Bentwood Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Florissant, Missouri.
- Location
- 1501 Charbonier Road, Florissant, Missouri 63031
- CMS Provider Number
- 265757
- Inspections on file
- 23
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Bentwood Nursing & Rehab during CMS and state inspections, most recent first.
A deceased resident’s trust fund balance of over $4,700 was not handled in accordance with TPL requirements and the facility’s admission agreement. After the resident’s death, the BOM issued a check for nearly the full balance directly to a family member based on receipts for a repast, clothing, a watch, a slip, and obituary costs, without consulting corporate finance. The Administrator later stated he would have expected any unused funds not legitimately applied to funeral expenses to be sent to TPL or the state, but the funds were instead disbursed at the facility level and the account closed, without proper final accounting and disposition within the required timeframe.
A resident with complex arterial and post-surgical wounds of the left hand and fingers had multiple detailed wound care orders over several months, including cleansing with wound cleanser or normal saline, application of betadine, Xeroform, collagen powder, alginate calcium, gauze, kerlix, and ace wraps. Facility policies required clear transcription and implementation of physician orders and evidence-based wound care per those orders. Review of the MAR/TAR showed numerous days where ordered daily wound treatments were not documented as completed, including entire stretches with no recorded wound care after hospital returns. During observation, the existing hand dressing lacked date, time, and initials, and the resident’s fingernails were long and curled into the palm. Interviews with the wound nurse, wound specialist, and ADON confirmed that treatments were expected to be completed and documented each shift, and that missed post-surgical treatments could harm the wound, but the record showed repeated failures to follow and document the prescribed wound care regimen.
A resident with severe cognitive impairment, paraplegia, diabetes, and multiple stage 3 and stage 4 pressure ulcers did not receive wound care and pressure-relief interventions as ordered. MAR review showed numerous missed BID and Q2D dressing changes to the sacrum, buttocks, ankle, and foot, and frequent failures to apply ordered barrier cream and bilateral Prevalon boots "at all times." Surveyors repeatedly observed the resident in bed without protective boots, with heavily drained or soiled dressings that had not been changed as scheduled, and with a low air loss mattress set far above the resident’s documented weight, alarming for failure, turned off, or completely deflated. During wound care, the peri-wound area around the coccyx/sacrum was not fully cleansed of barrier cream residue, and the resident was observed wearing a brief despite having a suprapubic catheter and buttock wounds. The DON and wound physician confirmed expectations that mattress settings match the resident’s weight, that briefs not be used in this situation, and that offloading and protective boots are essential, but staff interviews revealed lack of awareness of some orders and the rationale for proper mattress settings.
Two residents receiving enteral nutrition experienced significant weight loss when staff failed to ensure proper tube feeding delivery and bolus administration. One resident with multiple comorbidities and severe cognitive impairment had orders for continuous Jevity via G-tube, but observations over several days showed that, despite the pump being set at the ordered rate, only small amounts of formula actually infused while large volumes remained in the bottles, and the resident’s weight declined. Another resident with chronic kidney disease, diabetes, and severe cognitive impairment had orders for Jevity bolus feedings after meals and at bedtime, yet surveyors repeatedly observed full or unopened formula bottles at the bedside, with no corresponding documentation on the MAR, and a CNA reported that an LPN did not administer a bolus during breakfast despite the LPN’s claim that it had been given.
Surveyors observed multiple medication administration errors resulting in an 18.52% error rate. One resident with orders for dorzolamide-timolol eye drops, a Symbicort inhaler, and a Yupelri inhalation treatment received eye drops without the required inner canthus pressure and did not receive the ordered inhaler or breathing treatment during the observed pass. Another resident with orders for magnesium oxide 400 mg and polyethylene glycol 34 g received an incorrect 500 mg dose of magnesium oxide, and the polyethylene glycol mixture was discarded after the resident complained it was too cold, without being re-administered as ordered. Staff interviews showed that CMTs and an LPN understood the five rights and that CMTs can administer inhalers and breathing treatments, but they were unsure which eye drops required inner canthus pressure and the correct duration, despite the DON’s stated expectations.
A resident with severe cognitive impairment and a history of falls was left unsupervised in a locked wheelchair, resulting in a fall and wrist fracture. Two other high-risk residents also did not have consistent fall prevention interventions documented or implemented, with missing or inaccessible neurological evaluations, out-of-reach call lights, and absent safety equipment. Staff interviews revealed lapses in following fall prevention protocols and inconsistent documentation across care plans, physician orders, and progress notes.
Staff did not follow facility policy or physician orders for two residents with feeding tubes, including failures to document meal and fluid intake, improper labeling of tube feeding formula, and not maintaining the required head-of-bed elevation during tube feeding. There was confusion among staff about responsibilities for feeding assistance and documentation, and one resident had access to fluids inconsistent with their prescribed diet.
The facility failed to follow physician orders for wound care for two residents, leading to inconsistencies in treatment documentation and performance. A resident with multiple diagnoses did not receive daily wound care as ordered, with gaps in the treatment record and incorrect dressing dates. Another resident with a severe pressure ulcer had a dressing that was not changed as required, with a dressing dated several days prior found in the trash. Staff interviews confirmed lapses in care and documentation.
A resident with peripheral vascular disease (PVD) did not receive proper foot care, resulting in severe dryness and thickening of the skin. Despite being dependent on staff for bathing, there were no specific physician orders for foot care or podiatry consultation. The resident's condition worsened, leading to embedded socks and severe dryness, as confirmed by hospital staff. Facility staff acknowledged the expectation for better care but failed to document or implement necessary actions.
The facility failed to protect a resident from physical abuse by another resident with a known alcohol problem. Despite being aware of the aggressor's behavior and implementing 15-minute checks, staff did not consistently enforce these measures or provide adequate supervision, leading to multiple incidents of physical abuse.
