadriplegic resident with impaired cognition and total dependence for mobility and ADLs, a pressure injury to the sacral/right buttock area was identified in early November. The wound care company physician ordered a change in dressing from calcium alginate to calcium alginate with silver on 11/13, but the facility’s Treatment Nurse did not update the physician order sheet (POS) or treatment administration record (TAR). As a result, the TAR continued to list calcium alginate only through January, and staff nurses reported they would follow what was written on the TAR, meaning they may not have used the ordered calcium alginate with silver. The resident’s care plan also did not identify the presence of a current pressure injury despite documentation of a recurrent coccyx/right buttock wound and ongoing wound care. For the same resident, the wound care physician ordered amoxicillin‑clavulanate for the pressure injury on 1/2, but the POS and MAR instead showed Bactrim DS being administered twice daily starting 1/3, with no documentation explaining the change from the wound care physician’s written order. The DON later reported a verbal confirmation from the wound care physician that Bactrim DS was desired, but this clarification occurred after the period in which the MAR showed Bactrim being given in place of the originally ordered amoxicillin‑clavulanate. Throughout this time, the wound care physician’s subsequent notes continued to list amoxicillin‑clavulanate as the recommended antibiotic, while the facility records reflected Bactrim DS administration. The facility also failed to timely implement new wound care orders for two other residents and to ensure ordered off‑loading devices were in place. One resident with cerebral palsy, severe cognitive impairment, total dependence for mobility, and bowel and bladder incontinence had existing orders for skin prep to the left dorsal foot and left heel and for off‑loading boots to be worn at all times. On 1/2, the wound care physician documented new Stage 3 pressure injuries on the left dorsal foot and left heel and ordered calcium alginate with silver dressings once daily, along with continued use of pressure off‑loading boots. However, the POS and TAR were not updated to reflect the calcium alginate with silver until 1/5, and staff continued to document application of skin prep on 1/2–1/4. During observation on 1/5, the resident’s left dorsal foot and heel had open pressure injuries with dressings dated 1/2, and on 1/7 the resident was observed in bed without off‑loading boots; CNAs reported the boots had been sent to laundry and not yet returned, despite an order for boots to be on at all times. Another resident with a history of wound infection, diabetes, stroke, severe cognitive impairment, and total dependence for mobility had an order for zinc oxide ointment to the right buttock. On 1/2, the wound care physician documented a Stage 3 pressure injury on the right posterior thigh and ordered calcium alginate with silver once daily. The facility did not enter this new order on the POS and TAR until 1/5, and nurses continued to initial zinc oxide application on 1/2–1/4. On 1/5, observation showed open horizontal areas on the right posterior thigh without a dressing in place, and the Treatment Nurse acknowledged she had been on vacation when the wound care physician rounded and that the new order from 1/2 had not been added until her return. Across these cases, the facility’s own policies requiring prompt assessment, timely implementation of provider orders, and care plan updates for pressure injuries were not followed.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its Enhanced Barrier Precautions (EBP) policy during high-contact resident care activities for residents requiring EBP. The facility’s written policy required the use of gowns and gloves for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care for residents with wounds or indwelling medical devices. EBP signs were posted on the doors of residents requiring these precautions, and gowns and gloves were made available near or inside those rooms. The policy also stated that staff were trained on EBP upon hire and annually, and that the Infection Preventionist would periodically monitor adherence. For one resident with functional limitations in both upper and lower extremities, dependent in all ADLs, with a feeding tube and open areas on the right posterior thigh, surveyors observed an EBP sign on the door and PPE supplies inside the room. During a skin assessment, an LPN and the Treatment Nurse both donned gloves but did not wear gowns, despite the presence of a feeding tube stoma with a dressing and open skin areas. This resident’s record showed wound infection, diabetes, stroke, and tube feeding orders, but no specific physician order for EBP, even though the room was posted for EBP. Another resident with cerebral palsy, seizure disorder, total dependence in ADLs, incontinence of bowel and bladder, and a Stage 3 pressure ulcer had a care plan and physician order specifically requiring EBP with gown and gloves for high-contact care due to chronic wounds. Surveyors observed the Treatment Nurse performing a skin assessment and later wound treatment to open areas on the left dorsal foot and heel while wearing gloves but no gown, despite an EBP sign on the door and PPE available. On a separate occasion, two CNAs provided personal care and a bed bath to this resident while each wore gloves but no gowns. One CNA later stated awareness that a gown should have been worn, while the other CNA reported not knowing a gown was required during personal care. A third resident, totally dependent in ADLs with a history of stroke, seizure disorder, respiratory failure, a feeding tube, and a tracheostomy, had a physician order for EBP requiring gown and gloves for high-contact care. An EBP sign and PPE supplies were present at the room. During a skin assessment, an LPN and a CNA donned gloves but not gowns. While in the room, the resident had a large loose bowel movement, and both staff cleaned the resident and changed the incontinent brief without wearing gowns. A fourth resident with quadriplegia, dependence in all ADLs, and a sacral pressure injury had an EBP sign on the door and PPE supplies available. The Treatment Nurse performed a skin assessment of the sacral area while wearing gloves but no gown. In interviews, the Infection Preventionist, Treatment Nurse, DON, and Administrator all stated that staff were expected to follow the EBP signage and policy, and the Treatment Nurse and an LPN acknowledged that gowns should have been worn during these care activities.
