Beauvais Rehab And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 3625 Magnolia Avenue, Saint Louis, Missouri 63110
- CMS Provider Number
- 265699
- Inspections on file
- 35
- Latest survey
- September 26, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Beauvais Rehab And Healthcare Center during CMS and state inspections, most recent first.
A CNA misused a resident's debit card, originally entrusted for snack purchases, to transfer funds to themselves via Cash App over two months, resulting in unauthorized withdrawals totaling $454. The resident, who was cognitively intact but physically limited, had not authorized these transactions. The deficiency was identified after the resident's bank reported suspicious activity, revealing a failure to protect the resident from misappropriation of property.
A resident with a history of aggression physically assaulted and threatened their roommate with a knife during a verbal altercation. Both individuals had psychiatric and cognitive diagnoses, and although both were on one-to-one observation, staff were positioned outside the room, allowing the incident to occur before intervention. The assaulted resident sustained facial swelling, and a pocket knife was later found in the room.
A resident returned from a VA appointment with new prescriptions, but staff failed to clarify or document the medication orders, did not administer the medications, and did not follow up with the prescribing physician or facility PCP. In a separate incident, two residents on one-to-one supervision for behavioral concerns were left unsupervised in their room, resulting in a physical altercation and a threat with a knife, as staff sat in the hallway with the door closed instead of maintaining required direct observation.
A resident with a history of substance abuse and serious mental illness exhibited escalating aggressive and dangerous behaviors, including physical violence and threats, without receiving a comprehensive behavioral management program or a documented PASRR assessment. The facility's care plans and assessments did not adequately address the resident's behavioral health or substance use needs, and staff were unaware of key aspects of the resident's history, leading to repeated safety incidents and insufficient interventions.
The facility did not ensure that CMTs had completed competency checks for safe medication administration. CMT6 was observed preparing medications in advance, against policy, and had signed them as administered. The DON assumed CMTs were trained upon certification and did not require competency checks upon hire. A review of ten CMT files showed no evidence of competency checks.
The facility failed to ensure that binding arbitration agreements were explained in a manner that residents understood, affecting three residents. One resident, who was cognitively intact, signed the agreement but later stated she did not know what it was. Another resident, also cognitively intact, signed without understanding, and a third resident signed but did not know what the agreement was. The administrator and regional director of business development were unaware of the requirements for explaining these agreements.
A facility failed to protect residents' personal and medical records, leaving electronic medical records (EMR) open and accessible to unauthorized individuals. A CMT left EMR screens open in the dining room and hallway, exposing confidential information to residents and visitors. The Director of Nursing confirmed that EMR screens should be locked when unattended, highlighting a breach of privacy and confidentiality policies.
The facility failed to provide adequate staffing on the fifth floor, affecting resident care. Observations showed long call light response times, with one resident waiting over 17 minutes for assistance. Interviews revealed consistent staffing shortages, especially on weekends and night shifts, with only one staff member present at times. Staffing sheets confirmed these deficiencies, and facility staff acknowledged the issues, citing call-offs and staff preferences as contributing factors.
The facility failed to provide eight hours of RN coverage daily for all 136 residents, as required by policy. Staffing sheets for January, February, and March 2025 showed multiple days without RN coverage. Interviews with the Scheduler and interim DON confirmed the lack of RN coverage, citing staffing difficulties and call-offs. The interim DON managed RN-required tasks in the absence of other RN staff.
The facility failed to ensure proper labeling and disposal of medications, with insulin pens and eye drops found without open or discard dates, and some mislabeled with incorrect resident names. Staff were unaware of labeling requirements, leading to potential medication errors. The DON confirmed that expired medications should be discarded and insulin pens discarded 28 days after opening.
The facility failed to provide palatable food to residents, as observed in interviews and a meal test tray. Several residents, mostly cognitively intact, reported the food as unappetizing, bland, and served at inadequate temperatures. Some residents had conditions like malnutrition or chronic obstructive pulmonary disease, potentially worsened by poor nutrition. The Dietary Manager acknowledged complaints, and the DON expected residents to enjoy their meals.