The facility failed to utilize Enhanced Barrier Precautions (EBP) for three residents with medical devices, as observed during an initial tour. Staff interviews revealed a lack of knowledge and training regarding EBP, and the Director of Nursing confirmed the residents were not in EBP. The Regional Nurse Consultant acknowledged that the policy for EBP was still being developed.
The facility failed to maintain an IPCP that included a functional Antibiotic Stewardship Program following the McGeer Criteria. A resident was prescribed Cipro without documentation showing the sensitivity of the organism to the antibiotic, and the Antibiotic Stewardship Monthly Tracking logs did not indicate whether the criteria for antibiotic use were met. Staff interviews revealed inconsistent documentation and policy enforcement regarding antibiotic use.
The facility failed to offer and/or provide pneumococcal vaccines to two residents, increasing their risk of infection. Both residents' electronic medical records showed no evidence of the vaccine being offered or administered. The Director of Nursing confirmed the absence of documentation, and the Administrator stated that the Infection Preventionist nurse was responsible for this task.
A resident with moderate cognitive impairment was left with medications at the bedside without proper assessment or a physician's order for self-administration. The CMT admitted to leaving the medications unsupervised and giving incorrect doses, and the DON confirmed that facility policies were not followed.
The facility failed to maintain complete accounting records for the reconciliation of petty cash kept on hand for the resident trust account. The residents' petty cash box contained $289.49 but lacked a reconciliation sheet, and the Business Office Manager admitted that the petty cash should be reconciled daily but was not.
The facility failed to complete third party liability (TPL) forms within 30 days for the final accounting of three deceased residents who had money in their accounts. The Business Office Manager acknowledged the oversight, and the Administrator was unaware of the delay.
The facility failed to screen newly hired employees for Federal Indicators with the CNA Registry, as required by their Abuse Prevention Policy. Five out of ten sampled employees hired since the last survey did not have the necessary checks performed. Both the Human Resource Manager and the Administrator were unaware of the requirement.
The facility failed to send written notices of transfer or discharge to residents or their representatives for two residents who were hospitalized. Interviews with staff and the Administrator confirmed the absence of such notices and the lack of a specific policy regarding written notifications.
The facility failed to provide a bed hold notice to a resident with cognitive impairments during two hospital transfers. Despite the facility's policy requiring written information on bed hold to be given prior to transfers, no such notice was found in the resident's records, and staff interviews confirmed the oversight.
The facility failed to ensure an accurate Level 1 pre-screening for a mental disorder or intellectual disability was completed for a resident prior to admission. The resident, admitted with multiple diagnoses including major depression disorder and bipolar disorder, did not have the required PASARR documentation in their medical record. Interviews revealed the facility lacked a PASARR policy and necessary documentation could not be retrieved.
The facility failed to develop and implement activities care plans for two residents at risk for psychosocial decline and did not implement care plans for a resident receiving antidepressant medication and another with a catheter. Observations and interviews confirmed the absence of individualized care plans, with the responsible staff members unavailable due to attending a funeral.
The facility failed to provide one-to-one activities for two residents, leading to potential psycho-social decline. The activities calendar lacked variety, and care plans did not include activity planning. Observations and interviews revealed residents' boredom and desire for more engaging activities.
The facility failed to address a resident's aggressive behaviors and substance abuse issues, leading to multiple physical altercations and property damage. Despite having a care plan, interventions were not updated or effectively implemented, and staff communication was inadequate. The resident continued to consume alcohol and refused psychiatric evaluation, with no documented follow-up actions to provide necessary mental health support.
The facility failed to monitor the side effects and efficacy of Risperdal, an antipsychotic medication prescribed for anxiety, for a significantly cognitively impaired resident. Despite the resident's care plan and facility guidelines requiring such monitoring, no evidence of monitoring was found in the Medication Administration Record for April and May 2024.
A resident who was a full code was found unresponsive, but staff delayed CPR due to confusion about the resident's code status. The facility's policy did not clearly address the location of code status documentation, leading to further delays and confusion among staff.
The facility failed to verify and implement hospital discharge orders for a resident requiring BiPAP and oxygen therapy. The resident's care plan did not address the need for respiratory therapy, and the facility lacked a policy for BiPAP use. Medical records showed no orders for BiPAP or oxygen therapy, and staff were unaware of the resident's needs.
Failure to Properly Account for and Disburse Deceased Resident’s Trust Funds
Penalty
Summary
The facility failed to ensure that third party liability (TPL) requirements and its own admission agreement regarding resident funds were followed for a deceased resident with a trust fund balance. The admission agreement stated that residents have the right to manage their personal financial affairs or designate someone to do so, and that the facility would provide an accounting of funds upon request and at least quarterly. Record review showed that the resident had a trust fund balance of $4,708.23 at the time of death. Subsequent account activity included a large debit of $4,698.95 for personal needs, closing interest of $1.36, and a final debit of $10.64 to close the account. The Business Office Manager (BOM) reported that, upon the resident’s death, the family requested funds for funeral expenses and that a check in the amount of $4,698.95 was issued to a family member after receipts were provided. Review of the resident’s trust records and receipts showed that the expenditures submitted by the family included a repast at a banquet center, a Fossil watch from a department store, clothing items (jacket, blouse, pants) from a high-end retailer, a full slip and another unidentified item from another store, and obituary costs from a funeral home. The BOM stated that the regional manager had indicated it was acceptable to give the resident’s money to the family as long as receipts were provided, and that anything left over should be sent to TPL. The BOM acknowledged not consulting with the corporate BOM before issuing the check and confirmed that the check was printed and given at the facility level without corporate involvement. The Administrator stated that he would have expected the BOM to send any remaining resident funds to TPL or back to the state if not used for funeral expenses, indicating that the facility did not follow required procedures for final accounting and disposition of the resident’s funds within 30 days of death.