Failure to Obtain and Document Resident Vital Signs per Physician Orders
Penalty
Summary
Facility staff failed to follow physician orders and professional standards by not obtaining and documenting a resident's vital signs as ordered. The resident, who was cognitively intact and dependent on staff for most activities of daily living, had significant medical conditions including quadriplegia, malnutrition, chronic osteomyelitis, multiple stage three and four pressure ulcers, a suprapubic catheter, and an ostomy. Physician orders required that a full set of vital signs be obtained and abnormalities reported to the nurse practitioner or physician, initially on a specific date and then monthly. However, review of the Treatment Administration Record (TAR) and electronic medical record (EMR) showed that vital signs were either not documented or marked as not applicable, with several months lacking any record of vital signs being obtained. Interviews with staff revealed inconsistent understanding and implementation of the vital sign orders. An LPN stated that vital signs are typically obtained every shift and as needed, while a CNA reported only taking vital signs when instructed by a nurse and was unaware of any routine or monthly orders for the resident. The wound nurse indicated that vital signs are obtained every shift for new admissions and then monthly, but the resident's care plan did not address obtaining vital signs. The DON and Medical Director both expected staff to follow physician orders and document vital signs, but acknowledged there was no facility policy specifically related to obtaining vital signs. The resident's death was documented, but there was no evidence that vital signs were consistently monitored or recorded as ordered prior to the event.
Failure to Document Wound Treatments and Refusals
Penalty
Summary
The facility failed to accurately document completed wound treatments or treatment refusals for a resident with multiple pressure ulcers and significant medical needs. Review of the Treatment Administration Record (TAR) revealed that, for several wound care orders, numerous entries were left blank, indicating that staff did not record whether treatments were completed or refused. Specifically, for multiple wound care orders, between two and fourteen out of the total opportunities for documentation were left blank. The resident's care plan noted a history of resistance to care and frequent refusals of wound treatments, but the TAR did not consistently reflect whether treatments were administered or refused. Interviews with facility staff, including an LPN, the wound nurse, the DON, and a nurse practitioner, confirmed that staff are expected to document all treatments or refusals in the TAR, and that the electronic medical record system prompts for a reason if a treatment is not completed. However, staff were unable to explain the blank entries, with one LPN suggesting it could be due to forgetting to chart. The lack of documentation was not in accordance with facility policy, which requires clear and accurate recording of all medical provider orders and treatments.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
Facility staff failed to provide basic life support, including cardiopulmonary resuscitation (CPR), to a resident who was identified as full code, meaning that in the event of cardiac or respiratory arrest, CPR should be initiated and emergency services summoned. The resident, who had severe cognitive impairment and multiple diagnoses including high blood pressure, seizures, and muscle weakness, was transferred from a wheelchair to bed by a Certified Nurse Aide (CNA) and a Licensed Practical Nurse (LPN). During the transfer, the resident's oxygen was removed, and after being placed in bed, the resident was found to be unresponsive and not breathing. The LPN checked for a pulse and, finding none, called the Nurse Manager (NM) to confirm the resident's status. The NM used a stethoscope and verified there was no heartbeat or pulse. Despite the LPN informing the NM that the resident was a full code, the NM stated that the resident had died and that two nurses could verify the death, so no CPR was performed. The resident was pronounced dead, and no attempts at resuscitation were made, even though facility policy and physician orders required CPR to be initiated for full code residents unless a Do Not Resuscitate (DNR) order was in place or there were obvious signs of irreversible death. Interviews with staff and review of facility policies confirmed that the expectation was for staff to assess unresponsive residents, check code status, and initiate CPR if the resident was a full code. The failure to initiate CPR was attributed to a misunderstanding by the NM, who incorrectly assumed the resident was a DNR, and a lack of urgency in communication. The deficiency was identified as Immediate Jeopardy due to the failure to follow physician orders and facility policy regarding life-saving interventions for residents with full code status.
