Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avenir At Mark Twain during CMS and state inspections, most recent first.
A resident with multiple medical conditions experienced a fall after not locking their wheelchair. Nursing staff assessed the resident and notified the physician, but there was no documentation that the resident's representative was informed of the incident, contrary to facility protocol.
The facility did not consistently follow physician orders for blood glucose monitoring and failed to obtain or document parameters for physician notification for several residents with diabetes. In multiple cases, blood sugar checks were missed or out-of-range results were not reported to the physician as ordered, and staff practices varied when notification parameters were not specified.
A resident with multiple wounds and complex medical conditions was not thoroughly assessed or documented for surgical wounds upon admission and in subsequent weekly assessments, as required by facility policy. Key wounds were omitted from initial documentation, and wound tracking was delayed, with incomplete entries in the medical record and wound report. Staff interviews confirmed that expected assessment and documentation procedures were not followed.
A resident with multiple medical conditions and high risk for skin breakdown did not consistently receive ordered wound care, skin assessments, or use of heel protectors. Staff failed to complete and document weekly skin assessments, did not follow physician orders for compression wrap removal and wound dressing changes, and inconsistently recorded bathing and skin observations. The resident's skin was observed to be extremely dry, cracked, and bleeding, and staff interviews revealed confusion about treatment responsibilities and documentation.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or events that led to this failure.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines.
Surveyors found that food and drink served to residents was not consistently palatable, attractive, or at a safe and appetizing temperature, failing to meet required standards for meal service.
The facility did not consistently provide meals that accommodated resident allergies, intolerances, and preferences, and failed to offer appealing food options. Residents were observed receiving food that did not meet their individual dietary requirements or preferences.
The facility did not provide required documentation showing that CNAs received at least 12 hours of annual inservice training, with missing or incomplete records for several staff. The DON and Administrator confirmed the expectation for annual education, but stated that previous records may have been removed by a former DON, resulting in insufficient documentation for regulatory compliance.
A facility failed to maintain a clean, comfortable, and homelike environment when a resident's room remained hot because an AC unit was blowing warm air, multiple resident rooms contained feces, trash, debris, flies, and soiled surfaces, one resident's bed linens remained stained and unchanged despite needing assistance, and shower/hydrotherapy areas were blocked by lifts, carts, and other equipment.
Failure to safeguard residents’ personal belongings: two cognitively intact residents who were dependent on staff for ADLs reported missing personal items, including an iPad and a pair of shoes, while staff could not explain who was responsible for keeping inventory sheets updated. The admission packet also stated the facility was not liable for lost or stolen items, and the Administrator said the inventory process was not in place and the packet language was not familiar to him.
MDS assessments were inaccurate because side rails were coded as restraints for four residents even though the rails did not meet restraint criteria. Residents were observed using quarter-length, halo-shaped, U-shaped, or full-length rails for repositioning or bed mobility, and one resident’s care plan did not identify side rail use. The MDS Coordinator said she coded side rails in the restraint section whenever they were used, while the Administrator stated side rails used for repositioning are not restraints and should not be coded that way.
Respiratory care was not provided safely when staff failed to change and properly store nebulizer masks and oxygen tubing for two residents, and failed to keep oxygen concentrators set at the ordered rates for three residents. Observations showed contaminated or uncovered nebulizer equipment, oxygen tubing on the floor, and concentrators set above ordered levels. Staff and the DON confirmed that the equipment should have been changed weekly, stored properly, and set to the prescribed L/min.
A facility failed to assess residents for safe side rail use, obtain informed consent, and maintain a policy with guidance for side rails used as enabling devices rather than restraints. Multiple residents were observed with full, half, quarter, or halo-shaped rails in place, while records showed missing physician orders, missing nursing assessments, and missing signed consent for several residents. Staff interviews showed inconsistent understanding of when assessments, orders, and consent were required, and therapy could not locate side rail assessments for several residents.
Kitchen equipment failures and poor sanitation: Surveyors observed a broken oven that would not heat properly, a dishwasher that did not reach the required rinse temp, and a walk-in freezer door that would not fully close, with ice/slush and frostbite on packaged foods. They also found food and trash debris on the floors, liquid spills in refrigerators and around the oven, dust accumulation on ceiling tiles, and a black mold-like substance on ceiling tiles above food storage. Dietary staff and the ADM stated appliances should be in working order and food storage temps should be logged.
Failure to Maintain an Ongoing QAPI Program: The facility did not maintain documentation or evidence of an ongoing QAPI program showing systemic identification, reporting, investigation, analysis, and prevention of adverse events, or the development and evaluation of corrective actions. Staff interviews showed QAA meetings were infrequent, the last meeting had been months earlier, daily risk meetings did not include trend review, and the facility did not have a QAPI policy at the time of survey.
Infection control failures were identified involving incomplete employee TB screening, missed EBP use for residents with g-tubes and a chronic wound, and improper hand hygiene during cleanup of fecal material. Staff records showed missing two-step TB test documentation for three employees, while an RN and CNAs provided high-contact care to residents on EBP without wearing gowns. A restorative aide also cleaned fecal material and then touched clean surfaces and objects without changing gloves and performing hand hygiene before contact with those items.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet needs.
A facility failed to honor resident choice by not getting two dependent residents out of bed after breakfast as preferred and by delaying a requested shower for another resident. The two residents were cognitively intact but required Hoyer lift transfers with two staff, and staff reported there was only one aide assigned to the hall, making it difficult to complete all morning transfers before lunch. Another resident, dependent for bathing and transfers, requested a shower on a Sunday for a beautician appointment but was initially told showers were not done that day, despite staff confirming a shower could still be provided if requested.
Failure to submit TPL forms for deceased residents' trust funds. The facility did not complete TPL forms within 30 days for three residents who expired with money remaining in their trust accounts, including balances of $378.26, $183.00, and $12.69. The BOM said she was unsure how to handle funds left after a resident's death and was not aware that a TPL form had to be sent to Medicaid, while the Administrator stated the form should be submitted within 30 days of expiration.
Pre-employment screening failed when the facility did not complete criminal background checks before hire for several new employees and did not document Nurse Aide Registry screening for one OTA. The Abuse, Neglect, and Exploitation policy required background, reference, and credential checks, but it did not include NA Registry screening. The Administrator and Staffing Coordinator said background checks were being handled by a sister facility and that the facility did not currently have an HR manager.
A resident with cancer and Alzheimer’s disease who was dependent on staff for dressing and footwear did not receive proper foot care. CNA shower sheets were inconsistent about toenail needs, the resident was not on the podiatry list, and observation showed very dry feet with toenails curled under about half an inch and extremely thick. Staff interviews confirmed CNAs were to notify the nurse, nurses were to assess toenails, and an RN or podiatrist would trim nails if needed.