Failure to Follow Physician Wound Care Orders for Post-Surgical Hand Wound
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and its own policies for wound management and treatment administration for a resident with complex arterial and post-surgical wounds of the left hand. The facility’s Physician Order Policy required that physician orders be clearly documented, transcribed to the MAR/TAR, and implemented in accordance with professional standards and regulations. The Wound Management Policy required that wound treatment be provided per physician orders, including cleaning method, dressing type, and frequency of dressing changes. Despite these policies, multiple wound care orders for the resident’s left hand and fingers were not documented as completed on numerous ordered days. The resident had significant medical conditions including absence of a left finger, stroke, cognitive communication deficit, atrial fibrillation, kidney disease, muscle weakness, and an arterial wound on the left hand fingers 2–5. Hospital discharge paperwork documented left ring finger dry gangrene related to chronic digital ischemia and emphasized the importance of hand hygiene before and after bandage changes. The care plan identified an arterial wound on the left hand fingers 2–5, with goals to prevent infection or complications and interventions including monitoring for infection and weekly wound documentation. Wound physician evaluations and management summaries documented a post-surgical wound of the left fourth finger amputation with varying measurements and drainage characteristics over time, and detailed treatment plans specifying cleansing agents, primary and secondary dressings, and frequencies. Review of the TAR and MAR showed repeated failures to document completion of ordered wound care. An order for Xeroform Petrolate to the left hand between fingers once daily had no documented completion for all 11 opportunities in October. In November, an order for Xeroform Petrolate patch once daily showed 13 of 13 missed documentation opportunities; a subsequent detailed wound care order for the left fourth finger amputation showed 3 of 3 missed opportunities; and another Xeroform order for the left ring finger showed 4 of 11 missed opportunities. In January, an order for wound care to the left 2nd through 5th fingers was not documented as completed on two ordered days, and a later order including betadine and collagen powder was not documented as completed on 4 of 10 opportunities. In February, there were no wound care orders or documentation for several days after the resident returned from hospital leave, and a new order for daily wound care to the left index, middle, and ring fingers was not documented as completed on 8 of 10 opportunities. During observation, the wound dressing on the resident’s left hand lacked date, time, and initials from the prior change, and the resident’s fingernails were long and curled into the palm. Interviews with the wound nurse, wound specialist, and ADON confirmed that treatments not being done as ordered post-surgically could cause harm to the wound, that the wound specialist had been removed from the case while the surgeon directed care, and that facility expectations were for wound treatments to be completed every shift with appropriate documentation and progress notes, which did not occur in this case. Additional wound physician management summaries documented changes in the wound’s size and condition over time, including improvement at one point and later deterioration with necrotic tissue and an exacerbation attributed to arterial issues. The wound size increased significantly across assessments, and the resident was scheduled for additional left hand surgery. The wound specialist stated that she was not involved in the case during a period when the surgeon was directing care and that she was only re-consulted shortly before the resident experienced a complication and returned to the hospital. Throughout this period, the facility’s documentation showed multiple missed or undocumented wound care treatments despite detailed physician orders and care plan interventions, and the dressing observed during survey lacked required labeling to indicate when it had last been changed. Interviews with nursing leadership clarified the facility’s expectations that wound treatments be completed every shift, refusals be reported to the medical director and oncoming nurse, and progress notes be entered into the electronic medical record regarding wound dressings. However, the record review for this resident showed repeated gaps in documentation of ordered wound care across several months, including periods immediately following hospitalizations and surgical interventions. The combination of detailed wound care orders, the resident’s complex arterial and post-surgical wound status, and the absence of documented completion of those orders formed the basis of the deficiency for failure to provide treatment and care according to physician orders, resident preferences, and goals.
Failure to Follow Wound Care Orders and Pressure-Relief Protocols for a Resident With Multiple Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and its own wound management policy for a resident with multiple pressure injuries. The resident had severe cognitive impairment, paraplegia, diabetes, dependence in ADLs, and multiple pressure ulcers, including three stage 3 and one stage 4 ulcers that were not present on admission. The care plan and physician orders required specific wound treatments, use of a low air loss (LAL) mattress with settings checked every shift, regular skin assessments, and continuous use of bilateral protective boots for offloading. The facility’s wound management policy required that wound treatments be provided per physician orders, that dressings be changed when soiled or saturated, and that wound characteristics and care be documented. Record review of the MAR showed numerous missed wound care treatments and failure to implement ordered offloading devices. For the left lateral ankle, ordered dressing changes every two days were missed two of three times; for the left lateral foot, daily dressing changes were missed five of 11 times. For the left medial buttock, barrier care ordered every shift was missed 18 of 45 opportunities. For the left buttock, BID dressing changes were missed 14 of 30 opportunities, and for the sacrum, BID dressing changes were missed 43 of 44 opportunities. The order for Prevalon protective boots to be on both feet at all times was missed 17 of 46 opportunities. A CNA reported being unaware of the order for protective boots, and observations on multiple days showed the resident in bed without the ordered boots in place. Surveyor observations further documented failures in pressure-relief equipment management and wound care technique. The resident’s LAL mattress was repeatedly found set far above the resident’s documented weight, including settings at 350 lbs and later 490 lbs, despite the resident weighing 167 lbs and a wound physician’s prior recommendation to keep mattress settings at the patient’s weight. The mattress alarmed with “failure” messages on several occasions, and at one point was completely deflated while the resident remained in bed. The DON confirmed that the mattress settings were out of range and stated she would expect the mattress to be within the resident’s weight range. During wound care, the wound nurse did not clean the peri-wound area where barrier cream residue remained around the coccyx/sacrum wounds, and dressings were observed with heavy serosanguinous drainage and dates indicating they had not been changed over the weekend. The resident was also observed wearing a brief despite having a suprapubic catheter and buttock wounds, which the DON identified as contraindicated. The wound physician emphasized the importance of offloading, proper mattress settings, and protective boots, and noted that some CNAs did not understand the need to maintain mattress settings at the recommended weight levels. Across multiple days and shifts, the resident was repeatedly observed lying on the left side without protective boots, with soiled or heavily drained dressings, and with the LAL mattress either malfunctioning, turned off, or set above the resident’s weight. Staff interviews confirmed gaps in awareness of orders and expectations for wound care and offloading. These actions and inactions collectively demonstrate the facility’s failure to provide ordered wound treatments, maintain appropriate pressure-relieving equipment settings, and consistently implement offloading interventions as required by physician orders and facility policy for this resident with advanced pressure injuries.