Failure to Notify Physician of Critical Lab Results and Change in Condition
Penalty
Summary
The facility failed to notify the physician of a resident's critically low lab results for seizure medications and did not ensure that the Medical Director and other physicians had full access to lab results in the system they use. The resident, who had severe cognitive impairment and a history of seizures, had lab work drawn that showed subtherapeutic levels of both Keppra and Dilantin. There was no documentation that the physician was notified of these abnormal results, and no new orders were entered in response. Eighteen days later, the resident experienced seizure activity, and subsequent review revealed that the Medical Director was unaware of the low lab results due to incomplete transfer of information between electronic systems. Additionally, the facility failed to notify the physician promptly when the same resident exhibited a change in condition, specifically new purple discoloration to the fingertips. The change was first observed and reported to nursing staff at approximately 8:30 P.M., but the on-call Nurse Practitioner was not notified until about 4:30 A.M., after the resident had a fall. There was also a lack of documentation regarding the initial assessment of this change of condition in the medical record. Interviews with staff confirmed that the expectation was for abnormal findings and changes in condition to be reported to the physician or NP and documented accordingly, but this did not occur in this instance. Furthermore, the facility failed to check gastrostomy tube (g-tube) residuals for another resident with a g-tube, as required. The report details that the facility's policies require prompt notification of changes in condition, abnormal lab results, and proper documentation, but these were not followed. The sample included three residents, with a facility census of ninety-four.
Resident Altercation During Smoke Break
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. The incident occurred during a smoke break when one resident attempted to rush past another, resulting in a verbal exchange that escalated into physical aggression. Both residents hit each other before being separated by staff and other nearby residents. The altercation was witnessed by several individuals, including staff and other residents, who provided varying accounts of the events leading up to the physical confrontation. Resident #1, who has diagnoses including hypertension, kidney failure, Parkinson's disease, malnutrition, schizophrenia, and asthma, reported that their foot was run over by Resident #2's motorized wheelchair, which led to the altercation. However, witnesses and staff interviews could not conclusively determine if the foot was indeed run over. Resident #2, who has moderate cognitive impairment and a history of smoking marijuana in the facility, denied running over Resident #1's foot and claimed that Resident #1 initiated the physical contact. Both residents have no prior history of physical altercations with each other or other residents. The facility's investigation into the incident included interviews with the involved residents, witnesses, and staff. The investigation concluded that there was a physical altercation between the two residents, but it could not be determined if the alleged running over of the foot occurred. The facility's policy on abuse, neglect, and exploitation was reviewed, highlighting the need for immediate investigation and protection of residents from harm. Despite the altercation, both residents continued their normal routines and expressed feeling safe in the facility.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. One resident experienced a leaking air conditioning unit in their room, which resulted in puddles of water under the bed and a persistent wet smell. Despite the maintenance staff being aware of the issue and initially inspecting the unit, no repairs were made, and the problem persisted over several days. The resident reported that staff placed a blanket under the bed to absorb the water, but the issue remained unresolved, contributing to an uncomfortable living environment. Another deficiency involved a resident whose call light indicator above their room door was not functioning, leading to delays in staff response. Although the call light was activated in the resident's room, the hallway indicator did not light up, and staff were unaware of the resident's need for assistance. The call bell system at the nurse's station was operational, but the lack of a functioning hallway indicator compromised timely staff response to the resident's needs. Additionally, the facility's 300 hall was observed to be in disrepair, with chipped and missing floor tiles, chipped baseboards, and a door frame that had pulled away from the wall. The Maintenance Director acknowledged these issues but was unaware of some specific problems, such as the broken doorframe and call light. The Administrator noted that renovations had been halted by the current corporation, leaving the 300 hall in a state that was not conducive to a homelike environment.