Failure to maintain fall precautions and upright feeding position: Two residents assessed as high fall risks were observed with call lights out of reach, improper bed positioning, and incomplete fall mats, despite care plans and staff expectations for low beds, frequent rounding, and accessible call lights. A resident with dysphagia was also repeatedly observed eating while slumped in bed with the HOB only partially elevated, despite an order for upright 90-degree positioning during oral intake and after meals.
Failure to provide ordered lab services for a resident with stroke, muscle weakness, diabetes, and bowel/bladder incontinence. A physician ordered a UA and urine C&S for confusion and urinary incontinence, but the order was not reflected on the TAR/MAR, no test results were found in the chart, and RN staff said they were unaware of the order. The DON reported there was no documentation showing the urine specimen was not obtained or why.
Diet orders not followed for a resident with dysphagia and aspiration history. The resident had orders for a regular diet with nectar-thick liquids and double portions, but observations showed trays with standard portions and thin liquids, and no dietary slip was on at least one tray. Staff said dietary slips were not being sent with room trays, so CNAs and nursing staff did not know the resident needed double portions or thickened liquids.
Failure to Hold Required QAA Meetings: The facility failed to ensure QAA committee meetings were held at least quarterly and attended by the required members. Review of QAA sign-in sheets for the prior 12 months showed only two documented meetings, and the Administrator stated he had not yet held a QAA meeting since starting work, while the interim Administrator had held one meeting in April. The DON and Administrator said QAA meetings should occur monthly with department heads and the Medical Director present.
Failure to document influenza vaccination status: The facility did not have a standardized process for obtaining consent for or documenting vaccines for current and new residents, and three sampled residents had no record of influenza vaccine administration, refusal, or education in their charts. The residents had significant medical histories including ESRD, TIA, diabetes, COPD, dysphagia, and a-fib. Staff, including the DON and LPNs, stated there was no current staff member responsible for tracking immunization status, and the acting IP had not yet begun the process.
The facility failed to ensure residents were educated about COVID-19 vaccination and that vaccine status was documented in the medical record. Three sampled residents had no record of COVID-19 vaccine administration, refusal, or education; one had HTN, ESRD, hx of TIA, and DM, another had hx of TIA, encephalopathy, and PE, and a third had COPD, gastrostomy status, dysphagia, and paroxysmal a-fib. Staff and the DON stated there was no standardized process for consent, documentation, or tracking of immunizations, including COVID-19.
Kitchen Infested With Flies During Food Prep and Dishwashing: Surveyors observed multiple flies in the food prep and dishwashing areas, including flies landing on food, utensils, clean cups, and dishes. The Dietary Manager stopped food prep to kill a fly, and interviews showed the Maintenance Director was unaware of the extent of the problem while the Dietary Manager said the flies had been an issue since she started and had not been reported to maintenance.
A resident with full code status was found unresponsive and staff initiated but discontinued CPR before EMS arrived, with a significant delay in contacting 911. Staff were unclear on code status procedures, and some were not CPR certified. The facility also failed to ensure a CPR-certified staff member was present on multiple night shifts, contributing to inadequate emergency response.
A resident with severe cognitive impairment and a full code status was found unresponsive and CPR was initiated by two LPNs but stopped before EMS arrived, contrary to facility policy and physician orders. The incident, which met the criteria for alleged neglect, was not reported to the State Survey Agency within the required two-hour timeframe. The Administrator acknowledged the reporting failure, citing a misunderstanding about who was responsible for notifying authorities.
Three residents did not receive care in line with professional standards after falls and hospital transfers, as staff failed to complete required progress notes, post-fall follow-up, and notifications to physicians and families. Care plans were not updated with new interventions, and fall prevention indicators were missing, with vital signs and neuro checks not consistently documented as per facility policy.
A facility failed to ensure lab services were obtained as ordered by a physician for a resident with multiple health issues, including heart failure and diabetes. Despite physician orders for several lab tests due to the resident's confusion and agitation, there was no documentation that these tests were conducted or that the resident refused them. Interviews revealed that the nurse responsible for entering the orders did not ensure they were completed, and the lab confirmed the orders were not processed, leading to a deficiency.
The facility failed to report an allegation of staff-to-resident verbal abuse to DHSS within the required two-hour time frame. A resident overheard a staff member threatening another resident with physical harm and reported it to the Social Worker, who did not report the incident due to being busy with a respiratory outbreak.
A facility failed to investigate an allegation of verbal abuse reported by a resident, despite the facility's policy requiring immediate action. The Social Worker did not initiate an investigation, and the staff involved were not questioned or suspended until the surveyor's intervention.
Failure to Notify Resident Representative After Fall
Penalty
Summary
The facility failed to notify a resident's representative after the resident experienced a fall. The resident, who was cognitively intact and had diagnoses including diabetes, hypertension, and end stage renal failure requiring dialysis, was found on the bathroom floor after not locking their wheelchair. The resident was assessed by nursing staff, found to be stable, alert, and oriented, with no pain or neurological changes. Documentation showed that the medical doctor was notified, but there was no evidence that the resident's representative was informed of the incident. Interviews with nursing staff and facility leadership confirmed that the expected protocol was to notify the physician and the resident's representative after a fall and to document these notifications in the progress notes. However, the administrator acknowledged that there was no documentation to show the family had been notified following the fall, indicating a failure to follow the facility's notification procedures.
Failure to Follow Physician Orders and Obtain Notification Parameters for Blood Glucose Management
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not following physician orders related to blood glucose monitoring and physician notification for residents with diabetes. For one resident, there were multiple instances where blood sugar readings exceeded 300 mg/dl, as specified in the physician's sliding scale insulin order, but there was no documentation that the physician was notified as required. The Assistant Director of Nursing confirmed the lack of documentation for physician notification when blood sugars were outside the ordered parameters. Another resident had physician orders for blood glucose monitoring before each meal and a sliding scale for insulin administration, including instructions to notify the physician if blood sugar exceeded 350 mg/dl. However, documentation showed that blood glucose checks were not completed before supper, and there was no evidence that the physician order was changed to reflect this omission. The Assistant Director of Nursing stated that staff were expected to complete blood sugar checks before each meal as ordered. A third resident had an order for insulin administration before meals but lacked specific parameters for when to notify the physician of out-of-range blood glucose levels. On one occasion, the resident's blood sugar was documented as hypoglycemic at 57 mg/dl, and insulin was administered, but there was no documentation that the physician was notified. Interviews with nursing staff revealed inconsistent practices regarding when to notify the physician in the absence of specific parameters, and the Assistant Director of Nursing and Administrator both indicated that perimeter orders should be obtained and physician orders followed.
Failure to Accurately Assess and Document Surgical Wounds on Admission and Weekly
Penalty
Summary
The facility failed to thoroughly and accurately assess and document a resident's surgical wounds upon admission and then weekly, as required by facility policy. Specifically, the admission skin assessment did not include all wounds present, omitting the wound on the resident's left thumb and failing to provide a description of the wound on the left hand. Additionally, there was no admission note documented in the progress notes, and the care plan in use at the time of the survey did not reflect the wounds on the resident's left hand. The wound was not included in the facility's wound report for two consecutive weeks, and there was no wound documentation in the medical record until several weeks after admission. The resident involved had multiple diagnoses, including an open wound of the left hand, cellulitis of the left finger, abscess of the left hand, and diabetes, and required surgical wound care. Interviews with staff confirmed that wound assessments and documentation were expected to be completed on admission and weekly thereafter, including details such as location, size, drainage, odor, and surrounding tissue. However, these assessments and documentation were not completed as required, resulting in incomplete and delayed wound tracking for the resident.