The facility failed to prevent cross-contamination during meal delivery and medication administration. CNAs delivered meal trays to residents without performing hand hygiene between interactions, and a CMT and LPN did not sanitize their hands during medication administration. Despite the facility's policies and training, staff did not adhere to infection control protocols, potentially promoting the spread of infections.
A resident expressed concerns about the cleanliness of a shower room, which was found to have orange-colored stains identified as soap scum. The Housekeeping Manager confirmed the shower should be cleaned daily, but there was no documentation of this. Observations showed the stains could be removed with cleaning chemicals, indicating a lack of regular cleaning.
A resident experienced a severe weight loss and decline in mobility, but the facility failed to complete a significant change MDS within the required timeframe. The MDS Coordinator was unsure about the criteria for a significant change assessment and misinterpreted CMS guidelines, resulting in the oversight.
The facility failed to accurately complete MDS assessments for two residents, leading to potential unmet care needs. One resident experienced significant weight loss, but the MDS inaccurately recorded no weight loss due to outdated data. Another resident's discharge status was incorrectly documented, showing a discharge to a hospital instead of home. The MDS Coordinator acknowledged these errors.
A facility failed to update the PASARR Level One for a resident after a new diagnosis of mood disorder was added post-admission. The policy requires updates for significant changes, but the PASARR was not updated, and staff interviews revealed confusion over responsibility for this task.
A facility failed to develop and implement a care plan for hospice services for a resident who had an order for such services. The MDS Coordinator admitted the oversight was due to not updating the payor type, and the DON confirmed that a care plan should have been in place. This omission had the potential to cause unmet care needs.
A facility failed to follow physician orders for a resident's helmet use, intended for fall safety. The resident, with severe cognitive impairment and multiple diagnoses, was observed without a helmet, and staff interviews revealed a lack of awareness and documentation regarding the helmet order. The DON expected staff to follow orders and address any issues with the physician.
A resident's cataract surgery was canceled due to the lack of a Hoyer lift, and the facility failed to reschedule the procedure for over a year. Despite the resident being cognitively intact and the facility's policy to provide necessary care, the surgery was not revisited, potentially affecting the resident's well-being. Staff interviews revealed a lack of awareness and follow-up regarding the rescheduling of the surgery.
A resident with severe cognitive impairment and multiple diagnoses smoked unsupervised inside the facility, despite needing supervision while smoking. The resident locked himself in the bathroom, and staff detected smoke but could not immediately access the bathroom due to the locked door. The facility's policy prohibited smoking inside, and the failure to ensure compliance with this policy and address the locking bathroom door contributed to the deficiency.
A resident with chronic respiratory failure was observed receiving oxygen at three LPM continuously, contrary to the physician's order of two LPM as needed. The LPN failed to verify the correct LPM and did not document the oxygen use on the MAR. The DON confirmed the lack of documentation and monitoring, which could lead to increased oxygen exposure.
The facility failed to administer pneumococcal vaccines to two residents who had consented to receive them upon admission. Both residents, who were cognitively intact, had signed consents, but their immunization records showed no indication of receiving the vaccines. The ADON initially stated one resident declined the vaccine, but upon review, acknowledged the oversight. The DON confirmed the expectation that the vaccines should have been administered.
The facility failed to provide adequate care and pain management for two residents, leading to recurring issues with moisture-associated skin damage and deficits in hand hygiene. Staff did not consistently follow physician's orders or the facility's policies, resulting in inadequate care and interventions for the residents.
A resident with chronic pain and multiple medical conditions experienced significant breakthrough pain that was not effectively managed by the facility. Nursing staff failed to consistently assess, monitor, or implement interventions for pain, and physician's orders for a neurological consult for Botox injections were not carried out due to transportation issues.