Failure to Ensure Adequate Tube Feeding Delivery and Bolus Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents receiving enteral nutrition via feeding tubes had their nutritional needs met, as required by facility policy. For one resident with a history of stroke, COPD, dysphagia, altered mental status, cognitive communication deficit, and diabetes, the physician ordered Jevity 1.5 at 55 mL/hr via G-tube with 300 mL water flushes every four hours and monthly weights. The resident’s care plan called for monitoring for tube dysfunction or malfunction and for the registered dietitian to evaluate and make recommendations as needed. Weight records showed a decline from 191 lbs on a quarterly MDS to 186 lbs in early February, with a medical director note citing a -7.5% weight loss warning. Despite this, observations over multiple days showed that the tube feeding pump, although programmed at 55 mL/hr, was infusing far less formula than ordered. On several observation periods, large volumes of Jevity remained in the 1,000 mL bottles despite hours of supposed infusion. On one day, only about 100 mL infused over more than seven hours; on another, about 150 mL infused over more than five hours; and on a third day, about 250 mL infused over more than eight hours. During this time, the pump remained programmed at the ordered rate, but staff did not ensure that the pump was functioning properly or that the ordered volume was actually delivered. A weight obtained with a mechanical lift scale showed the resident at 179.4 lbs with clothing, which was adjusted to 176 lbs after subtracting the clothing weight, indicating further weight loss. The care plan intervention to monitor for tube dysfunction or malfunction was not effectively implemented, as the resident’s tube feeding was leaking and a small hole in the tube was later identified, but only after prolonged periods of inadequate infusion had been observed. For a second resident with chronic kidney disease, type 2 diabetes, muscle weakness, and severe cognitive impairment, the care plan identified that the resident received alternative nutritional intake via tube feeding with a goal to prevent aspiration. The physician’s order specified enteral feedings of Jevity 1.2, 300 mL per G-tube after meals and at bedtime. Weight records showed a decline from 101.9 lbs to 95.2 lbs, a -6.58% weight loss. Observations over multiple days showed unopened or full 1,000 mL bottles of Jevity 1.2 on the resident’s nightstand, with seals intact or full volumes remaining, indicating that ordered bolus feedings were not being administered as prescribed. An LPN stated that the resident received bolus feedings and claimed to have given a morning bolus using a different bottle, but there was no documentation of the bolus on the MAR, and a CNA who assisted the resident at breakfast reported that the LPN did not administer a bolus while the resident was in the dining room. This demonstrates a failure to provide the ordered bolus feedings and to accurately document their administration for a resident already experiencing weight loss.
Medication Administration Errors Resulting in Elevated Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 5 errors out of 27 observed opportunities, resulting in an 18.52% error rate. Facility policies required medications to be administered as prescribed, using the five rights of medication administration and employing the MAR during administration, as well as following specific procedures for eye drop administration. The manufacturer’s instructions for dorzolamide-timolol ophthalmic solution also required pressing on the inner canthus for about two minutes after instillation to limit systemic absorption. For one resident, the MAR showed orders for dorzolamide-timolol eye drops three times daily, Symbicort inhaler twice daily, and Yupelri inhalation solution once daily. During observation, a CMT who was new to the facility and being oriented by another CMT administered the resident’s oral medications and eye drops. The resident tilted their head back and the CMT applied the drops, after which the resident immediately began blinking and was given a tissue to wipe their eyes. The CMT did not press on or hold the inner canthus after instilling the eye drops, and neither CMT administered the ordered Symbicort inhaler or the Yupelri breathing treatment at that time. For another resident, the MAR showed an order for magnesium oxide 400 mg once daily and polyethylene glycol 34 g once daily. During observation, a CMT removed a 500 mg magnesium oxide tablet from a bottle on the cart, crushed all of the resident’s medications, and mixed them with pudding, and mixed the polyethylene glycol with water. A second CMT administered the crushed medications and the polyethylene glycol mixture; after one sip, the resident stated the water was too cold. The CMT then took the polyethylene glycol mixture to the bathroom, returned with warm water in the resident’s bedside cup, and later discarded the original polyethylene glycol mixture in the trash on the medication cart. Staff interviews confirmed expectations to follow the five rights, administer medications in their entirety, and that CMTs may give inhalers and breathing treatments, but also revealed uncertainty among staff, including an LPN and CMT, about which eye drops require inner canthus pressure and for how long, despite the DON’s expectation that staff know this information.
Failure to Provide Adequate Supervision and Consistent Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to ensure that areas were free from accident hazards and did not provide adequate supervision to prevent accidents for residents identified as high risk for falls. One resident with severe cognitive impairment, hemiplegia, and a history of falls was placed near the nurses' station in a locked wheelchair for observation. Staff left the area unattended, during which time the resident attempted to get up and fell, resulting in a fractured wrist. The resident had experienced multiple falls since admission, and the care plan interventions, such as use of a low bed and activity apron, were inconsistently implemented and not always present during observations. Additionally, the facility did not consistently and accurately document fall prevention interventions for three high-risk residents across care plans, physician orders, and progress notes, as required by facility policy. For example, one resident's care plan included fall mats and frequent rounding, but the physician order sheet did not reflect these interventions, and an incident was not documented in the progress notes. Another resident's care plan did not reflect a recent fall or any new interventions, and observations showed the resident's call light was out of reach and fall risk identification (bracelet) was not in place. Wheelchair safety features, such as roll bars, were also missing despite being listed as interventions. The facility's neurological evaluations post-fall were not maintained in the electronic medical record as required, but instead were kept in a filing cabinet, making them less accessible. Staff interviews revealed inconsistent understanding and implementation of fall prevention measures, with some staff forgetting to provide required interventions like activity aprons or failing to ensure call lights were within reach. The Director of Nursing and other staff acknowledged expectations for consistent documentation and implementation of fall prevention interventions, but these were not met, leading to deficiencies in resident safety and supervision.