Failure to Provide and Document Ordered Wound Care and Skin Assessments
Penalty
Summary
Facility staff failed to provide care and treatment in accordance with professional standards for a resident with significant skin integrity issues. The staff did not consistently administer treatments as ordered for non-pressure wounds, failed to complete comprehensive skin assessments on a routine basis, and did not reassess the efficacy of treatments for ongoing skin problems. Documentation was incomplete or missing for weekly skin assessments, and there was a lack of follow-through on physician orders for wound care, application of creams, and use of heel protectors. Staff also failed to accurately document the administration of treatments, sometimes marking them as completed when they were not actually provided. The resident involved had multiple complex medical conditions, including paraplegia, morbid obesity, amputation, kidney failure, and osteomyelitis, and was at high risk for pressure ulcers and other skin breakdown. The resident was dependent on staff for mobility, hygiene, and wound care. Observations revealed that the resident's compression wraps were not being removed at night as required, heel protectors were not in place, and wound dressings were not changed according to schedule. The resident's skin was noted to be extremely dry, cracked, and in some areas bleeding, indicating that current treatments were not effective. Staff interviews confirmed a lack of clarity regarding treatment responsibilities and documentation procedures. Further review showed that shower and bed bath documentation was inconsistent, with missing or incomplete records of skin assessments during these activities. Staff were unsure about the use of certain lotions and the availability of bariatric shower chairs, despite one being present in the facility. The wound nurse and other staff acknowledged that skin assessments and treatments were not always completed as ordered, and that communication and documentation lapses contributed to the deficiencies. The facility's policies required regular skin assessments, accurate documentation, and adherence to physician orders, but these were not consistently followed.
Failure to Honor Resident Rights to Dignity and Self-Determination
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions, inactions, or events that led to this deficiency. No further information about the residents involved or their conditions at the time of the deficiency is included in the report.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the facility did not maintain the required level of care as expected by professional standards, but does not provide specific details about the actions or inactions of staff, nor does it mention any particular residents or their medical conditions at the time of the deficiency.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through surveyor observation and review, indicating that the food and beverages did not consistently meet standards for taste, appearance, or temperature at the time of service.
Failure to Accommodate Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not provide appealing options. This deficiency was identified based on observations that the facility did not consistently provide meals tailored to individual dietary needs and preferences, as required. The report notes that residents were not always offered food choices that considered their specific allergies or intolerances, nor were the meals always presented in an appealing manner.
Lack of Documentation for CNA Annual Inservice Training
Penalty
Summary
The facility failed to provide documentation of ongoing educational training for active Certified Nursing Aides (CNAs), as required by regulation, which mandates at least 12 hours of education per year. Record review showed that for four of six sampled active CNAs, there was insufficient or no documentation of completed inservice training for the required period. Specifically, some CNAs only had records of inservices from January 2025 onward, with no documentation for prior months, while others had no record of inservices for the past year from their hire date. The sample included 18 CNAs, and the facility census was 75.1. During interviews, the DON stated she was unable to locate annual education logs for four of the six sampled CNAs and did not have access to any annual training records completed before January 2025. The DON and Administrator both acknowledged that all CNAs are expected to receive 12 hours of ongoing education annually. It was reported that the previous DON may have taken inservice records and education documentation upon resigning, contributing to the lack of available documentation.
Unclean rooms, hot resident environment, soiled linens, and obstructed shower areas
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents by allowing resident rooms to remain uncomfortably hot, unclean, and cluttered, and by leaving shower areas obstructed. Surveyors observed multiple resident rooms with cleanliness concerns, a room temperature above the stated acceptable range, and shower rooms and a hydrotherapy room blocked by stored equipment. One resident with bipolar disorder, depression, seizure disorder, generalized muscle weakness, difficulty walking, unsteadiness on feet, and other gait abnormalities was observed in a room where the AC unit was set to cool but was blowing warm air. The room temperature was measured at 80.2 degrees F when the outside temperature was 92 degrees F, and later at 83.4 degrees F and 83.8 degrees F when outside temperatures were 93 and 95 degrees F. The resident stated the room was hot, that the AC had been broken for months, and that the issue had been reported to maintenance. The maintenance communication log had no documentation over the prior two months regarding the AC unit. Another cognitively intact resident with Ogilvie syndrome, COPD, and major depressive disorder had dirty incontinence briefs and liquid matter on the floor, liquid splatters in the room and bathroom, flies around the room, and a mattress with a large brown stain and flies on it. On a later observation, the room had an odor of feces, bowel movement smears near the bed, matter splatter on the wall and call light, and flies around the bed. A third cognitively intact resident with type 2 diabetes, muscle weakness, and major depressive disorder had a toilet with brown and yellow matter on the seat and sides, brown matter on the bathroom floor, and trash and debris around the nightstand and bed. The resident stated housekeeping did not clean the room or bathroom enough and that the bathroom was sometimes unusable. A resident with depression, seizure disorder, and a history of stroke, who required partial/moderate assistance with walking 10 feet, had a fitted sheet with a yellow stain and dark brown chunks on the bed during repeated observations. The resident stated staff had not helped change the sheets and that assistance was needed because of unsteadiness. Surveyors also observed the hydrotherapy room and a shower room near the nurse's station with Hoyer lifts, a sit-to-stand lift, wheelchairs, a bedside commode, and a clean linen cart blocking access, and a loose ceiling tile exposing the ceiling and wiring above the hydrotherapy doorway.
Failure to Safeguard Residents’ Personal Belongings
Penalty
Summary
The facility failed to have a system in place to safeguard residents’ personal belongings for two cognitively intact residents who were dependent on staff for personal hygiene, toilet hygiene, upper and lower body dressing, and bed-to-chair transfers and used wheelchairs. Review of the admission packet showed language stating the facility would not be liable for any resident items that were lost or stolen, except for certain items under state guidelines. The Social Service Director said larger and more expensive items were usually added to the inventory list on admission, CNAs were responsible for updating the list when new items arrived, and the inventory sheets were kept in her office, but she also stated the process had not been completed lately. Staff interviews showed uncertainty about where the inventory sheets were kept and who was responsible for keeping them updated, and the Administrator said the process was currently not in place and he was not aware the inventory sheets were not being filled out. Resident #68 reported a missing iPad that had been gone for about four months, and Resident #9 reported missing brown shoes purchased by a family member about two weeks earlier for use with physical therapy. Both residents said staff looked for the missing items but could not find them, and neither resident had been compensated or offered a lock box to secure belongings. Observation of their shared room showed multiple personal items, including a curio cabinet with figurines, a cordless phone, lotions, colognes, perfumes, a digital clock, plastic drawers filled with personal items and snacks, and closets filled with clothing. The Administrator also stated he was not familiar with the admission packet language stating the facility was not responsible for lost or stolen items and said the packet needed to be updated to reflect the regulations related to residents’ personal belongings.
