Bernard Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 4335 West Pine Blvd, Saint Louis, Missouri 63108
- CMS Provider Number
- 265500
- Inspections on file
- 20
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Bernard Care Center during CMS and state inspections, most recent first.
Multiple deficiencies were observed, including excessive noise from loud announcements and a slamming smoke room door, unsanitary conditions such as soiled briefs left on a bathroom floor and a clogged, dirty toilet that remained unaddressed for days, and widespread maintenance issues like dirt buildup, chipped paint, broken fixtures, and exposed wiring throughout the facility. Staff interviews confirmed that short staffing and lack of a set deep cleaning schedule contributed to the failure to maintain a clean and comfortable environment for residents.
Several residents with cognitive impairment and chronic conditions did not receive proper foot care, including podiatry services, as required by facility policy and physician orders. Observations showed long, thick toenails and extremely dry feet, while interviews revealed that residents had not been seen by a podiatrist and desired better foot care. Staff interviews confirmed inconsistent assessment, documentation, and referral practices, resulting in unmet foot care needs.
The facility did not maintain proper food temperatures or palatability during meal service, as observed with cold and unappetizing food items and confirmed by two residents with multiple medical and mental health diagnoses. Staff interviews revealed that elevator malfunctions led to delays in food delivery, resulting in meals being served below required temperatures and in an unpalatable state.
A resident with bilateral leg amputations was unable to access their electric wheelchair while it was being repaired in the basement due to a nonfunctional elevator. The resident, who requires total assistance and has no trunk control, was left in bed without a suitable alternative mobility device, leading to frustration and distress.
The facility did not maintain a functioning exhaust system in the indoor smoke room, resulting in cigarette smoke and odor spreading into hallways and dining areas. Multiple staff and residents reported strong smoke odors and visible smoke outside the smoke room, and ventilation fans were found to be either turned off or not working due to power issues.
Surveyors found that multiple hallways and areas lacked required handrails or had handrails that were loose, broken, or missing. Observations included missing handrails near dining rooms, nurses' stations, and restrooms, as well as handrails pulled away from the wall. Interviews with the Maintenance Director and Administrator confirmed awareness of the issue and ongoing replacement efforts, but also revealed gaps in knowledge regarding handrail placement requirements.
A resident with a suprapubic catheter experienced pain after an LPN flushed the catheter without a physician's order, contrary to facility policy. The resident's medical records lacked documentation of the procedure, and the incident led to an ER visit where trauma from the manipulation was suspected. Staff interviews confirmed the deviation from protocol.
The facility failed to ensure that personal funds withdrawn from the resident trust account were appropriately accounted for and used exclusively for the residents. Withdrawals for personal spending were not properly authorized, and items purchased with these funds were not found in the residents' possession. The facility's Financial Coordinator and Life Enrichment Director admitted to mixing up gift cards and receipts, leading to improper accounting of resident funds.
The facility failed to follow general accounting principles by not addressing outstanding checks during monthly resident trust fund reconciliations. Multiple checks, some dating back to 2015, remained outstanding, indicating a lapse in following procedures. The Financial Coordinator was not trained to investigate these checks and lacked the authority to void them, leading to the deficiency.
The facility failed to provide a homelike environment by serving meals on Styrofoam plates with plastic utensils, which residents found difficult to use. Additionally, a resident was given a visibly dirty wheelchair, and multiple resident rooms were observed to be unclean with sticky floors, dirty privacy curtains, and dusty air conditioning units. Staff interviews confirmed these deficiencies.
The facility failed to update care plans to reflect the needs of three residents who smoke and one resident who frequently refuses medications. Despite observations and staff interviews confirming these behaviors, the care plans did not include this critical information.
The facility failed to appropriately assess and investigate a series of falls resulting in head injuries for a resident, did not use functional equipment during mechanical lift transfers for two residents, and did not apply gait belts properly during transfers or assisted ambulation for three residents. Additionally, the facility did not ensure residents were routinely and accurately assessed for smoking safety.
The facility failed to ensure that residents using side rails were appropriately assessed for safety, as required by their policy. Four residents were observed with side rails without proper assessments or documentation in their care plans. Staff interviews revealed confusion about the responsibility and frequency of these assessments, indicating a systemic issue in policy adherence.
