Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 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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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.
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Nursing homes near Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of St Louis | 1.3 mi | ★★★★★ | 14 | 0 |
| Magnolia Wellness Center | 1.7 mi | ★★★★★ | 10 | 1 |
| Pine Grove Manor | 2 mi | ★★★★★ | 20 | 1 |
| Lansdowne Village | 2.1 mi | ★★★★★ | 18 | 0 |
| Bernard Care Center | 2.3 mi | ★★★★★ | 31 | 0 |
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