MDS coded side rails as restraints for residents who did not meet restraint criteria
Penalty
Summary
The facility failed to ensure residents received accurate MDS assessments reflective of their status at the time of assessment by coding side rails as restraints for four residents when the side rails were determined not to meet the definition of a restraint. The sample was 18 residents, and the census was 75. The facility’s RAI policy stated it would follow CMS regulations and use the CMS RAI manual for completion of the RAI process, including accurate MDS coding. For Resident #49, the record showed diagnoses of morbid obesity and generalized muscle weakness. The Device/Restraint evaluation dated 11/21/24 identified side rails as the device and stated the device did not meet the definition of a restraint per the RAI manual. However, the quarterly MDS coded physical restraints as bed rails used daily. The resident was observed in bed with quarter-length rails raised on both sides of the bed at the head of the bed and stated the side rails were used for repositioning. For Resident #10, diagnoses included generalized muscle weakness and anxiety, and the quarterly MDS coded physical restraints as bed rails used less than daily. The resident was observed in bed with halo-shaped rails raised on both sides of the bed at the head of the bed and stated the rails were used when wanting to sit up. For Resident #11, diagnoses included dementia and a history of stroke, and the quarterly MDS coded bed rails as used less than daily. The resident was observed with U-shaped rails raised on both sides of the bed and stated not knowing what the rails were or what to do with them. For Resident #35, diagnoses included neurofibromatosis and the quarterly MDS coded bed rails as used less than daily, while the care plan did not identify side rail use. The resident was observed with full-length side rails raised on both sides of the bed and stated having minimal movement of the arms due to tumors on the spine and not being able to use the rails. During interview, the MDS Coordinator stated that when a resident uses side rails, she marked them as in use in the restraint section of the MDS and was not aware that side rails not used as restraints should not be coded there. The Administrator stated restraints were not used by any resident in the facility and that side rails used to assist with repositioning are not restraints and should not be marked as restraints on the MDS.
Respiratory equipment not cleaned, stored, or set per orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care when staff did not ensure oxygen tubing and nebulizer face masks were changed when contaminated and properly stored for two residents. For one resident with COPD, Ogilvie syndrome, and major depressive disorder, the nebulizer mask was observed on the floor next to the bed with brown matter underneath it, and later was seen hanging uncovered on a dusty, unused concentrator. The mask and tubing were dated months earlier, and the inside of the mask had a dusty film. During observation, an RN realized the nebulizer equipment needed to be changed, stated he was not aware the tubing had not been changed since 2024, and said the resident’s treatments were usually not administered by nursing staff. Another RN and the DON stated the resident should have been receiving nebulizer treatments from nurses and that the mask and tubing should have been changed weekly and stored properly when not in use. For another resident with hemiplegia, dementia, acute respiratory failure, and asthma, observations showed the resident’s nebulizer mask uncovered on the bed and the oxygen nasal cannula on the ground next to the bed. The oxygen concentrator was turned on and set to 4 L, although the resident’s order was for oxygen at 2 L as needed. Staff interviews confirmed that oxygen concentrators were expected to be set at the prescribed rate and that masks should be stored in a bag when not in use. The DON stated the concentrator should have been set to 2 L, not 4 L, and that the nasal cannula and nebulizer mask should have been stored properly when not in use. The facility also failed to ensure ordered oxygen settings were followed for two additional residents. One resident with malnutrition, dysphagia, adult failure to thrive, and dependence on oxygen had an order for oxygen at 1 L continuously, but the concentrator was repeatedly observed set at 2 L. A nurse stated the resident was supposed to be on 1 L and did not know why the concentrator was set higher. Another resident with chronic respiratory failure with hypoxia, chronic systolic heart failure, and dependence on supplemental oxygen had an order for oxygen at 2 L continuously, but the concentrator output was observed at 3.5 L on multiple occasions. Staff interviews stated nurses were responsible for checking oxygen concentrator settings each shift, ensuring the output matched the order, and notifying the physician if more oxygen was needed.
Failure to Assess, Obtain Consent, and Guide Side Rail Use
Penalty
Summary
The facility failed to assess residents for safe use of side rails, failed to obtain informed consent for side rail use, and did not have a policy that gave staff guidance for assessing residents for side rails that were not used as restraints. The facility identified 14 residents with side rails, and the sample included 18 residents. The facility’s Use of Restraints policy defined physical restraints and stated that the definition depended on the resident’s functional status, but it did not provide procedural guidance for side rails, grab bars, or enabling devices that were not used to restrict movement. Resident #35 had diagnoses including neurofibromatosis, no physician order for side rails, no nursing assessment for side rails, and no signed consent. The resident’s MDS showed cognitive intactness, impairment of both upper and lower extremities, dependence for bed mobility, and bed rails used less than daily. The care plan addressed ADL deficits and total dependence for repositioning and turning, but did not identify side rail use. The resident was observed in bed with full-length side rails raised on both sides, and the resident stated he/she had minimal movement of the arms due to tumors on the spine, could not turn independently, and was not sure why the rails were on the bed because he/she could not use them. RN B stated he/she did not think the resident had side rails because the resident could not move the arms. Resident #11 had diagnoses including dementia and a history of stroke, with no physician order, no nursing assessment, and no signed consent for side rails. The MDS showed memory problems and partial to moderate assistance needed for bed mobility. The care plan stated the resident had 1/4 rails to increase independence in transferring and/or bed mobility, but the resident was observed with U-shaped rails raised on both sides of the bed at the head of the bed, and the resident said he/she did not know what the rails were or what to do with them. Resident #48 had diagnoses including morbid obesity, generalized muscle weakness, lack of coordination, and abnormal posture, with no physician order, no nursing assessment, and no signed consent. The MDS showed cognitive intactness, bilateral lower extremity impairment, and dependence for bed mobility. The care plan stated the resident required maximum assistance and used two half-length side rails to assist with bed mobility. The resident was observed with half-length rails raised on both sides of the bed, said he/she used the rails for positioning, and RN A said the resident used side rails for repositioning. Resident #10 had diagnoses including generalized muscle weakness and anxiety, with no physician order, no nursing assessment, and no signed consent for side rails. The MDS showed cognitive intactness and dependence for bed mobility. The care plan stated the resident used 1/4 rails to increase bed mobility due to impaired mobility, and the resident was observed with halo-shaped rails raised on both sides of the bed. The resident said he/she used the rails when he/she wanted to sit up, and RN A said the resident used side rails for repositioning. Resident #49 had diagnoses including morbid obesity and generalized muscle weakness, with no physician order and no signed consent. A Device/Restraint evaluation dated 11/21/24 was marked in progress and identified side rails as the device with bed positioning or transferring as the medical symptoms necessitating it. The MDS showed cognitive intactness, dependence for bed mobility, and bed rails used daily. The care plan stated the resident used 1/4 rail to increase independence with bed mobility and included completing initial assessment and consent per facility protocol, but the resident was observed with quarter-length rails raised on both sides of the bed and said he/she used the side rails for repositioning. Resident #2 had diagnoses including right-sided hemiplegia and hemiparesis, aphasia, and Parkinson’s disease. The resident was observed multiple times in a low bed with 1/2 rails up on both sides. The assessments showed no documented evaluation for safe use of bed rails, there was no active physician order for bed rails, and the care plan did not mention side rail use or the need to evaluate the resident for the device. RN A stated the resident used side rails for mobility. Staff interviews showed RN C said any resident with side rails requires a safety assessment and that a physician order is obtained if the resident is deemed safe, while RN A said nurses should complete an assessment on admission and that documentation of consent was not required. The Director of Rehabilitation said therapy could assess residents for side rails and obtain or route the physician order, but could not locate side rail assessments for Residents #35, #11, #48, #10, or #49. The DON stated that when residents have side rails, nurses must obtain signed consent and document it, and that nurses should complete an assessment for safe use of side rails, though she and the Administrator were unsure how often reassessments were done.