Failure to Follow Feeding Tube Policies and Physician Orders
Penalty
Summary
Staff failed to follow facility policy and physician orders regarding the care and management of feeding tubes for two residents. For one resident with a history of hemiplegia, malnutrition, diabetes, and dysphagia, staff did not consistently document the percentage of meals and fluid intake after a certain date, despite orders to monitor and document intake and output. Observations showed the resident's head of bed was not elevated to the required degree during tube feeding, and the feeding pump and formula bag were not always labeled with necessary information such as the formula name, date, and time hung. Interviews revealed confusion among staff regarding who was responsible for feeding assistance and documentation, with both LPNs and CNAs unsure of the resident's dietary needs and intake. Another resident with dysphagia, diabetes, and a PEG tube also experienced lapses in care. Staff did not document meal and fluid intake as required, and the feeding pump and formula bag lacked proper labeling. Observations showed the resident had access to thin liquids despite a diet order for nectar thick fluids, and there was no documentation of food or fluid intake in the progress notes. The resident reported not receiving breakfast and demonstrated access to inappropriate fluids, indicating a lack of adherence to dietary orders. Interviews with staff, including the DON and Administrator, confirmed expectations that staff should follow facility policies, physician orders, and care plan interventions, including proper positioning during tube feeding and accurate documentation. However, the observed and documented actions showed that these expectations were not met, leading to deficiencies in the care provided to residents with feeding tubes.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that residents received care consistent with professional standards, as evidenced by the failure to follow physician orders and perform wound treatments for two residents. Resident #9, who had diagnoses including cancer, diabetes, and end-stage renal disease, had a physician order for daily wound care on the right first toe. However, the treatment was not consistently documented as completed, with gaps in the treatment administration record (eTAR) and discrepancies in the dressing dates. Interviews with nursing staff revealed that treatments were sometimes missed or completed late, and documentation was not always accurate. Resident #11, who had severe cognitive impairment and a stage four pressure ulcer, also experienced lapses in wound care. The resident's treatment orders required daily dressing changes for a sacral wound, but observations indicated that the dressing was not changed as frequently as required. A dressing dated several days prior was found in the trash, suggesting it had not been changed according to the schedule. Staff interviews confirmed that there were inconsistencies in documenting and performing the wound care treatments. The facility's policies on wound management and physician orders were not adhered to, leading to these deficiencies. Staff were expected to follow physician orders and document treatments accurately, but the survey revealed that these practices were not consistently followed. The facility's administration acknowledged that staff should not mark treatments as completed if they were not done and emphasized the need to adhere to policies and procedures.
Failure to Provide Adequate Foot Care for Resident with PVD
Penalty
Summary
The facility failed to provide adequate foot care for a resident with peripheral vascular disease (PVD) and other health conditions, leading to severe dryness and thickening of the skin on the resident's feet. The resident was dependent on staff for bathing and foot care, as indicated in the Minimum Data Set (MDS) and care plan. Despite the care plan's instructions to monitor and maintain foot health, there were no specific physician orders for foot care or podiatry consultation, and the resident's feet were not adequately inspected or treated. The resident's condition deteriorated, resulting in extremely dry, cracked skin and thick, jagged toenails. Hospital photographs revealed severe dryness and callus-like skin on both feet, with socks embedded into the skin due to neglect. Interviews with hospital staff confirmed the resident's poor foot condition upon arrival at the emergency room, requiring significant effort to remove the socks and clean the feet. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), indicated that the resident's feet were consistently dry and that the resident did not refuse care. However, there was a lack of communication and follow-up with the physician regarding the resident's foot condition, and no documentation of podiatry services being offered. The Interim Director of Nursing and the Administrator acknowledged the expectation for staff to address the resident's foot care needs and consult with a physician, but these actions were not documented or implemented.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. Resident 73, who has a history of bipolar disorder, anxiety disorder, attention deficit hyperactivity disorder, and major depressive disorder, reported being physically abused by Resident 84. Despite having a BIMS score indicating no cognitive impairment, Resident 73 experienced multiple incidents where Resident 84, who has a known alcohol problem, physically assaulted her. These incidents included pushing her head with his fingers, pushing her face with an open hand, and pushing her wheelchair into a door. Resident 73 also reported that staff were aware of Resident 84's aggressive behavior when intoxicated but failed to implement effective measures to prevent further abuse. The facility's response included starting 15-minute checks, but these were not consistently enforced, and no other substantial measures were taken to separate the residents or address the underlying issues causing Resident 84's aggression. Interviews with staff revealed that they were aware of the ongoing issues between Resident 73 and Resident 84. Staff reported that Resident 84 would become aggressive, especially when intoxicated, and had a history of leaving the facility to obtain alcohol. Despite this knowledge, the facility did not implement adequate measures to monitor Resident 84's behavior or restrict his access to alcohol. Staff also failed to consistently enforce the 15-minute checks and did not provide sufficient supervision to prevent further incidents. Additionally, there was a lack of communication among staff regarding the monitoring and separation of the two residents, leading to continued interactions and altercations. The facility's Director of Nursing and other staff members acknowledged the incidents but did not take effective action to address the situation. Although Resident 84 was attending Alcoholics Anonymous meetings, there were no psychiatric services in place to address his underlying issues. The facility's failure to protect Resident 73 from physical abuse by Resident 84, despite being aware of the risks and previous incidents, constitutes a significant deficiency in ensuring the safety and well-being of its residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to utilize Enhanced Barrier Precautions (EBP) for three residents, which was observed during an initial tour. Residents R19, R60, and R77 did not have signage on their doors indicating they were under EBP. R19 had a feeding tube due to dysphagia, R60 had an indwelling catheter due to obstructive and reflux uropathy, and R77 had an indwelling catheter with a diagnosis of neurogenic bladder. These conditions necessitate the use of EBP to prevent the spread of infections, but the facility did not implement these precautions for the mentioned residents. Interviews with various staff members, including a Certified Medication Technician, Certified Nursing Assistants, Licensed Practical Nurses, the Director of Nursing, and the Regional Nurse Consultant, revealed a lack of knowledge and training regarding EBP. Some staff members were unaware of what EBP entailed, while others had only a vague understanding. The Director of Nursing confirmed that the residents were not in EBP and admitted to needing to read up on the specifics. The Regional Nurse Consultant acknowledged that the policy for EBP was still being developed and that staff had not been trained in its implementation.