Misappropriation of Resident Funds by CNA
Penalty
Summary
A deficiency occurred when a Certified Nurse Aide (CNA) took a resident's debit card under the pretense of purchasing vending machine snacks, but instead used the card to transfer money to themselves via Cash App over a period of two months. The resident had only authorized the CNA to use the card for snack purchases, not for personal transfers. The CNA withdrew a total of $483.40 from the resident's bank account, later crediting back $29.40, resulting in a net unauthorized withdrawal of $454.00. The resident involved was cognitively intact, as confirmed by recent assessments, but had significant physical limitations, including hemiplegia following a stroke, and required assistance with mobility and personal care. The resident reported that they allowed the CNA to use their card for snacks due to their limited mobility and need for assistance. The resident did not give permission for any other use of the card and was surprised to learn of the unauthorized transactions. The resident did not report any other items or funds missing and stated that the CNA never asked for money directly. The facility's policies prohibit misappropriation of resident property and require staff to protect residents from such actions. Despite these policies, the CNA was able to access and misuse the resident's funds over an extended period. The incident was discovered when the resident's bank notified the facility of suspicious charges, prompting an internal investigation. The CNA had previously been on a settlement agreement with the Employee Disqualification List, requiring additional oversight, but there had been no prior incidents reported with this employee before the misappropriation was identified.
Resident Assaulted and Threatened with Knife by Roommate
Penalty
Summary
A deficiency occurred when a resident with a history of aggressive behaviors physically assaulted their roommate by punching them in the face and threatening them with a sharp knife. The incident took place in a shared room, where both residents had cognitive or psychiatric diagnoses, including schizoaffective disorder, bipolar disorder, and substance abuse. The aggressor had previously demonstrated verbal and physical aggression, and their care plan noted a potential for such behaviors. At the time of the incident, both residents were on one-to-one observation, but the assigned staff were sitting in the hallway with the door closed, rather than inside the room. This allowed the aggressive resident to move their bed next to the roommate's, initiate a verbal altercation, and escalate to physical violence and a threat with a weapon. Staff only intervened after hearing the commotion, at which point they entered the room, witnessed the altercation, and called for additional help. The assaulted resident sustained moderate swelling to the right eye and refused an x-ray. Both residents were assessed following the incident, and the aggressor was found to be in possession of a pocket knife, which was later recovered from the room. The facility's abuse prevention policy required screening for potentially abusive residents and protection of residents during investigations, but the events indicate that these measures were not sufficient to prevent the altercation and threat.
Failure to Follow Physician Orders and Inadequate One-to-One Supervision
Penalty
Summary
The facility failed to follow up with a resident's primary care physician or VA physician to obtain medication orders after filled prescription bottles were found in the resident's room following a medical appointment. The resident, who had a history of stroke, traumatic brain injury, and cognitive impairment, returned from a VA appointment with new prescriptions for Diphenhydramine and Prednisone. Facility staff removed the medications from the resident's possession but did not document the removal, did not clarify the orders with the prescribing physician or the facility's primary care physician, and did not enter the new medication orders into the resident's medical record. The resident repeatedly requested the medications, expressing discomfort and symptoms related to their absence, but staff failed to administer them or ensure proper follow-up, as required by facility policy and professional standards of practice. Additionally, the facility failed to provide care consistent with professional standards during one-to-one observation for two residents with behavioral health diagnoses. Both residents were placed on one-to-one supervision due to behavioral concerns, including smoking in the room and aggressive or erratic behaviors. However, staff assigned to observe the residents sat in the hallway with the door closed, rather than maintaining line-of-sight or arm's length supervision as required by facility policy. This lapse in supervision allowed a physical altercation to occur between the two residents, during which one resident threatened the other with a knife. Interviews with staff and facility leadership confirmed that the expected practice was for staff to remain within arm's length or at least in direct line of sight of residents on one-to-one observation. Staff admitted to not following this protocol, citing personal discomfort and misunderstanding of the requirements. Facility policies and leadership statements emphasized the importance of direct supervision and proper documentation, both of which were not followed in these incidents.