Kitchen equipment failures and poor sanitation
Penalty
Summary
The facility failed to ensure kitchen cooking appliances were in working order, failed to keep the kitchen and appliances clean, and failed to ensure the dishwasher was working properly. The kitchen daily cleaning schedule assigned the cook to clean the oven, deep fryer, steam table, preparation station table, and microwave, and dietary aides to clean stainless steel surfaces, the walk-in freezer, dish machine area, reach-in refrigerator, and walk-in refrigerator. The kitchen maintenance logs showed no maintenance requests from 1/1/25 to 8/20/25 for the broken oven, range oven, or walk-in freezer door. On 8/14/25 and 8/15/25, surveyors observed multiple sanitation and equipment issues in the kitchen. The walk-in freezer door did not close all the way, was cracked open, and later remained ajar and unable to fully close and latch; ice, slush, and frostbite were observed on the floor and on packaged foods. The dry storage room had food and trash debris on the floor under the racks, two ceiling tiles above food storage had a black mold-like substance, the walk-in refrigerator had trash and food debris on the floor, and the reach-in refrigerator by the oven had liquid spill and food debris on the bottom. The floor around the oven and in the dish wash station had food debris and liquid buildup, and ceiling tiles above the steam cart serving station had dust accumulation and buildup. The oven was not functioning properly, as the Dietary Manager stated the temperature dial did not work and that setting it to 375 degrees F only allowed the oven to reach about 120 degrees F. On 8/15/25, meat in the oven measured 125 degrees F after being in the oven for an hour and a half while the dial was set at 375 degrees F. The dishwasher also did not reach the required rinse temperature, with observations showing 95 degrees F and then 90 degrees F when the instructions on the machine indicated it needed to reach 120 degrees F. During interviews, Dietary staff and the Administrator stated appliances should be in working order, temperatures should be logged for food storage, the dishwasher should reach 120 degrees F, and the kitchen should be clean and free from trash, food debris, dust accumulation, and mold-like substance.
Failure to Maintain an Ongoing QAPI Program
Penalty
Summary
The facility failed to maintain documentation and provide evidence of an ongoing QAPI program that demonstrated systemic identification, reporting, investigation, analysis, and prevention of adverse events, along with development, implementation, and evaluation of corrective actions or performance improvement activities. The census was 75. During interviews, the DON and Administrator said they had started at the facility about two months earlier and stated that QAA meetings should occur monthly with department heads and the Medical Director, but they were unable to provide documentation of the facility's QAPI plan when asked. Staff interviews showed that QAA meetings were inconsistent and infrequent. The MDS Coordinator said there had been one QAA meeting that year and the last meeting was several months earlier, with no PIPs in months. The Rehabilitation Manager said the last QAA meeting was in April and that daily risk meetings discussed new business and individual events such as falls, but there was no discussion of trends. The Social Services Director said she held a QAA meeting in April 2025 while serving as interim Administrator and that there had not been another since then. The Administrator said the last QAA meeting was in April 2025 and that the facility did not have a QAPI policy. A QAPI Program was submitted after the survey exit and the Administrator stated it was drafted after survey.
Infection Control Failures With TB Screening, EBP Use, and Hand Hygiene
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not completing employee two-step TB skin testing in accordance with State guidelines for three of 10 employees reviewed. Employee personnel files for three staff members showed no documentation of completed TB tests. The facility policy required TB screening for healthcare workers upon hire and yearly thereafter, with initial testing completed as a two-step procedure and documented in the employee medical record. During interviews, the Administrator and DON stated that new employees were expected to complete the two-step TB test process and that the tests should be documented in the personnel file. The facility also failed to implement Enhanced Barrier Precautions for residents with gastrostomy tubes and chronic wounds requiring treatment. Resident #10 had diagnoses including malnutrition, dysphagia, g-tube status, and adult failure to thrive, and had an order for EBP related to the g-tube site requiring gown and gloves for high-contact resident care activities. During observation, an RN administered medications, water flush, and bolus tube feeding through the resident’s g-tube while wearing gloves but not an isolation gown, despite an EBP sign posted on the door. Resident #4 had diagnoses including sepsis due to pseudomonas, pneumonia due to pseudomonas, and gastrostomy status, with an order for EBP related to the g-tube site. During observation, a CNA provided incontinence care and turned the resident side to side while changing the resident, wearing gloves but not a gown. Resident #3 had cancer and Alzheimer’s disease, with an order for EBP related to a chronic sacral wound. During observation, a CNA bathed the resident and changed bed sheets while wearing gloves but not a gown, even though an EBP sign was posted and the resident had a sacral dressing in place. The facility also failed to maintain appropriate hand hygiene during cleanup of fecal material in Resident #1’s room. A restorative aide cleaned fecal material from the resident’s room and bathroom with gloves, touched the doorknob and dirty linen cart, handed the resident a remote from the floor with gloved hands, then removed the gloves and washed hands before touching the resident’s doorknob. The DON stated that staff were expected to remove dirty gloves, wash hands, and apply new gloves before touching clean surfaces and objects.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs. No further details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Honor Resident Preferences for Getting Up and Shower Requests
Penalty
Summary
The facility failed to implement residents’ self-determined preferences for when to get out of bed and failed to provide a requested shower. Two cognitively intact residents with significant physical dependence, including lower extremity impairment and dependence on Hoyer lift transfers with two staff, were not assisted out of bed after breakfast as they preferred. One resident reported waiting hours for staff to get him/her up and said this was typical, while the other resident was observed remaining in bed late in the morning on multiple occasions and stated a preference to be up earlier and to be part of the facility. The care plan for one resident identified the need for maximum assistance and Hoyer lift transfers with two staff, but the resident’s preference to be out of bed earlier in the day was not identified in the care plan. Staff interviews described that many residents on the hall required Hoyer transfers, that only one aide was assigned to the hall, and that this was not enough staff to complete all transfers and care needs. Staff stated that residents on the hall often had to wait and could not always be gotten up before lunch, despite residents liking to get up after breakfast or between late morning hours. A third cognitively intact resident, dependent on staff for bathing and transfers, requested a shower on a Sunday so the resident’s hair would be clean and dry for a beautician appointment. The resident was told showers were not done on Sundays because none were scheduled that day. The resident later received the shower after the request had already been delayed. Staff interviews confirmed that no showers were scheduled on Sundays, but that a shower could still be provided if requested, and the DON stated she would expect staff to give the resident a shower when requested.