Failure to Maintain Functional Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an infection prevention and control program (IPCP) that included a functional Antibiotic Stewardship Program following the McGeer Criteria for antibiotics. This deficiency was identified in the case of a resident who was readmitted with diagnoses of urinary tract infection and paraplegia. The resident complained of a burning sensation and issues with catheter flow, leading to a physician's order for Cipro 250 mg twice a day for seven days. However, the facility did not provide documentation showing the sensitivity of the organism to the specific antibiotic prescribed, and the Antibiotic Stewardship Monthly Tracking logs did not indicate whether the criteria for antibiotic use were met or not met for this resident or others listed on the logs. Interviews with staff revealed that while the facility claimed to follow McGeer's Criteria, there was no consistent documentation or policy enforcement to ensure this. The Licensed Practical Nurse (LPN) and the Regional Nurse Consultant (RNC) both acknowledged the use of McGeer's Criteria but admitted that the criteria were not documented for antibiotics on the logs. The facility's policy on antibiotic stewardship required a review of antibiotic utilization and documentation on a tracking form, but this was not consistently followed. The Infection Preventionist was identified as the sole person responsible for infection control, but the Quality Assurance and Performance Improvement (QAPI) meetings did not consistently discuss McGeer's criteria for antibiotic use.
Failure to Provide Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer and/or provide pneumococcal vaccines to two residents, increasing their risk of infection. Resident 77, who was readmitted with a urinary tract infection and paraplegia, had no documentation of a pneumonia vaccine being offered or provided. Similarly, Resident 98, admitted with diabetes and chronic obstructive pulmonary disease, also lacked documentation of a pneumonia vaccine. Both residents' electronic medical records (EMR) under the Immunizations tab showed no evidence of the vaccine being offered or administered. During interviews, the Director of Nursing confirmed the absence of documentation for the pneumonia vaccines for both residents. The Administrator stated that the documentation should be in the EMR and that the Infection Preventionist nurse was responsible for this task. However, the Infection Preventionist nurse was unavailable for an interview. The facility's policy, dated 04/28/22, mandates that residents be offered the pneumococcal vaccine upon admission and that immunizations be documented in the electronic health record.
Failure to Assess and Monitor Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed for self-administration of medications before leaving medications at the bedside and that the correct dose was given. Resident 69, who was admitted with diagnoses including muscle weakness, neuropathy, and hypertension, had a BIMS score indicating moderate cognitive impairment. The resident's care plan did not include self-administration of medications, and there was no physician's order for self-administration. Despite this, medications were left at the resident's bedside without supervision, and the resident was unable to identify the medications in the cup left for her. The Certified Medication Technician (CMT) confirmed that she left the medications at the bedside and did not observe the resident taking them, stating she was unaware that a physician's order was required for self-administration. Additionally, the CMT admitted to giving two doses of Methocarbamol and Gabapentin at one time, which was against protocol, and revealed she had not received any training on medication administration. The Director of Nursing (DON) acknowledged that the facility's policy required an assessment and a physician's order for residents to self-administer medications. The facility's policy, revised in August 2014, stated that residents who wish to self-administer medications must be assessed by the interdisciplinary team for cognitive, physical, and visual ability, and there must be a prescriber's order. The DON confirmed that the policy was not followed in this case, and it was not acceptable for staff to administer two doses at one time. The failure to adhere to these protocols led to the deficiency identified in the report.
Failure to Reconcile Resident Petty Cash
Penalty
Summary
The facility failed to provide and maintain complete accounting records for the reconciliation of petty cash kept on hand for the resident trust account. The facility's Business Office Resident Trust Fund Policy and Procedure mandates that residents' funds be safeguarded and accounted for, with a specific procedure for maintaining a Resident Trust Cash Box. However, the monthly reconciled bank statements did not include the reconciliation of the petty cash kept on hand. During an observation and interview, it was found that the residents' petty cash box contained $289.49 but lacked a reconciliation sheet. The receptionist was unaware of the starting balance and did not have a reconciliation sheet, indicating a lack of proper record-keeping and oversight. The Business Office Manager (BOM) admitted that the petty cash should be reconciled daily but was not, and the Administrator was unaware of the issue. The BOM is responsible for the resident petty cash box and acknowledged that reconciliation is necessary to ensure the funds balance and prevent theft. The failure to reconcile the petty cash in a timely manner led to a deficiency in maintaining accurate and complete accounting records for the resident trust account.
Failure to Complete TPL Forms Timely for Deceased Residents
Penalty
Summary
The facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting of residents who expired. This deficiency affected three residents who had money in their accounts at the time of their death. Resident #201 had an ending balance of $5781.19, Resident #202 had an ending balance of $3029.82, and Resident #203 had an ending balance of $200.34. The Business Office Manager (BOM) acknowledged that some TPL forms were overlooked and not completed in a timely manner. The Administrator was unaware of the delay and expected the TPL forms to be completed within the required timeframe.