Inadequate Supervision During Meals and Smoke Breaks
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for its residents. One resident, diagnosed with dementia and dysphagia, was observed during a meal service in a tilted-back wheelchair, which was not corrected by staff. This improper positioning led to a coughing episode as the resident attempted to feed themselves, highlighting a lack of appropriate supervision and intervention by the staff present, including a speech pathologist who was aware of the resident's swallowing difficulties. Additionally, the facility did not adequately monitor smoke breaks, failing to ensure residents followed the facility's safe smoking protocol. During observed smoke breaks, residents were left unsupervised, resulting in unsafe practices such as flicking lit cigarettes into the grass and improper disposal of cigarette butts. The facility's policy required supervision for residents identified as needing it, but this was not consistently provided, as evidenced by the unsupervised smoking activities of several residents. Interviews with facility staff, including the Administrator, DON, and Activity Director, confirmed that supervision was required for residents during smoking breaks. However, the lack of staff presence and failure to correct unsafe smoking practices during the observed smoke breaks indicated a breach in protocol and supervision, contributing to the deficiency.
Failure to Maintain RN Staffing Requirements
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a review of the facility's Payroll-Based Journal (PBJ) Staffing Data Report for the second quarter of 2024, covering January 1 to March 31. The report highlighted specific dates where no RN hours were recorded, including March 21, 22, 23, 24, 30, and 31. During interviews, the facility's administrator acknowledged that Corporate Staff B was responsible for the PBJ reports and confirmed their accuracy. Corporate Staff B admitted to assisting with the PBJ reports and suggested borrowing RNs from sister facilities to cover the missing hours, which was not implemented, leading to the deficiency.
Deficiency in Controlled Substance Record-Keeping
Penalty
Summary
The facility failed to maintain an accurate system of records for the receipt and disposition of controlled drugs, specifically narcotics, as evidenced by the review of two narcotic books. The facility's policy, dated 9/1/21, mandates that controlled substances be monitored in compliance with state and federal regulations, with safeguards to prevent loss or diversion. However, the review of the Controlled Substance Shift Change Count - Check Sheet for July 2024 revealed significant documentation gaps. At Station 300, 73 out of 87 opportunities for recording the number of packages were left blank, and there were numerous instances where nurses' initials were missing. Similar issues were observed at Station 100/700, with 23 out of 87 opportunities left blank for the number of packages and missing initials for both oncoming and off-going nurses. During interviews, the Director of Nursing acknowledged that the oncoming nurse should count controlled substances with the off-going nurse, and both should document this on the count sheet. The Director expected the count to be completed without blanks, but noted that the form was set up for eight-hour shifts, which confused some nurses who worked 12-hour shifts. Despite this, the expectation was for staff to adhere to the facility's policy and procedures, which was not consistently followed, leading to the deficiency in maintaining accurate records for controlled substances.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 14.81% error rate. This was observed in the administration of medications to three residents. For one resident with diabetes, an LPN administered insulin lispro without priming the pen, contrary to the manufacturer's instructions, after checking the resident's blood sugar level. Another resident, who had severe cognitive impairment and was receiving medications via a gastrostomy tube, was given crushed enteric-coated aspirin and Vitamin C, which should not have been crushed according to the facility's medication administration policy. Additionally, a resident with intact cognitive skills was administered Fluorometholone eye drops by a CMT who did not follow the manufacturer's guidelines for application, failing to apply gentle pressure at the corner of the eye after administration. Interviews with the DON and LPNs confirmed that the staff did not adhere to acceptable nursing practices and manufacturer's recommendations for medication administration, contributing to the high medication error rate.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards and facility policy. During observations and interviews, it was found that medication carts contained several issues, including undated and opened insulin pens, pre-popped medications in cups without identification, and multiple bottles of medications and eye drops that were opened and undated. Additionally, some medications were found to be expired, such as allergy relief tablets, sodium bicarbonate tablets, and multivitamins. The Director of Nursing (DON) acknowledged these deficiencies, stating that insulin should be dated when opened, and medications should be checked for expiration dates and removed if expired. The DON also mentioned that eye drops should be dated when opened and are good for 30 to 45 days after opening, and liquid medications should be dated when opened. Despite these expectations, the facility did not adhere to its policies, resulting in improper storage and labeling of medications.