The facility failed to maintain accurate records for controlled substances, as manual end-of-shift narcotic counts were not consistently completed for two out of three medication carts. Staff interviews confirmed the requirement for daily counts, but records showed multiple instances of non-compliance.
The facility failed to ensure that food delivered to residents was palatable and at the required temperatures. Observations and interviews revealed that food served to residents in their rooms on the 300 and 400 hallways was often unappetizing, bland, and not at the proper temperatures. For instance, a resident who is dependent on assistance with eating and has diagnoses including stroke and dysphagia, was served rubbery grits that could not be cut with a fork and pureed food that was unidentifiable and unpalatable. Another resident, who requires setup or clean-up assistance with eating and has similar diagnoses, reported that the food was
The facility failed to maintain cleanliness in the kitchen, walk-in refrigerator, and bulk storage areas, and did not ensure the ice machine had an air gap. Observations revealed water pooling, trash, food debris, and grime in various areas, with dietary staff and management confirming cleaning responsibilities were not met.
The facility failed to obtain and document necessary medical orders for a resident with severe cognitive impairment and multiple medical conditions, leading to lapses in care for PICC line, nephrostomy tube, and suprapubic catheter. Additionally, a required yearly EKG was not completed due to a backlog with the service provider.
The facility failed to ensure residents requiring assistance with ADLs received necessary services to maintain personal hygiene. One resident was left soiled for an extended period, resulting in a rash, while three other residents were observed with poor personal hygiene, including unshaven faces and long, jagged nails. Staff interviews revealed inconsistencies in care practices and documentation.
The facility failed to identify and obtain treatment orders for newly acquired skin issues in two residents, despite multiple observations and interactions with staff. The residents' care plans and progress notes did not document the skin conditions, and staff interviews confirmed that the required protocols for reporting and treating new skin issues were not followed.
The facility failed to ensure proper catheter care for two residents, leading to potential contamination and UTIs. Catheter bags were observed above the bladder and tubing was frequently in contact with the floor, contrary to the facility's policy.
The facility failed to ensure proper dialysis care and communication for a resident with end-stage renal disease. The resident did not have appropriate physician orders for pre and post-dialysis assessments, and there was a lack of documentation and communication with the dialysis center. Interviews with staff revealed inconsistencies in the documentation process, and the Director of Nursing confirmed that a new communication form was not consistently used.
The facility failed to follow infection control standards during peri-care for a resident and catheter treatment for another. A CNA did not change gloves or perform hand hygiene after providing peri-care, and an LPN did not clean scissors before using them to cut a dressing for a catheter site. Staff interviews confirmed these practices were against facility policies.
The facility failed to ensure all call lights were in working order, affecting a resident with multiple diagnoses including MS and hemiplegia. Despite the resident's care plan indicating the need for a functioning call light, the issue remained unresolved for about three weeks. Staff interviews revealed a lack of proper reporting and communication regarding the non-functioning call light.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and interviews. Excessive noise levels were noted, including loud overhead announcements that interrupted resident conversations and a smoke room door that repeatedly slammed shut, disturbing residents in the vicinity. Despite previous attempts to fix the door, the issue persisted, and the noise was audible even in the administrator's office. No complaints were reported regarding the overhead speakers, but residents expressed discomfort with the noise disruptions. Sanitation and cleanliness issues were observed throughout the facility. In one instance, a resident's bathroom contained soiled briefs on the floor over multiple days, with staff indicating that residents were expected to request trash bags for disposal, and that housekeeping would not remove soiled briefs from bathrooms. Another resident's toilet was clogged and dirty with feces and toilet paper for at least two days, resulting in a strong odor permeating the room. The resident, who had diagnoses including major depressive disorder, schizoaffective disorder, and epilepsy, and was moderately cognitively impaired, reported being unable to use the toilet during this time. Widespread maintenance and cleanliness deficiencies were documented in various facility areas, including hallways, dining rooms, bathrooms, and common spaces. Observations included dirt buildup on floors and cove bases, chipped and missing paint, broken fixtures, exposed wiring, cracked tiles, and dirty or damaged windows. Staff interviews revealed that short staffing, particularly in housekeeping and floor technician roles, contributed to lapses in deep cleaning and maintenance. Housekeeping and laundry staff were often required to cover for each other, and there was no set schedule for deep cleaning. Staff acknowledged that the environment was not being maintained to expected standards, with visible dirt, dust, and damage throughout the facility.