Failure to Provide Behavioral Health Services and PASRR Assessment
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident who exhibited frequent disruptive and dangerous behaviors, including yelling, cursing, threatening staff and other residents, and using illicit substances. The resident's behaviors escalated to physical violence, including punching a roommate, displaying a knife, and making threats to kill. Despite these incidents, there was no evidence that a comprehensive behavioral management program was implemented as required by the facility's own policy. Documentation showed that staff did not consistently assess, monitor, or evaluate the effectiveness of interventions, and there was a lack of ongoing psychiatric support, with no documented psychiatric visits for two months. The resident had a documented history of substance abuse, including recent cocaine use, and multiple hospital admissions for related health issues. The initial assessments and care plans did not adequately address the resident's substance use or behavioral health needs. The care plan focused primarily on smoking safety and oxygen therapy, with minimal attention to behavioral management or substance abuse interventions. Staff interviews revealed a lack of awareness regarding the resident's substance use history and uncertainty about whether federally mandated Pre-admission Screening and Resident Review (PASRR) was completed, which is required for residents with serious mental illness or substance use disorders. Throughout the resident's stay, there were repeated incidents of verbal and physical aggression, including threats and altercations with staff and other residents. Interventions such as one-to-one monitoring and police involvement were only implemented after significant escalation. The facility's failure to identify, assess, and address the resident's behavioral health and substance use needs, as well as the lack of a documented PASRR, contributed to ongoing safety risks for the resident and others. The deficiency was further compounded by inadequate interdisciplinary collaboration and incomplete documentation of behavioral incidents and interventions.
Lack of Competency Checks for CMTs in Medication Administration
Penalty
Summary
The facility failed to ensure that Certified Medication Technicians (CMTs) had completed the necessary competency checks for safe medication administration. During an observation, CMT6 was seen preparing multiple medication cups in advance, contrary to facility policy, and had already signed off on the medications as administered. Interviews revealed that the Director of Nursing (DON) assumed CMTs had the required training upon certification and did not require competency checks upon hire. A review of ten CMT personnel files showed no documented evidence of medication administration competency checks for any of the CMTs reviewed.
Failure to Ensure Understanding of Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that binding arbitration agreements were explained in a manner that residents understood, and that the residents or their representatives acknowledged understanding the agreement. This deficiency was identified for three residents out of a sample of 48. Resident 92, who was cognitively intact with a BIMS score of 14, signed a binding arbitration agreement electronically but later stated she did not know what a binding arbitration agreement was and did not recall signing one. Similarly, Resident 95, also cognitively intact with a BIMS score of 15, signed the agreement without the provision that they understood it, and was unavailable for interview. Resident 189, who had several medical conditions, also signed the agreement but stated they did not know what it was. The facility's administrator, who had been in the position for two years, was not responsible for explaining the agreements and was unaware of their contents. The regional director of business development, who had previously explained arbitration agreements to residents, was unaware of the requirement to inform residents that they were giving up their constitutional right to a trial and that they had a right to a neutral venue and arbitrator. The director also did not know that residents needed to sign that they understood the agreement. This lack of understanding and communication led to the deficiency in ensuring residents were properly informed about the binding arbitration agreements.
Failure to Secure Residents' Medical Records
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records, as required by their own policies and state and federal laws. During observations, it was noted that a Certified Medication Technician (CMT) left electronic medical records (EMR) open and accessible to unauthorized individuals. This occurred in multiple locations, including the dining room and hallway, where residents and visitors could view the confidential information. The facility's policy mandates that active records should not be accessible to unauthorized persons, and the Director of Nursing confirmed that EMR screens should be locked when unattended. On several occasions, the CMT left the EMR open while administering medications to residents, making private medical information visible to others. This included leaving the EMR open in the dining room and hallway, where multiple residents and visitors were present. The CMT admitted to not realizing the screens were left open, and the Director of Nursing acknowledged the privacy concerns associated with this oversight. The facility census at the time was 136, and the failure to secure the EMR affected 27 residents on the secure unit.
Inadequate Staffing on Fifth Floor Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing on the fifth floor, affecting four residents out of a sample of 48. The facility's policy requires sufficient nursing staff based on resident assessments and individual care plans. However, observations and interviews revealed that call light response times were excessively long, with one resident waiting over 17 minutes for assistance. This resident, who was blind and had acute respiratory failure, reported difficulty breathing due to the delay. A Certified Medication Technician (CMT) was observed talking on the phone instead of attending to the resident's needs. Interviews with residents and staff indicated a consistent lack of staffing, particularly on weekends and night shifts. One resident reported no staff availability on weekends, while another mentioned that call lights were not answered at night. A staff member confirmed that she was often the only person on the floor during the night shift, despite the presence of residents with significant medical needs, such as seizures. The facility's staffing sheets for February and March 2025 showed multiple instances where only one staff member, either a CMT or a Licensed Practical Nurse (LPN), was present on the fifth floor during the night shift. On some nights, there was no CMT or LPN coverage, leaving only a Certified Nurse Aide (CNA) on duty. The Scheduler and interim Director of Nursing acknowledged the staffing issues, citing call-offs and staff preferences as contributing factors. They also noted that phone usage by staff was a problem, despite policies against it.