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies in the kitchen. Observations on multiple occasions revealed that the backdoor to the outside was left open, allowing flies to enter the food preparation areas, outside the walk-in cooler, and inside the dry food storage room. These observations were made on three separate days, with flies consistently present throughout the kitchen and a swarm of flies noted outside the walk-in cooler. During an interview, the administrator acknowledged the expectation for the kitchen to be free of flies and for the backdoor to be closed.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, as evidenced by an incident involving a resident who was cognitively intact and had multiple diagnoses, including neurogenic bladder, wound infection, quadriplegia, malnutrition, and depression. The resident was dependent on staff for various activities of daily living, including personal hygiene. During an interaction with a Certified Nurse Aide (CNA), the resident requested assistance with a towel, which led to a verbal altercation. The CNA reportedly used profanity and was rough while wiping the resident's face, which the resident perceived as aggressive and an assault. The incident was witnessed by a Licensed Practical Nurse (LPN) who heard cursing from both the resident and the CNA. The LPN observed the CNA tossing a towel onto the resident's head and leaving the room, stating an inability to work with the resident due to perceived rudeness. The resident reported feeling that the CNA was rough and aggressive during the face-wiping, and the CNA admitted to repeating the resident's profanity back to them. The CNA denied being rough or cursing directly at the resident, claiming to have only repeated what was said to them. The facility conducted an investigation, which included interviews with the involved parties and witnesses. The investigation concluded that while a negative interaction occurred, abuse could not be substantiated. The CNA was terminated for violation of policy and procedure. The resident continued to participate in their normal daily routine without any noted negative psychosocial impacts following the incident.
Deficiencies in Physician Orders and Neuro Check Documentation
Penalty
Summary
The facility failed to adhere to professional standards of quality by not obtaining a physician order for a resident using a Bi-level positive airway pressure (bi-pap) machine. The resident, who had a history of obstructed sleep apnea, was observed using the bi-pap machine without a corresponding physician order documented in the facility's records. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that a physician order should have been obtained for the bi-pap machine. Additionally, the facility did not complete the required neurological check documentation for a resident who experienced a fall. The resident, who had severe cognitive impairment and a history of high blood pressure, stroke, and seizure disorder, was found on the floor after rolling out of bed. Although neuro checks were initiated, the documentation was incomplete, with several entries left blank for critical assessments such as level of consciousness, movement, pupil response, and vital signs. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing, revealed that the facility's protocol for post-fall assessments was not fully followed. The staff acknowledged that neuro checks should be conducted and documented for 72 hours following an unwitnessed fall, but the neuro check sheets were not completed as expected. This lapse in documentation and adherence to protocol represents a failure to provide services based on acceptable standards of practice.
Failure to Administer Seizure Medication Timely
Penalty
Summary
The facility failed to keep a resident with a seizure disorder free from a significant medication error when it did not obtain Vimpat, a medication used to prevent seizures, from the pharmacy in a timely manner. This resulted in the medication not being administered for four and a half days. The resident, who was cognitively intact and diagnosed with a seizure disorder, had an order for Vimpat 200 mg to be given twice daily. However, the medication was not documented as administered for several doses over a period of four days. The facility's Unavailable Medication Policy requires immediate action when a medication is unavailable, including notifying the physician and obtaining alternative treatment orders. Despite this policy, there was no documentation showing that the physician was made aware of the missed doses or that any alternative treatment or monitoring orders were obtained. Interviews with staff, including the Director of Nursing (DON), Licensed Practical Nurses (LPNs), and Certified Medication Technicians (CMTs), revealed that while attempts were made to contact the pharmacy and the medical doctor (MD) for a new prescription, the medication was not obtained in a timely manner. The pharmacy confirmed that the facility contacted them about the need for the medication, but there were no refills on the script, and a new script was required. The pharmacy reached out to the MD's office, and the script was eventually obtained, but not before the resident missed multiple doses. The DON stated that she expected staff to reorder medications when they were low and to follow the facility's policy and procedures, but this did not occur in this instance.