Failure to Submit TPL Forms for Deceased Residents' Trust Funds
Penalty
Summary
The facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting of residents who expired and had money remaining in their resident trust accounts. This affected three of five sampled residents who expired and had funds in their accounts: Resident #77 with an ending balance of $378.26, Resident #78 with an ending balance of $183.00, and Resident #79 with an ending balance of $12.69. Review of the resident trust fund policy showed the facility managed resident funds in accordance with State and Federal regulations, but the policy did not identify the federal requirement for notice and conveyance of funds to be completed within 30 days upon a resident's death when funds remained in the account. Record review showed no TPL form was submitted to Medicaid for any of the three residents. Resident #78 had been discharged to the hospital and was later confirmed expired. During interview, the Business Office Manager stated she was unsure what to do when a resident expired with funds left in the account, was unsure how payor source factored in, and was not aware that a TPL form should be submitted to Medicaid for residents who expired with funds left in their account. The Administrator stated he expected the facility to notify Medicaid of funds left in the resident trust account following a resident's expiration and that the BOM should submit the TPL as soon as possible, within 30 days of expiration.
Pre-employment screening policy missing NA Registry checks and background checks not completed
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after interview and record review showed the facility did not complete criminal background checks on newly hired employees before their start dates and did not ensure newly hired employees were screened for a Federal Indicator through the Nurse Aide Registry for 5 of 10 employees hired since the last survey. The facility’s Abuse, Neglect, and Exploitation policy, revised June 2024, required screening of potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property and stated that background, reference, and credential checks would be conducted, but it did not include completion of checking the Nurse Aide Registry. Record review showed CNA KK was hired 6/17/25, but the Administrator and Staffing Coordinator could not locate the personnel file during interview, and the employee was working that day. Dietary Aide JJ was hired 8/15/25, with an FCSR check requested but results not received and no criminal background check completed. Housekeeper II was hired 6/10/24, with an FCSR check requested but results not received and no criminal background check completed. [NAME] V was hired 2/15/24, with an FCSR check requested but results not received and no criminal background check completed. OTA LL was hired 9/3/24, and no Nurse Aide Registry check was documented. The Administrator and Staffing Coordinator stated the facility did not currently have a Human Resource manager and that pre-employment background checks were being run by a sister facility.
Failure to Provide Proper Foot and Toenail Care
Penalty
Summary
The facility failed to ensure proper foot care for one resident with cancer and Alzheimer's disease who was dependent on staff for dressing and putting on and taking off footwear. The facility's Nail and Foot Care policy required nursing staff to assess nail and foot status on admission and quarterly, document care needs, and ensure residents with diabetes, peripheral vascular disease, neuropathy, or anticoagulation therapy received podiatry or licensed nursing intervention for toenail care. The resident was not listed among residents currently seeing the podiatrist, and the CNA shower review sheets repeatedly showed blank or inconsistent responses about whether toenail cutting was needed. During observation, the resident was found in bed with socks removed, large flakes of dry skin on both feet, and toenails on both feet curled under approximately one half inch and extremely thick. A CNA stated the resident needed toenails cut and lotion applied. Staff interviews showed CNAs were expected to notify the nurse if nails required trimming, nurses were expected to assess toenails during bathing and weekly skin checks, and an RN or podiatrist would trim nails if they were too thick. The DON stated staff were expected to identify when toenail trimming was needed and place the resident on the podiatrist list as needed, and to apply lotion when feet were dry.
Failure to Maintain Fall Precautions and Upright Feeding Position
Penalty
Summary
The facility failed to ensure fall interventions were in place for two residents identified as high fall risks. One resident with cancer and Alzheimer’s disease had a history of falling out of bed and rolling out of bed, and the care plan included interventions such as mats at the side of the bed, a bolster mattress, a low bed, a night light, and limiting time in a Broda chair. During multiple observations, the resident’s bed remained approximately 30 inches from the floor, fall mats were placed only on one side of the bed, and the call light was found under the bed or under a pillow rather than within reach. The resident was also observed yelling for staff while staff walked past the room, and the room had a strong odor of bowel movement. A second resident, who was cognitively intact and had diagnoses including hemiplegia, dementia, and acute respiratory failure, was assessed as high risk for falls and had a care plan focused on fall prevention. During observation, the resident was positioned in bed with legs hanging off the bed and stated being uncomfortable but unable to reach the call light. The call light was on the floor next to the bed and out of reach, and staff observed the resident without assisting for an extended period before help was provided. The facility also failed to ensure a resident with dysphagia was positioned upright during meals. The resident had diagnoses including malnutrition, dysphagia, gastrostomy status, and adult failure to thrive, and the physician order required upright positioning at 90 degrees during oral intake and for at least 30 minutes afterward. Although swallowing precautions were posted in the room, the resident was repeatedly observed eating while slumped in bed with the head of the bed elevated only 15 to 30 degrees and the chin down toward the chest. The resident was observed eating chopped meat, scrambled eggs, and shredded pork in this position, and staff provided food while the resident remained improperly positioned.
Failure to Obtain Ordered Urine Testing
Penalty
Summary
The facility failed to provide or obtain laboratory services to meet the needs of one resident. Resident #9 was cognitively intact, dependent on staff for toilet hygiene, always incontinent of bowel and bladder, and had diagnoses including stroke, muscle weakness, and diabetes. The resident's comprehensive MDS dated 6/16/25 reflected these conditions, and the care plan did not reflect any laboratory orders being implemented. The resident's physician order sheet for August 2025 showed an order dated 8/5/25 for a urinalysis and urine culture and sensitivity related to confusion and urinary incontinence. The progress notes documented that the physician saw the resident on 8/5/25 at 8:00 P.M. and entered new orders for UA and urine culture and sensitivity, but there was no further documentation related to the urine test. The TAR and MAR did not show the urine test order, and the clinical results tab did not show results for the urine tests. RN A stated he/she was not aware of the physician's order and said the order should be placed on the TAR or MAR for the nurse to complete. The DON stated she did not have any urine test results for the resident and had been told staff had difficulty obtaining a urine sample; she expected documentation in the progress notes if the urine test was not obtained and a reason why, and expected the order to be clearly and accurately placed on the MAR or TAR.