Failure to Provide Proper Foot Care and Podiatry Services
Penalty
Summary
The facility failed to provide appropriate foot care to five residents, as evidenced by observations, interviews, and record reviews. Residents with moderate cognitive impairment and various diagnoses, including diabetes, peripheral vascular disease, and schizophrenia, were found to have unaddressed foot care needs. Despite facility policies requiring assessment, routine care, and referral to a podiatrist for residents with complicating conditions, there was no documentation of podiatry visits or consults for these residents, even when physician orders allowed for podiatrist visits. Direct observations revealed that several residents had excessively long, thick, jagged, and curled toenails, as well as extremely dry feet with large flakes of skin. Some residents wore socks with holes or soiled socks, and in one case, a resident reported discomfort due to a long toenail rubbing against footwear. Interviews with residents confirmed that they had not received podiatry services or adequate foot care, and some expressed a desire for their feet to be moisturized or toenails to be trimmed by a professional. Staff interviews indicated that while there were expectations for nurses and aides to assess, moisturize, and refer residents for podiatry care, these actions were inconsistently carried out. Staff acknowledged that refusals of care should be documented, but there was no evidence of such documentation or follow-up in the medical records. The lack of documented podiatry visits, inadequate routine foot care, and failure to address residents' expressed needs and physician orders led to the deficiency.
Failure to Serve Palatable and Properly Heated Food
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature during tray service, as required by their dietary food preparation policy. Observations revealed that hot foods, such as sausage patties and scrambled eggs, were served below the acceptable temperature threshold, with the sausage patty measuring 93°F and the eggs at 115.9°F, both of which felt cold. Additionally, lunch service included chicken strips that tasted rubbery, limp and damp bread, and mashed potatoes that were dry, bland, and powdery without gravy. These issues were directly observed during meal service on different halls. Interviews with two residents confirmed dissatisfaction with the food, citing that it was often cold and unpalatable. One resident, with diagnoses including major depressive disorder, schizoaffective disorder, and epilepsy, reported that the food was not always warm and tasted bad. Another resident, with bipolar disorder, major depressive disorder, type two diabetes, and schizoaffective disorder, stated that the food was frequently cold and could be better. The Food Service Manager attributed the temperature issues to frequent elevator breakdowns, which forced staff to carry food up the stairs, causing delays in meal delivery.
Failure to Maintain Elevator Results in Resident's Loss of Wheelchair Access
Penalty
Summary
The facility failed to maintain essential equipment in a safe and operable condition by not ensuring the consistent operation of the elevator. This deficiency was observed when the elevator became nonfunctional, preventing access between floors. As a result, a resident who is a bilateral knee amputee and relies on an electric wheelchair for mobility was unable to access their wheelchair while it was being repaired in the basement. The repair could not be performed in the resident's room or hallway, and the elevator outage meant the wheelchair remained inaccessible to the resident. The resident, who has a history of high blood pressure, chronic atrial fibrillation, and bilateral leg amputations, was left in bed without access to an appropriate alternative mobility device. The resident expressed frustration and distress about being confined to bed, especially given a previous prolonged period of immobility due to a wound. Staff interviews confirmed that the resident was offered a geri-chair, but it was not suitable due to the resident's lack of trunk control and the absence of a proper reclining or seatbelt-equipped chair to ensure safe positioning.
Failure to Maintain Proper Ventilation in Smoke Room
Penalty
Summary
The facility failed to maintain an appropriate exhaust system to remove cigarette smoke from the indoor smoke room, resulting in smoke and odor permeating areas frequented by residents and staff. Multiple observations over several days showed that residents and staff entered and exited the smoke room, with several residents smoking inside. The odor of smoke was detected from the lobby entrance, throughout the hallway, and inside and outside the 300 Hall dining room. On one occasion, a visible haze of smoke was observed outside the smoke room. Two floor fans and two garage fans intended to ventilate the area were not turned on during these observations. Interviews with residents, staff, and facility leadership confirmed the presence of smoke odor and visible smoke in the hallways and dining areas. One resident reported smelling smoke in their room when the door was open, and a housekeeper and CNA both noted strong smoke odors and visible smoke outside the smoke room. The Maintenance Director acknowledged that the fans should have been operating but were either turned off by residents or not functioning due to a power issue. The Administrator confirmed that the exhaust fans were broken and that the smoke odor was more pronounced during colder weather when more residents smoked indoors.