Resident Left Exposed in Hallway After Shower
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity when a resident was left exposed in the hallway after a shower. The incident involved a resident who was cognitively intact and required partial/moderate assistance for showers and substantial/maximal assistance for transfers. After completing a shower, the resident was left unclothed in a wheelchair in the hallway by a CNA, who refused to get a gown or blanket for the resident. The resident was exposed in the hallway with other residents present, causing significant distress to the resident. The incident occurred when the CNA assisting the resident with the shower did not bring a gown or blanket into the shower room. The resident, feeling unsteady and concerned about falling, requested the CNA to bring the wheelchair closer, but the CNA refused and instructed the resident to walk to the wheelchair in the hallway. The resident, sliding on the wet floor, had no choice but to walk into the hallway naked to sit in the wheelchair. The CNA then left the resident exposed in the hallway, calling the resident difficult and rude. Another CNA noticed the resident sitting naked in the hallway and quickly covered the resident with a gown before assisting the resident back to their room. The incident was reported to the facility's administration, and an investigation confirmed the resident's account. The CNA responsible for the incident was terminated for poor customer service and discourteous behavior.
Failure to Provide Necessary Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. Resident #2, who had diagnoses including diabetes and morbid obesity, was observed with a left heel unstageable pressure ulcer. Despite the presence of blood on the resident's heel and fitted sheet, no treatment orders were in place, and the wound nurse confirmed that the resident should have had a protective boot to prevent the area from opening. The resident reported that staff noticed the blood the previous day but did not take appropriate action to cover the wound or obtain treatment orders. The wound nurse eventually applied a bandage but acknowledged that the staff should have addressed the issue immediately when it was first noticed. Resident #7, who had diagnoses including severe protein-calorie malnutrition and multiple pressure ulcers, was also observed receiving inadequate care. The resident had orders for specific wound treatments, including the use of Vashe for cleansing. However, during an observation, the wound nurse was unable to find the Vashe and instead used a different wound cleanser. The nurse applied the new dressing without the prescribed Vashe, which was available the previous Friday but had gone missing over the weekend. The Director of Nursing confirmed that physician orders should be followed, and treatments should be completed as ordered. The DON also stated that it is unacceptable to leave a wound uncovered overnight until the wound nurse arrives the next day. The facility's failure to follow physician orders and provide timely and appropriate wound care for residents with pressure ulcers resulted in deficiencies. The staff did not take immediate action to address open and draining wounds, and the necessary treatment supplies were not reordered as needed. These actions and inactions led to the observed deficiencies in the care provided to Residents #2 and #7.