Diet Orders Not Followed for Double Portions and Nectar-Thick Liquids
Penalty
Summary
The facility failed to ensure that one resident received double portions and nectar-thick liquids in accordance with physician orders. Resident #47 had diagnoses including pneumonitis due to inhalation of food and vomit, dysphagia, history of stroke, epilepsy, and hypertension. The resident’s record included a physician order for a regular diet with regular texture, nectar-thick liquids, and double portions, and the care plan identified a nutritional problem with a regular diet and nectar-thick liquids. However, the dietary slip available for the resident did not document double portions, and there was no documentation on the slip regarding the ordered double portions. During interview, the resident stated he/she was not getting enough food and described receiving small breakfast portions such as one egg, one piece of bacon, or one hashbrown. Observations showed the resident receiving trays with the same portion sizes as other residents on the hall, including meals with one meat patty on a bun, baked beans, fruit, and thin liquids, as well as breakfast trays with scrambled eggs, biscuit, cereal, and thin liquids. Another observation showed a breakfast tray with a donut and thin milk and orange juice, and no dietary slip was on the tray. Staff interviews confirmed that dietary slips were not being sent out with room trays and that nursing staff passing trays did not know what items should be included. CNAs and RN staff stated that dietary slips should identify double portions and nectar-thick liquids, but they were not seeing nectar-thick liquids on the carts for hall trays. The dietary manager and other staff reviewed the resident’s dietary slip and noted that double portions were not indicated, while the DON and Administrator stated dietary slips should accompany trays and include diet details such as double portions and nectar-thick liquids.
Failure to Hold Required QAA Meetings
Penalty
Summary
The facility failed to ensure that Quality Assessment and Assurance (QAA) committee meetings were held at least quarterly and that the committee had the required participation to carry out its responsibilities. During interview, the DON and Administrator stated they had started working at the facility about two months earlier and said QAA meetings should occur monthly and be attended by the facility's department heads and Medical Director. Review of the QAA sign-in sheets for the prior 12 months showed only two documented meetings, one held on 9/6/24 and one held in April 2025, with no documentation of any other QAA meetings during that timeframe. The Administrator later stated the sign-in sheets provided were the only ones he could locate, that the interim Administrator had held one meeting in April 2025, and that he had not yet held a QAA meeting since beginning work in June 2025.
Failure to Document Influenza Vaccination Status
Penalty
Summary
The facility failed to develop and implement policies and procedures ensuring all residents were offered influenza vaccination and that vaccination documentation was placed in the medical record. Review of the facility’s Resident Immunizations and Vaccinations policy showed that all residents were to be offered influenza vaccination annually, new admissions were to be screened and given the influenza vaccine unless specifically ordered otherwise by the Primary Physician, and a record of vaccination was to be placed in the resident’s medical record. However, the medical records for three of five sampled residents did not contain documentation of influenza vaccine administration, refusal, or education. Resident #5 was admitted with diagnoses including hypertension, ESRD, history of TIA, and diabetes, and had no recorded documentation of influenza vaccine administration or refusal/education. Resident #11 was admitted with diagnoses including history of TIA, encephalopathy, and pulmonary embolism, and also had no recorded documentation of influenza vaccine administration or refusal/education. Resident #4 was admitted with diagnoses including COPD, gastrostomy status, dysphagia, and paroxysmal atrial fibrillation, and likewise had no recorded documentation of influenza vaccine administration or refusal/education. During interviews, the LPNs and DON stated there was no standardized process for obtaining consent for or documenting vaccines for current and new residents, and the acting IP had not yet begun tracking vaccinations. The Administrator and DON later stated there was no standard process for tracking immunizations and no staff member currently responsible for tracking immunization status.
Missing COVID-19 Vaccine Documentation and Tracking
Penalty
Summary
The facility failed to develop policies and procedures to ensure residents were educated about COVID-19 vaccination and that vaccination status was documented in the medical record. Review of the facility’s Resident Immunizations and Vaccinations policy, revised in 2019, showed requirements for influenza and pneumococcal vaccination only, with no mention of COVID-19 vaccination education or documentation. The resident sample was 18, and the facility census was 75. Record review showed no documentation of COVID-19 vaccine administration, refusal, or education for three sampled residents. Resident #5 was admitted on 1/10/2025 and had diagnoses including HTN, ESRD, history of TIA, and DM. Resident #11 was admitted on 3/14/25 and had diagnoses including history of TIA, encephalopathy, and pulmonary embolism. Resident #4 was admitted on 3/12/25 and had diagnoses including COPD, gastrostomy status, dysphagia, and paroxysmal atrial fibrillation. During interviews, the LPNs and DON stated there was no standardized process for obtaining consent for or documenting vaccines for current and new residents, and that the acting IP had only recently started and had not yet begun tracking vaccinations. The Administrator and DON also stated there was no standard process for tracking immunizations and no staff member currently responsible for tracking COVID-19 immunization status.
Kitchen Infested With Flies During Food Prep and Dishwashing
Penalty
Summary
The facility failed to ensure the kitchen was free from flies, as multiple flies were observed in the food preparation and dishwashing areas on two survey days. Review of the pest control logs showed the kitchen was treated for pests on 6/20/25, 7/18/25, and 8/15/25. On 8/15/25, surveyors observed multiple flies around the food preparation station landing on food and utensils, and later observed flies around the dishwashing station landing on clean and dirty dishes; the Dietary Manager stopped food preparation to kill a fly with a bottle of cleaning wipes. On 8/18/25, surveyors again observed multiple flies in the dishwashing station landing on clean cups and flies in the food preparation area landing on utensils. During interviews, the Maintenance Director said he was not aware of the amount of flies in the kitchen and expected dietary staff to report pest control concerns, while the Dietary Manager said the flies had been a problem since she started working at the facility a week prior and that she did not report the issue to maintenance. The Administrator stated he expected the kitchen to be free from flies and pests and that dietary staff should report pest control concerns to maintenance.
Failure to Provide Timely and Appropriate CPR and Maintain CPR-Certified Staff
Penalty
Summary
The facility failed to provide appropriate basic life support, including cardiopulmonary resuscitation (CPR), to a resident who was found unresponsive and without a pulse. The resident had a full code status, as documented in the care plan and physician orders, and had expressed a clear desire to be resuscitated in the event of cardiac arrest. When the resident was discovered unresponsive, staff initiated CPR but discontinued efforts before emergency medical services (EMS) arrived. There was a significant delay in contacting EMS, with over an hour passing between the time the resident was found without a pulse and the time 911 was called. During this period, staff made phone calls to the family and physician, and CPR was not in progress when EMS arrived on the scene. Interviews with staff revealed confusion and lack of knowledge regarding code status determination and CPR procedures. Certified Nurse Aides (CNAs) on duty did not know how to access or determine a resident's code status, and some staff members involved in the event were not CPR certified. There were inconsistencies in staff accounts regarding who performed CPR, for how long, and whether appropriate equipment such as a backboard or ambu bag was used. Documentation and interviews indicated that CPR was stopped based on staff judgment rather than the arrival of EMS or a qualified medical professional pronouncing death, which was contrary to facility policy and standard practice. Additionally, a review of staffing records showed that the facility failed to ensure the presence of at least one CPR-certified staff member on 14 night shifts within a 30-day period, despite having a significant number of residents with full code status. The staffing coordinator was unaware of the requirement to have CPR-certified staff on each shift and did not maintain an updated list of staff CPR certifications. Human Resources did not provide the staffing coordinator with information on which staff were CPR certified, and there was no system in place to identify CPR-certified staff on staffing sheets. This lack of oversight contributed to the deficiency in providing timely and appropriate life-saving measures.