Failure to Ensure RN Coverage for Residents
Penalty
Summary
The facility failed to ensure eight hours of Registered Nurse (RN) coverage every day of the week for all 136 residents, as required by their policy. The facility's staffing sheets for January, February, and March 2025 revealed multiple days without RN coverage. Specifically, there was no RN coverage on several days across these months, including 01/02/25, 01/09/25, 01/18/25, 01/23/25, 01/27/25, 01/30/25, 02/01/25, 02/06/25, 02/10/25, 02/13/25, 02/15/25, 02/20/25, 02/24/25, 02/27/25, 03/01/25, 03/02/25, 03/10/25, 03/15/25, and 03/16/25. Interviews with the Scheduler and the interim Director of Nursing (DON) confirmed the lack of RN coverage, citing difficulties in staffing and call-offs as contributing factors. The interim DON stated that she would handle any facility needs requiring an RN in the absence of other RN staff.
Medication Labeling and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and disposal of medications, which was observed during a survey of four medication carts. Insulin pens and vials were found without open or discard dates, and some were mislabeled with incorrect resident names. For instance, an insulin pen used for a resident was not labeled with open or discard dates, and the nurse administering it was unsure of the discard timeline. Additionally, expired medications were found on the carts, and some medications were labeled with the names of residents who were no longer in the facility. During the survey, it was noted that eye drops and other medications were not labeled with open or discard dates, and some were expired. Staff members, including Certified Medication Aides and Licensed Practical Nurses, were unaware of the labeling requirements and the duration for which medications could be used after opening. This lack of knowledge and adherence to labeling protocols was acknowledged by the Assistant Director of Nursing, who confirmed that medications should be labeled with open and discard dates and that expired medications should be discarded. The Director of Nursing confirmed that the standard of care requires insulin pens to be discarded 28 days after opening and that expired medications should be removed from the carts. The failure to label medications properly and dispose of expired ones could lead to medication errors and adverse reactions, as the staff did not consistently follow the facility's policy on medication storage and labeling.
Facility Fails to Provide Palatable Food to Residents
Penalty
Summary
The facility failed to ensure that food prepared was palatable for seven residents reviewed for palatability, out of a total sample of 48. Observations and interviews revealed that residents consistently found the food unappetizing, with complaints about taste, temperature, and lack of variety. For instance, one resident stated that the food did not taste good and obtaining alternatives was difficult, while another mentioned that the food was bland and lacked flavor. Additionally, a test tray revealed that the food was served at an inadequate temperature, with beef dip meat and tater tots both measuring 110 degrees Fahrenheit. The residents involved in the deficiency were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores, except for one resident who was moderately cognitively impaired. Some residents had diagnoses of moderate protein-calorie malnutrition or chronic obstructive pulmonary disease, which could be exacerbated by poor nutrition. The Dietary Manager acknowledged hearing complaints about the food and noted that some residents requested more seasoning, which the facility did not offer. The Director of Nursing expressed an expectation that residents would be served food they enjoyed, highlighting a disconnect between expectations and the current state of food service.
Infection Control Deficiencies in Meal Delivery and Medication Administration
Penalty
Summary
The facility failed to deliver meal trays in a manner that prevents cross-contamination for several residents. During the noon meal tray delivery, two CNAs were observed delivering meal trays and drinks to residents without performing hand hygiene between each resident interaction. The CNAs touched overbed tables and personal belongings of residents without sanitizing their hands, which is against the facility's hand hygiene policy. Despite the facility's policy and regular in-service training on hand hygiene, the CNAs did not adhere to the required procedures, potentially promoting the spread of infections. In addition to the meal delivery issues, the facility also failed to administer medications in a manner that prevents cross-contamination. During medication administration observations, a CMT and an LPN were noted to have not performed hand hygiene between resident interactions and after glove changes. The CMT administered medications and handled items without sanitizing her hands, while the LPN failed to perform hand hygiene after administering an insulin injection and before handling other items. These actions were contrary to the facility's infection control policies and could contribute to the spread of infections. Interviews with the staff, including the CNAs, CMT, LPN, and the facility's ADON and DON, revealed a lack of adherence to the hand hygiene protocols despite ongoing education and reminders. The staff acknowledged their failure to perform hand hygiene as required, and the facility's leadership reiterated the importance of hand hygiene in preventing the transmission of infections. However, the observed deficiencies indicate a gap between the facility's policies and the actual practices of the staff.