Failure to Maintain and Secure Corridor Handrails
Penalty
Summary
The facility failed to ensure that all corridors had handrails and that existing handrails were securely affixed to the walls, as observed during multiple walkthroughs. Specific deficiencies included missing handrails between rooms and common areas, around the perimeters of nurses' stations, and in various hallways across the 100, 200, 300, and 400 halls. Additionally, several handrails were found to be loose, broken, or pulled away from the wall. These issues were directly observed by surveyors at different times throughout the facility. Interviews with the Maintenance Director and the Administrator revealed that the facility was aware of the missing and damaged handrails. The Maintenance Director stated that handrails were checked every three months and acknowledged the absence of necessary replacement parts, as well as the ongoing process of replacing plastic handrails with wooden ones. Both the Maintenance Director and the Administrator were not fully aware of the requirement for handrails to be present outside nurses' stations and on both sides of all corridors used by residents. The facility's area audit and preventative maintenance inspection listed handrails as an item for staff to inspect, but deficiencies persisted.
Improper Catheter Care Without Physician Orders
Penalty
Summary
The facility failed to provide catheter care consistent with physician orders for a resident with a suprapubic catheter. The resident, who had diagnoses including quadriplegia, neuromuscular dysfunction of the bladder, and a history of urinary tract infections, did not have a physician order to flush the suprapubic catheter. Despite this, an LPN flushed the catheter due to clotting issues, which was not documented in the resident's Treatment Administration Record or progress notes for November and December 2024. The facility's policies require that catheter care, including flushing, be performed only under physician orders and documented accordingly. However, the resident's medical records showed no such orders or documentation of the flushing procedure. The resident later presented to the emergency room with pain at the suprapubic catheter site, which was suspected to be due to trauma or mechanical pain from the catheter manipulation rather than a urinary tract infection. Interviews with facility staff revealed that the LPN acknowledged flushing the catheter without a physician's order, and the Director of Nursing confirmed that such actions should be documented and only performed with proper orders. The incident highlights a failure to adhere to established protocols for catheter care, leading to potential harm to the resident.
Mismanagement of Resident Trust Funds
Penalty
Summary
The facility failed to ensure that personal funds withdrawn from the resident trust account were appropriately accounted for and used exclusively for the residents. Specifically, the facility did not ensure that withdrawals for personal spending were authorized by the resident or their legal guardian and signed off by the appropriate facility staff. This deficiency affected three residents, all of whom had cognitive impairments and were listed as their own financial responsible parties despite having legal guardians. The facility's policy required that personal funds be safeguarded and used exclusively for the resident, with proper authorization and documentation, which was not followed in these cases. For Resident #36, a withdrawal of $2,000 was made without proper authorization, and the funds were used to purchase gift cards. The receipts for these purchases were not signed by the resident, and there was a discrepancy of $10 between the withdrawal and the receipt totals. Additionally, items purchased with another withdrawal of $1,000 were not found in the resident's possession, and the resident's inventory sheets were not updated. Similar issues were found with Resident #48, where a $2,000 withdrawal was used to purchase gift cards, and the receipts were not signed by the resident. Items purchased with another $1,000 withdrawal were also not found in the resident's possession, and the inventory sheets were not updated. Resident #26 also experienced similar issues, with a $2,000 withdrawal made without proper authorization and used to purchase items that were not found in the resident's possession. The facility's Financial Coordinator and Life Enrichment Director admitted to mixing up gift cards and receipts, leading to improper accounting of resident funds. The Administrator was unaware of these practices and expected proper authorization and accurate record-keeping for all transactions involving resident funds. The facility's failure to follow its own policies and procedures resulted in the mismanagement of resident funds and a lack of accountability for the purchases made with those funds.
Failure to Address Outstanding Checks in Resident Trust Fund
Penalty
Summary
The facility failed to ensure general accounting principles were followed by not addressing outstanding checks during monthly resident trust fund reconciliations. The facility's policy required the Resident Trust Clerk to void and reissue checks that were outstanding for over two months. However, a review of the facility's monthly resident trust reconciliation from April 2023 through March 2024 revealed multiple checks, some dating back to 2015, that remained outstanding. These checks ranged in amounts from $10.00 to $2,740.00, indicating a significant lapse in following the established procedures for managing resident trust funds. Interviews with the Financial Coordinator and the Administrator revealed that the monthly reconciliation was performed by an accountant from the facility's management company. The Financial Coordinator, who was responsible for factoring outstanding checks into the reconciliation, was not trained to investigate these checks and did not have the authority to void them. The Administrator expected the accountant to notify the Financial Coordinator of any issues, but there was no follow-up on the outstanding checks, leading to the deficiency in managing the resident trust funds properly.