Failure to Timely Report Alleged Neglect After CPR Was Stopped Before EMS Arrival
Penalty
Summary
The facility failed to ensure that an alleged violation involving neglect was reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency. The incident involved a resident with severe cognitive impairment, lower extremity impairment, and diagnoses including COPD, emphysema, and dependence on supplemental oxygen. The resident was designated as a full code, with physician orders and care plan interventions specifying immediate initiation of CPR and calling 911 in the event of cardiac arrest. On the day of the incident, an LPN found the resident unresponsive and cold to the touch. The LPN, along with another nurse, attempted resuscitation per protocol but determined the resident had no heartbeat or oxygenation and ceased CPR before EMS arrived. The LPN notified the resident's family and physician, and subsequently called 911. Administration was notified early after the incident and assisted with contacts. However, CPR was not continued until EMS arrival, as required by facility policy and the resident's code status. The Administrator acknowledged during interviews that the incident should have been reported to the state as neglect within two hours, as stopping CPR prior to EMS arrival constituted a failure to follow physician orders and facility policy. The Administrator did not report the incident, stating that the Assistant Fire Chief indicated he would report it to the hotline. The facility's policies require immediate reporting of all alleged violations involving neglect, but this was not followed in this case.
Failure to Document and Follow Post-Fall Protocols and Notifications
Penalty
Summary
The facility failed to ensure that three residents received care in accordance with professional standards and facility policies following falls and hospital transfers. Specifically, staff did not complete required progress notes after residents experienced falls, were sent to the hospital, or returned from the hospital. There was also a lack of documentation regarding notifications to physicians and family members when these incidents occurred. Additionally, the facility did not consistently complete post-fall follow-up for 72 hours, which should have included progress notes per shift, vital signs monitoring, and neurological checks as outlined in facility protocols. For one resident, there was no documentation of the fall, notifications to the physician or emergency contact, or the resident being sent to or returning from the hospital. The care plan was not updated with appropriate interventions, and required fall prevention signage was missing from the resident's room. Vital signs were not monitored or documented for 72 hours post-fall. Another resident, who had severe cognitive impairment and was dependent on staff for most activities, also lacked documentation of family notification after a fall, and there was a missing neurological assessment entry. The care plan did not include interventions for the most recent fall. A third resident, identified as high risk for falls, had no progress notes regarding a fall or notification to the physician. There was also no documentation of post-fall follow-up notes for several shifts, and fall prevention indicators were not present in the resident's room. Across all three cases, the facility did not adhere to its own fall prevention, clinical protocol, and notification of changes policies, resulting in incomplete assessments, lack of care plan updates, and insufficient communication with medical providers and families.
Failure to Obtain Ordered Lab Services for Resident
Penalty
Summary
The facility failed to meet professional standards of practice by not ensuring that laboratory services were obtained as per physician orders for one resident. The resident, who was cognitively intact, had multiple diagnoses including heart failure, high blood pressure, diabetes, and COPD. On a specific date, the physician ordered several lab tests, including a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and others, due to the resident's confusion and agitation. However, there was no documentation that these labs were drawn, nor was there evidence that the resident refused the blood draw or that the family was notified of the new orders. The progress notes indicated attempts to obtain a urine sample through catheterization, but there was no success until several days later. Despite the physician's orders, the facility did not follow up with the lab to ensure the tests were conducted. The lab representative confirmed that the facility was responsible for entering lab orders into the computer system, and the phlebotomist would check for these orders during routine visits. However, the lab did not have records of the orders being entered for the specified period. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that the nurse who obtained the order was responsible for entering it into the system. The DON acknowledged that the lab orders might have been overlooked or the resident might have refused the blood draw, but there was no documentation to confirm this. The lab admitted to not drawing the labs, and the facility did not have a system in place to verify the completion of lab orders, leading to the deficiency.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to immediately report an allegation of staff-to-resident verbal abuse to the Department of Health of Senior Services (DHSS) within the required two-hour time frame. Resident #1 overheard a staff member threatening Resident #2 with physical harm if the resident pinched the staff member again. The incident occurred in the shared bathroom of the two residents. Resident #1 reported the incident to the Social Worker (SW) on 4/4/24, but the SW did not report the allegation to DHSS as required. The SW admitted to not reporting the incident due to being busy with a respiratory outbreak in the facility. Resident #1, who is able to make needs and wants known, has diagnoses including chronic pain, anxiety, and depressive disorder. Resident #2, who can make some needs and wants known, has diagnoses including diabetes, dementia with behavioral disturbances and agitation, depression, and muscle weakness, and requires moderate to total assistance with daily care needs. The Administrator confirmed that the SW should have reported the allegation to DHSS immediately upon receiving the report from Resident #1.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to follow its policy to investigate an allegation of verbal abuse between a Certified Nurse Aide (CNA) and a resident. The incident was reported by another resident who overheard the alleged abuse from a shared bathroom. Despite the report being made to the facility's Social Worker (SW), no investigation was initiated, and the allegation was not taken seriously. The SW admitted to not starting an investigation due to being busy with a respiratory outbreak in the facility. The resident who reported the incident described the staff member based on their voice and physical appearance. The description matched CNA A, who frequently cared for the resident involved in the alleged abuse. However, neither the Assistant Director of Nursing (ADON) nor the Director of Nursing (DON) were aware of the allegation until informed by the surveyor. The staff involved had not been interviewed or suspended as per the facility's abuse prohibition policy. Interviews with other staff members, including Licensed Practical Nurse (LPN) C and CNA B, revealed that they were not questioned about the incident, and no witness statements were taken. The Administrator confirmed that the SW should have started the investigation immediately upon receiving the report. The facility only began the investigation and took necessary actions after the surveyor's intervention.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 875 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bridgeton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ssm Health Depaul Hospital - Anna House | 0.4 mi | ★★★★★ | 1 | 0 |
| Parkwood Skilled Nursing And Rehabilitation Center | 0.6 mi | ★★★★★ | 7 | 0 |
| Stonebridge Maryland Heights | 1.1 mi | ★★★★★ | 4 | 0 |
| Life Care Center Of Bridgeton | 1.5 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Maryland Heights | 1.6 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.