Failure to Maintain Cleanliness in Shower Room
Penalty
Summary
The facility failed to maintain a clean and safe environment in the fifth-floor shower room, as required by their policy. This deficiency was identified during an observation and interview process involving a resident, a Certified Nurse Aide (CNA), the Maintenance Director, a Housekeeper, and the Housekeeping Manager. The resident, who was cognitively intact and had a history of chronic health conditions, expressed dissatisfaction with the cleanliness of the shower area. Observations revealed orange-colored stains on the shower tiles and grout, which were identified as soap scum by the Maintenance Director. The Housekeeping Manager confirmed that the shower was supposed to be cleaned daily, but there was no documentation to support that this was being done. The Housekeeper, who was not regularly assigned to the fifth floor, observed the stains and noted that the shower rooms were normally cleaned. The Housekeeping Manager demonstrated that the stains could be removed with cleaning chemicals, indicating that the area had not been deep cleaned for some time. This lack of regular cleaning and documentation led to the deficiency, potentially affecting the resident's ability to safely use the shower area.
Failure to Complete Significant Change MDS for Resident
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) within 14 days of a significant change in condition for one resident. This resident experienced a severe weight loss of 11.28% over six months and a decline in mobility status, which impacted multiple areas of their health. Despite these changes, the facility only completed a quarterly MDS rather than a significant change assessment, as required by the facility's policy and CMS guidelines. The resident, who had diagnoses including Alzheimer's disease, anxiety disorder, insomnia, mood disorders, dysphagia, dementia, and depression, showed a notable decline in health status. The MDS Coordinator acknowledged the need for a significant change assessment but was unsure if changes in two care areas were necessary to qualify for such an assessment. The coordinator also incorrectly interpreted CMS guidelines regarding the timing of weight measurements, leading to the oversight in completing the required assessment.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents, leading to potential unmet care needs. For one resident, who was admitted with conditions including Alzheimer's disease and depression, there was a significant weight loss over a six-month period. However, the quarterly MDS inaccurately recorded no significant weight loss, as the weight data used was not within the required 180-day timeframe according to CMS guidelines. The MDS Coordinator acknowledged the error, noting that the August weight was outdated and should not have been used for assessing significant weight loss. For another resident, who had diagnoses of congestive heart failure and chronic kidney disease, there was a discrepancy in the discharge documentation. The resident was discharged home, but the discharge MDS inaccurately indicated a discharge to a short-term general hospital. The MDS Coordinator could not explain the discrepancy, which was attributed to information taken from the electronic medical record (EMR). This inaccuracy in the discharge status was later acknowledged and the discharge MDS was modified.
Failure to Update PASARR with New Diagnosis
Penalty
Summary
The facility failed to update the Pre-Admission Screening and Resident Review (PASARR) Level One for a resident after a new diagnosis of mood disorder was added post-admission. The facility's policy requires that a Level One screen be conducted for current residents who experience a significant change in their condition. However, there was no documented evidence that the PASARR was updated to include the new diagnosis, which was added to the resident's electronic medical record (EMR) on December 6, 2023. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for updating the PASARR. The Social Services Director stated she did not handle PASARRs, and the Business Office Manager indicated that the Regional Business Office Manager (RBOM) usually received updates. The MDS Coordinator admitted to updating the diagnosis in the EMR but not informing the BOM or RBOM. The Interim Director of Nursing was unsure who was responsible for sending updates, and the Administrator believed it was between Social Services or the BOM. This lack of coordination and communication led to the failure to update the PASARR with the new diagnosis.