Failure to Screen New Hires for Federal Indicators
Penalty
Summary
The facility failed to ensure newly hired employees were screened to rule out the presence of a Federal Indicator with the Certified Nurse Aide (CNA) Registry for five of ten sampled employees hired since the last survey. The facility had hired at least 200 new employees since the last survey, and the census was 111. The facility's Abuse Prevention Policy, dated 10/21/22, mandates that the facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals or misappropriation of property. However, the review of employee files for Dietary Manager A, Dietary Aide B, Dietary Aide C, Receptionist D, and Dietary Aide E showed no CNA registry checks were performed for these individuals, despite their hire dates ranging from 1/14/19 to 12/6/23. This indicates a failure to adhere to the facility's own policy on pre-screening new employees for a history of abusive behavior. During interviews, both the Human Resource Manager and the Administrator admitted they were not aware that all newly hired staff needed to have a CNA registry check performed, believing it was only necessary for CNAs. The Human Resource Manager has been with the facility since October 2022.
Failure to Provide Written Notice of Transfer/Discharge
Penalty
Summary
The facility failed to send written notices of transfer or discharge to residents or their representatives for two residents who were hospitalized. Resident 108, who had diagnoses including a nondisplaced fracture of the left tibial tuberosity, morbid obesity, and congestive heart failure, was transferred to the hospital on two occasions. However, there was no written notice of transfer or discharge found in either the electronic medical record or the hard chart for these hospitalizations. Similarly, Resident 63, who had diagnoses including epilepsy, unspecified dementia, and chronic kidney disease, was transferred to the hospital on two occasions. No written notice of transfer or discharge was found in the electronic medical record or the hard chart for these hospitalizations either. Interviews with the facility staff revealed that the Social Worker and Licensed Practical Nurse did not send written notices of transfer or discharge, and the Administrator confirmed the absence of such notices for both residents. Additionally, the Administrator stated that the facility did not have a specific policy regarding written notices of transfers or discharges. This lack of written notification is a deficiency in the facility's compliance with regulatory requirements for resident transfers and discharges.
Failure to Provide Bed Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold notice to a resident or the resident's representative during hospital transfers. The resident, who had diagnoses including epilepsy, dementia, and chronic kidney disease, was admitted to the facility and later transferred to the hospital on two separate occasions. Both times, the resident's Minimum Data Set (MDS) indicated cognitive impairments, with the second transfer showing severe impairment. Despite these transfers, no bed hold notice was found in the electronic medical record or the hard chart at the nurse's station. Interviews with the Social Worker and the Administrator confirmed that the facility did not provide bed hold notices for the resident's hospital transfers. The facility's policy, last reviewed in November 2022, mandates that written information regarding bed hold policy be provided to residents or their representatives prior to hospital transfers or therapeutic leave, as required by state and federal guidelines. However, this policy was not followed in the case of the resident in question.
Failure to Complete Accurate PASARR Screening
Penalty
Summary
The facility failed to ensure an accurate Level 1 pre-screening for a mental disorder (MD) or intellectual disability (ID) was completed or correct for one resident prior to admission. The resident, who was admitted with diagnoses including end-stage renal disease, hypertension, major depression disorder, and bipolar disorder, did not have a PASARR Level I or Level II documented in their medical record. The resident's electronic medical record indicated the use of psychotropic medications and a high risk for depression, but no PASARR documentation was found to support the necessary pre-admission screening and review. Interviews with the Social Services Supervisor and the Administrator revealed that the facility did not have a policy for PASARR, and the necessary documentation could not be retrieved from the Central Office Medical Review Unit due to the age of the original application. The Director of Nursing confirmed that the expectation would be to reapply for the PASARR documentation. This lack of documentation and policy adherence led to the deficiency noted in the report.
Failure to Develop and Implement Care Plans for Activities and Medical Conditions
Penalty
Summary
The facility failed to develop and implement activities care plans for two residents, R20 and R40, who were at risk for psychosocial decline. R20, admitted with diagnoses including end-stage renal disease, hypertension, major depressive disorder, and bipolar disorder, did not have an activities care plan in place as of the review date. Observations showed R20 frequently sitting near the nurse's station and engaging in conversations with staff and other residents, but no formal activities care plan was documented in the electronic medical record (EMR). The Director of Nursing (DON) confirmed the expectation to individualize activity care plans, but the care plan nurse was unavailable due to attending a funeral. Similarly, R40, admitted with diagnoses including end-stage renal disease, hypertension, hyperkalemia, and chronic diastolic heart failure, also lacked an activities care plan. Observations noted R40 sitting near the nurse's station, expressing a desire to participate in activities such as trips to Walmart, and later sitting in a wheelchair with eyes closed. Despite these observations, no activities care plan was documented in the EMR. The DON reiterated the importance of individualized activity care plans, but the responsible care plan nurse was absent. Additionally, the facility failed to implement care plans for R69, who was receiving antidepressant medication, and R77, who had a catheter. R69, with moderate cognitive impairment and a diagnosis of depression, had no care plan for self-administration of medications despite having a physician's order for Mirtazapine. R77, with moderate cognitive impairment and using a urinary catheter, also lacked a care plan for catheter use despite having a physician's order for indwelling catheter care. The DON acknowledged the importance of care planning for these conditions but noted the MDS Coordinator responsible for care plan implementation was also attending a funeral and unavailable for an interview.