Failure to Provide Homelike Environment and Maintain Cleanliness
Penalty
Summary
The facility failed to provide a homelike environment by serving meals on Styrofoam plates with plastic utensils, which was observed during multiple meal times. Residents expressed dissatisfaction with the use of these materials, stating that they would not use them at home and found them difficult to use. One resident, who had hemiplegia, struggled to eat with the plastic utensils, resulting in a significant portion of their meal being uneaten. Another resident, who was totally dependent on staff for eating, had difficulty consuming their meal as the plastic fork could not cut through the food properly. Staff interviews confirmed that the use of Styrofoam and plastic utensils was not considered homelike, and the Dietary Manager acknowledged that the dishwasher was fixed but residents were still using disposable items until she felt comfortable with the dishwasher's performance. The facility also failed to provide clean and properly maintained equipment. One resident was transferred to a new wheelchair that was visibly dirty, with white crusty and reddish-brown stains on the seat and thick cobwebs on the wheels. Staff interviews revealed that the night shift CNAs were responsible for cleaning wheelchairs, but the provided wheelchair was not cleaned before being given to the resident. The Director of Nurses stated that she expected staff to provide clean wheelchairs to residents. Additionally, the facility did not maintain clean resident rooms. Observations of three different rooms showed sticky floors, dirty privacy curtains with brown stains, dusty air conditioning units, and trash debris. One resident expressed distress over the state of their room, which had not been cleaned adequately. Staff interviews indicated that housekeeping was expected to follow cleaning schedules, but the observed conditions did not meet these expectations. The Housekeeping Supervisor and the Administrator both stated that they expected residents' rooms to be clean and orderly, but this was not the case during the survey observations.
Care Plan Deficiencies for Smoking and Medication Refusals
Penalty
Summary
The facility failed to ensure each resident's care plan was updated and accurate to reflect the resident's needs. This deficiency affected three residents whose care plans did not identify their smoking status and one resident whose care plan did not identify medication refusals. The facility's policy requires comprehensive care plans to be completed within 14 days of admission and baseline care plans within 48 hours of admission, with information gathered from direct observation, communication with the resident, and input from the interdisciplinary team (IDT). However, these requirements were not met for the affected residents. Resident #283, who has diagnoses including high blood pressure, COPD, and a history of stroke, was observed smoking multiple times in the facility's smoking area. Despite this, the resident's care plan did not include any information about their smoking status. Interviews with facility staff confirmed that the resident is a smoker and that smoking should be included in the care plan to ensure staff are aware of the resident's specific health conditions. Resident #65, who has diagnoses including hemiplegia, multiple sclerosis (MS), and high blood pressure, had a history of medication refusals documented in their progress notes. Despite this, the resident's care plan did not address medication or treatment refusals. Interviews with facility staff confirmed that the resident frequently refuses medications and treatments, and this information should be included in the care plan to direct staff approaches during medication administration and treatments. Additionally, Residents #64 and #18, both listed as smokers, were observed smoking in the facility's smoking area, but their care plans did not address their smoking status. Interviews with the MDS Coordinator, DON, and Administrator confirmed that smoking and medication refusals should be included in the care plans to address each resident's unique health concerns.
Failure to Assess and Investigate Falls, Use Functional Equipment, and Apply Gait Belts Properly
Penalty
Summary
The facility failed to appropriately assess and investigate a series of falls resulting in head injuries for one resident. The resident experienced multiple falls, each resulting in head injuries, but the facility did not document investigations regarding the specific circumstances of these falls or hold care plan meetings to discuss fall interventions. Additionally, the resident's care plan did not identify the resident's transfer status, behavior of lowering him/herself to the floor, or updated interventions following the falls, such as the use of a low bed and fall mat. The facility also failed to ensure appropriate techniques and functional equipment were utilized during mechanical lift transfers for two residents. One resident reported feeling unsafe using a broken sit-to-stand lift, which staff continued to use despite its malfunctioning legs. Observations confirmed that staff manually pushed the lift's legs open, and the lift was wobbly. Another resident was transferred using a Hoyer lift without the wheelchair brake being locked, and the wheelchair was tilted backward, posing a safety risk. Furthermore, the facility did not ensure staff applied and used gait belts properly during transfers or assisted ambulation for three residents. Observations showed that staff lifted residents under their arms without using gait belts, and one resident's gait belt was left too loose during ambulation. Additionally, the facility failed to ensure residents were routinely and accurately assessed for smoking safety for three residents, as required by their policy.