Failure to Maintain Nutritional Status and Administer Supplements
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident diagnosed with severe protein-calorie malnutrition, categorized as severely underweight, and who had a wound. The staff did not accurately monitor the resident's weights, failed to timely document weights obtained, and did not accurately document nutritional supplement administration. This led to the registered dietician using inaccurate weights and information to determine the resident's nutritional status and needs. Additionally, the facility did not provide the physician and dietician-ordered nutritional supplements to the resident, resulting in a weight loss of 3.9% from March to April 2024 and the resident's continued severely underweight status. The resident's care plan indicated nutritional problems, including chronic wounds and underweight status, with a goal to prevent significant weight loss. However, the resident's weight log showed inconsistencies and missing entries, and the weights documented were found to be incorrect. The resident's meal tickets did not consistently include the prescribed nutritional supplements, and observations confirmed that the resident did not receive the ordered supplements during meals. Interviews with staff revealed confusion about the administration of supplements, with some staff unaware of the specific orders or the availability of the supplements. The dietary manager acknowledged that the facility had been out of the prescribed supplement for several months and substituted ice cream instead. The new registered dietician was not aware of the resident's needs and had not been following the resident's case. The Director of Nursing confirmed that physician orders should be followed and that supplements should not be documented as administered if they were not given. The Medical Director emphasized the importance of proper nutrition for the resident, given their compromised condition due to low BMI and wounds.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide pain management consistent with professional standards of practice for a resident who required such services. The resident, who had multiple diagnoses including diabetes, arthritis, and a history of stroke, was on a scheduled pain medication regimen. However, the facility did not administer the prescribed pain medications, including Acetaminophen and Oxycodone, in a timely manner. The resident's pain was frequently rated as high as 8 out of 10, and the lack of timely medication administration exacerbated their discomfort and pain levels. The facility's Medication Reordering policy and Physician's Orders policy were not followed. The policies required timely reordering and administration of medications, including the use of emergency drug kits if necessary. Despite these guidelines, the resident's Oxycodone was unavailable for several days, and staff failed to offer alternative pain relief such as Tylenol, which was available in the facility. The resident reported significant pain, and staff interviews revealed confusion and lack of clarity regarding the medication reordering process and the status of the Oxycodone prescription. Interviews with facility staff, including an LPN and the Regional Nurse, indicated that there were communication issues between the facility, the pharmacy, and the physician. The pharmacy was awaiting a signed script from the physician, which had not been received, leading to a delay in medication delivery. The facility administrator acknowledged that there were lapses in following physician's orders and expected protocols, including the use of the Pyxis machine for emergency medication and timely reordering of medications to prevent lapses in administration. The resident's pain management was compromised due to these failures, resulting in prolonged periods of unmanaged pain.
Failure to Provide Consistent Wound Care
Penalty
Summary
The facility failed to provide necessary care and services to promote the healing of a foot wound for a resident. The resident, who had multiple medical conditions including diabetes and neuropathy, had a wound on the left plantar foot that required specific wound care treatments as per physician's orders. However, the wound care was not consistently provided, as evidenced by the resident's report and observations that the last treatment was received during a podiatrist visit, and not by the facility staff as required. The resident's care plan and physician's orders detailed the necessary wound care, including cleansing with normal saline, applying a Silver foam non-adhesive dressing, and wrapping with Kerlix gauze every other day. Despite these orders, the resident reported that wound care was not being completed, and observations confirmed that the dressing on the resident's foot was dated several days prior, indicating a lapse in the prescribed treatment schedule. The resident also experienced significant pain, which was not adequately managed, further complicating the wound healing process. During an interview, the LPN confirmed the treatment orders and acknowledged that the resident had an active blister and continued to peel the skin off the foot, causing pain and further injury. The facility administrator stated that staff are expected to follow physician's orders and that any failure to document or administer treatments as ordered is considered falsification of records. This deficiency in wound care management could hinder the resident's healing process and increase the risk of infection, as the necessary treatments were not consistently administered as prescribed.
Failure to Serve Meals at Safe Temperatures
Penalty
Summary
The facility failed to ensure that residents received meals that were palatable and at safe temperatures. Specifically, Resident #1 and Resident #3 reported receiving cold food. Resident #1, who has diagnoses including anemia, high blood pressure, acid reflux, paraplegia, and depression, stated that breakfast was cold and that this was a common occurrence. Observations confirmed that the food temperatures for Resident #1's meal were below the required levels, with dressing at 122.7°F, turkey at 111.0°F, and peas at 111.0°F. Similarly, Resident #3, who has multiple diagnoses including anemia, atrial fibrillation, coronary artery disease, heart failure, acid reflux, renal failure, diabetes, arthritis, and stroke, also reported that lunch was cold and that this was a frequent issue. The facility's policy mandates that hot foods be held at 135°F or greater and that food temperatures be recorded to ensure compliance. However, the dietary temperature log for the day in question showed that the food was initially at the correct temperatures when prepared. The Administrator acknowledged that the facility does not have a heated cart for transporting trays and relies on nursing staff to pass trays timely. Despite this, the food served to the residents did not meet the required temperature standards, indicating a failure in maintaining food temperatures during the distribution process.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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