Lack of Individualized Activities for Residents
Penalty
Summary
The facility failed to ensure one-to-one activities for two residents, leading to a potential decline in their psycho-social well-being. The facility's policy mandates an ongoing program to support residents' choices of activities based on their comprehensive evaluation, care plan, and preferences. However, the activities calendar for March, April, and May 2024 revealed the same activities every week with no variety. Resident R20, who is cognitively intact and at risk for depression, expressed boredom and a lack of engaging activities. Observations showed R20 frequently sitting near the nurse's station and expressing a desire for more activities. Similarly, Resident R40, also cognitively intact and at risk for depression, was observed sitting near the nurse's station and expressed a desire for more varied activities, such as trips to Walmart. The care plans for both residents did not include activity planning, and the activities supervisor confirmed the need for more variety in the activities calendar. The deficiency was further highlighted by the observations and interviews conducted with the residents and staff. R20 and R40 were often seen sitting near the nurse's station or in their rooms with limited engagement in activities. The activities supervisor mentioned that many residents prefer one-on-one activities like magazines, cards, and painting, but the current activities calendar did not reflect this variety. The administrator also confirmed the need for more diverse activities. This lack of variety and individualized activity planning had the potential to negatively impact the residents' psycho-social well-being.
Failure to Address Resident's Aggressive Behaviors and Substance Abuse
Penalty
Summary
The facility failed to appropriately address a resident's aggressive behaviors and implement interventions to assist the resident with proper coping skills to prevent violent outbursts and acts of aggression. The resident, identified as R84, was admitted with diagnoses including cognitive communication deficit and had a history of substance abuse. Despite having a care plan that acknowledged the potential for physical behaviors related to anger and poor impulse control, the interventions in place were not updated or effectively implemented. The resident was involved in multiple altercations with other residents and a visitor, which included physical aggression and property damage, such as punching holes in the wall. These incidents were documented in the electronic medical record (EMR) by various staff members, including LPNs, RNs, and the Social Services Supervisor (SSS). However, the interventions to manage these behaviors were inadequate and not consistently followed. For instance, 15-minute checks were not reliably performed, and there was a lack of effective communication among staff regarding the resident's behavior and the need to keep certain residents apart. Additionally, the resident's substance abuse issues were not adequately addressed, as evidenced by the resident's continued alcohol consumption and the lack of a comprehensive plan to manage his aggression and emotional instability. Interviews with staff members, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed that while they were aware of the resident's aggressive behavior and substance abuse issues, there were no effective measures in place to address these problems. The resident had refused a psychiatric evaluation, and there were no documented follow-up actions to ensure that the resident received the necessary mental health support. The facility's failure to implement and update appropriate interventions for the resident's aggressive behaviors and substance abuse issues led to multiple incidents of physical altercations and property damage, highlighting a significant deficiency in the care provided to the resident.
Failure to Monitor Antipsychotic Medication Side Effects and Efficacy
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. Specifically, the facility did not monitor for side effects or efficacy of Risperdal, an antipsychotic medication prescribed for anxiety, for one resident. The resident, who was significantly cognitively impaired and diagnosed with generalized anxiety disorder, had an order for Risperdal 1 mg twice daily but no corresponding order to monitor for side effects. This lack of monitoring was confirmed by the Director of Nursing during an interview. The resident's Comprehensive Care Plan included interventions to administer medications as ordered and to monitor and document side effects and effectiveness. However, a review of the Medication Administration Record for April and May 2024 showed no evidence of such monitoring. The facility's Psychotropic Management Guidelines also required the interdisciplinary team to individualize the resident care plan and address outcomes, including monitoring and evaluating the potential reduction of psychotropic medications. Despite these guidelines, the facility did not adhere to its own procedures, leading to the deficiency.
Failure to Provide Timely CPR Due to Code Status Confusion
Penalty
Summary
The facility failed to provide basic life support, including CPR, in a timely manner for a resident who was a full code and found by staff without a pulse. The resident, who had diagnoses including heart failure, Alzheimer's Disease, chronic obstructive pulmonary disease, bradycardia, and the presence of a cardiac pacemaker, was found unresponsive by a CNA. Despite the CNA's immediate recognition of the resident's full code status, there was confusion and delay among the staff in verifying the code status and initiating CPR. The LPN initially believed the resident was a DNR and instructed the CNA to return the crash cart, leading to a delay in starting CPR until the code status was confirmed in the electronic medical record. Additionally, the facility's policy did not address the location of the code status documentation, leading to further delays and confusion among staff. Interviews with other staff members revealed that not all direct care staff were aware of where to find the code status in the residents' records. This lack of clarity and communication contributed to the delay in providing life-saving measures to the resident. The facility's failure to ensure that staff could immediately verify code status and initiate CPR as required by the resident's advance directives resulted in a significant deficiency. The incident highlighted the need for clear policies and staff training on the location and communication of code status documentation to prevent such delays in emergency situations.
Failure to Implement BiPAP and Oxygen Therapy Orders
Penalty
Summary
The facility failed to verify and implement hospital discharge orders for a resident requiring BiPAP and oxygen therapy. The resident, diagnosed with acute or chronic hypoxemic respiratory failure, was discharged from the hospital with specific orders for BiPAP use nightly and during naps, as well as daytime oxygen therapy via nasal cannula. However, these orders were not transcribed into the facility's medical records, and the resident's care plan did not address the need for respiratory therapy via BiPAP or oxygen therapy. Additionally, the facility lacked a policy regarding BiPAP use to guide staff in providing appropriate care. Review of the resident's medical records revealed no orders for BiPAP or oxygen therapy, and no documentation of oxygen monitoring. Interviews with facility staff, including Licensed Practical Nurses and the Director of Nursing, confirmed that the discharge orders were not verified or implemented. The staff were unaware of the resident's need for BiPAP, and the care plan did not reflect the resident's respiratory needs. The facility's failure to transcribe and implement the hospital discharge orders for BiPAP and oxygen therapy resulted in the resident not receiving the prescribed respiratory care. The physician confirmed that all hospital discharge orders should be transcribed and that wearing the BiPAP would have likely improved the resident's condition. The facility did not have a policy in place to address the use of BiPAPs, contributing to the deficiency in care provided to the resident.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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