Failure to Implement Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a care plan for hospice services for a resident, identified as R57, who was admitted to the facility and had an order for hospice services dated 02/07/25. Upon review of R57's care plan, it was found that there was no evidence of a care plan developed for hospice services. During interviews, the MDS Coordinator acknowledged that the care plan update was missed due to the payor type not being updated. The Director of Nursing confirmed that a care plan should have been implemented for hospice services. This oversight had the potential to cause unmet care needs for the resident.
Failure to Follow Physician Orders for Helmet Use
Penalty
Summary
The facility failed to ensure staff followed physician orders for a resident's helmet use, which was intended for fall safety. The resident, who had severe cognitive impairment and multiple diagnoses including Parkinson's with dyskinesia and vascular dementia, was supposed to wear a helmet to prevent major injuries from continuous falls. The care plan noted that the resident often refused to wear the helmet, and physician orders required documentation of any refusals. However, there was no documentation in the progress notes indicating that the helmet was offered or refused by the resident. Observations over two days showed the resident was not wearing a helmet, and staff interviews revealed a lack of awareness and adherence to the helmet order. An LPN admitted to not documenting refusals and was unaware of the helmet's whereabouts, while a CNA was unsure of the helmet requirement and speculated that the family might have taken it home. The Director of Nursing stated that staff should have followed physician orders and contacted the physician if there were issues, and they should have attempted to locate the helmet.
Failure to Reschedule Cataract Surgery for Resident
Penalty
Summary
The facility failed to ensure that a resident received necessary vision services related to cataract surgery. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had a scheduled cataract surgery appointment that was not completed due to the absence of a Hoyer lift, which was required for the procedure. The surgery center did not have the equipment to assist the resident into the chair for surgery, leading to the cancellation of the procedure. Despite this, the facility did not reschedule the surgery, leaving the resident without the necessary treatment for over a year. Interviews with the resident and staff revealed that the issue of rescheduling the surgery was not revisited after the initial cancellation. The Director of Nursing and the unit staff were unaware of why the surgery was not rescheduled, indicating a lapse in follow-up care. The facility's policy emphasizes providing necessary care and services to maintain residents' well-being, but in this case, the failure to reschedule the surgery potentially compromised the resident's physical well-being.
Resident Smokes Unsupervised Inside Facility
Penalty
Summary
The facility failed to ensure that a resident, who was assessed to need supervision while smoking, did not smoke inside the facility. The resident, who had severe cognitive impairment and multiple diagnoses including Parkinson's, functional quadriplegia, and schizoaffective disorder, locked himself in his bathroom and smoked. The facility's policy prohibited smoking inside and required residents to smoke only in designated areas under supervision. Despite this, the resident was able to obtain cigarettes from other residents and smoke unsupervised in his room. Staff interviews revealed that the resident's bathroom door was locked, and smoke was detected, but the staff was unable to immediately access the bathroom due to the locked door. The maintenance staff was not aware of the issue with the bathroom door lock until after the incident, and the Director of Nursing was not aware of any changes made to the resident's care plan following the incident. The facility's failure to ensure the resident's compliance with the smoking policy and to address the locking bathroom door contributed to the deficiency.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to ensure that a resident, identified as R51, received oxygen therapy according to the physician's order. R51 was readmitted to the facility with a diagnosis of chronic respiratory failure with hypoxia and was prescribed oxygen at two Liters per Minute (LPM) via nasal cannula as needed for shortness of breath. However, observations on multiple occasions revealed that R51 was receiving oxygen at three LPM continuously, contrary to the physician's order. Additionally, there was no documentation of oxygen use on the Medication Administration Record (MAR) for specific dates, indicating a lack of proper record-keeping. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed the oversight. The LPN admitted to assuming the resident was on continuous oxygen and did not verify the correct LPM, nor did she document the oxygen use on the MAR. The DON acknowledged that there should have been documentation on the MAR when a resident was placed on oxygen and that staff should check the oxygen flow rate every shift. This lack of adherence to the physician's order and documentation protocol had the potential to expose the resident to increased oxygen levels, risking hyperoxia.
Failure to Administer Pneumococcal Vaccines to Consenting Residents
Penalty
Summary
The facility failed to offer pneumococcal vaccines to two residents, R92 and R95, despite both having signed consents to receive the vaccination upon admission. R92, who was admitted with diagnoses including hypertension, chronic kidney disease, and diabetes, was cognitively intact with a BIMS score of 14 out of 15. Despite consenting to the pneumococcal vaccine on 11/21/23, R92's immunization record showed no indication of receiving the vaccine. Similarly, R95, who was admitted with orthostatic hypotension, alcohol dependence, and mild cognitive impairment, also consented to the pneumococcal vaccine on 08/11/23. R95's immunization record indicated that the vaccine was not administered, although the Assistant Director of Nursing initially stated that R95 had declined it. Upon being informed of the consent, the ADON acknowledged the oversight. The Director of Nursing confirmed that it was expected for both residents to have received the vaccines they consented to upon admission.
Failure to Provide Adequate Care and Pain Management
Penalty
Summary
The facility failed to provide services to promote the highest practicable physical well-being for two residents. One resident with severe cognitive impairment and osteoarthritis experienced recurring issues with moisture-associated skin damage (MASD) due to resistance to repositioning and transfers. Nursing staff also failed to consistently carry out physician's orders to get the resident out of bed for meals, which was necessary for improving intake and providing pressure relief. The resident's care plan indicated a need for extensive assistance with daily activities, but staff did not consistently follow through with these requirements, leading to skin breakdown and weight fluctuations. Interviews with staff revealed challenges such as staffing issues, lack of supplies, and the resident's resistance to care, which contributed to the deficiency in care provided to the resident. Another resident with moderate cognitive impairment and a contracted hand due to a stroke experienced deficits in hand hygiene. The resident resisted staff attempts to open and clean the contracted hand, leading to concerns about moisture buildup and potential infection. The resident's care plan included extensive assistance with daily activities and monitoring for pain, but staff did not consistently address the resident's pain or ensure proper hand hygiene. Interviews with staff and the physician indicated that the resident's pain and resistance to care were not adequately managed, resulting in the deficiency. The facility's policies on pain management and physician orders were not consistently followed, leading to inadequate care for the residents. Staff interviews highlighted issues such as insufficient staffing, lack of supplies, and residents' resistance to care, which contributed to the deficiencies. The facility's failure to adhere to its policies and provide necessary care and interventions resulted in the residents not achieving their highest practicable physical well-being.
Inadequate Pain Management and Failure to Execute Physician's Orders
Penalty
Summary
The facility failed to adequately address the pain management needs of a resident with chronic pain and multiple medical conditions. The resident, who was cognitively intact, had diagnoses including chronic pain, low back pain, osteoarthritis, spinal stenosis, sciatica, hemiplegia, and hemiparesis. Despite having a scheduled pain medication regimen, the resident experienced significant breakthrough pain that was not effectively managed. The facility's nursing staff did not consistently assess, monitor, or implement interventions to address the resident's pain, which impacted the provision of rehabilitation services and assistance with activities of daily living (ADLs). Additionally, the facility failed to carry out physician's orders for a neurological assessment to secure Botox treatments to relax the resident's tightly contracted joints. The resident's pain management was not adequately documented or addressed according to the facility's pain management policy. The resident's pain levels were frequently recorded as high, and the resident reported that the pain medications provided were not potent enough to manage severe spasms. The resident's care plan included interventions for pain management, but these were not effectively implemented. Observations showed the resident lying in a contorted position in bed due to pain, and interviews with staff indicated that the resident was often in pain and that the medications only provided minimal relief. The facility also failed to use non-pharmacological interventions, such as wedges and positioning aids, to help manage the resident's pain. The facility's failure to carry out physician's orders for a neurological consult for Botox injections further exacerbated the resident's pain and discomfort. The resident's physician had ordered the consult to address severe joint contractures and muscle spasms, but the order was not executed due to transportation issues. The facility's Director of Nursing (DON) and Administrator acknowledged the transportation problems but did not ensure that alternative arrangements were made or that the physician was informed of the delays. This lack of follow-through resulted in the resident not receiving the necessary medical intervention to alleviate pain and improve quality of life.
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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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