Failure to Assess Side Rail Safety
Penalty
Summary
The facility failed to ensure that residents using side rails were appropriately assessed for safety in accordance with the facility's policy. This deficiency was observed in four residents, who were not properly evaluated for the risks and benefits of side rail use. The facility's policy mandates that all residents using side rails must have a Restraint/Entrapment Assessment completed upon initial use, quarterly, and as needed if there is a significant change in the resident's condition. However, these assessments were either missing or incomplete for the residents in question. Resident #125, who had severe cognitive impairment and physical limitations due to a stroke, was observed with side rails raised on multiple occasions. Despite this, there were no entrapment or side rail assessments found in the resident's medical record, and the care plan did not identify the use of side rails. Interviews with CNAs revealed that they were unsure why the resident had side rails and indicated that nurses were responsible for informing them about such interventions. Similarly, Resident #36, who had severe cognitive impairment and multiple physical disabilities, was observed with a U-shaped rail raised on the bed. The entrapment assessment for this resident was incomplete, and the care plan did not document the use of side rails. Interviews with CNAs and the DON indicated that side rails were added during a recent hospitalization without proper assessment. Residents #30 and #46 also had incomplete or outdated assessments, and their care plans did not reflect the use of side rails. Staff interviews revealed a lack of clarity on the frequency and responsibility for conducting these assessments, highlighting a systemic issue in the facility's adherence to its own policies.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to establish a system of record for all controlled drugs with sufficient detail to enable accurate reconciliation for two out of three medication carts reviewed. Specifically, the controlled substance count sheets for the 400 and 300 halls showed that manual end-of-shift narcotic counts were not completed and documented per facility policy. For the 400 hall, the count was incomplete on multiple days in March and April, with some shifts not being counted at all. Similarly, the 300 hall had several days in April where the narcotic count was not completed for all shifts. This failure to adhere to the policy was confirmed through interviews with staff, including a Certified Medication Technician (CMT), a Licensed Practical Nurse (LPN), and the Director of Nursing (DON), all of whom acknowledged the requirement for narcotic counts to be conducted every shift, every day, with one oncoming and one off-going staff member participating in the count. The facility's Medication Storage and Destruction Policy mandates that a manual end-of-shift narcotic count be completed with the oncoming nurse counting and the outgoing nurse verifying. The policy also states that any nurse leaving the facility without properly conducting the narcotic count will face disciplinary action. Despite these clear guidelines, the review of the controlled substance count sheets revealed significant lapses in compliance. The DON confirmed that she expected the CMTs and nurses to follow the policy, but the records showed numerous instances where the counts were either partially completed or not done at all, indicating a systemic issue in maintaining accurate records for controlled substances.
Failure to Ensure Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to ensure that food delivered to residents was palatable and at the required temperatures. Observations and interviews revealed that food served to residents in their rooms on the 300 and 400 hallways was often unappetizing, bland, and not at the proper temperatures. For instance, Resident #125, who is dependent on assistance with eating and has diagnoses including stroke and dysphagia, was served rubbery grits that could not be cut with a fork and pureed food that was unidentifiable and unpalatable. Resident #84, who requires setup or clean-up assistance with eating and has similar diagnoses, reported that the food was
Facility Fails to Maintain Kitchen Cleanliness and Ice Machine Safety
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen, walk-in refrigerator, and bulk storage areas, as well as ensure the ice machine had an air gap. Observations on multiple dates revealed water pooling, trash, food debris, and grime in various areas of the kitchen and storage rooms. Specifically, the bulk storage room had water pooling and dirty lids on bulk bins, while the walk-in refrigerator had caked-on grime and food debris on the floor and shelves. The main kitchen area and pots room also had food debris and dried liquid stains. Additionally, the ice machine lacked an air gap, with its piping going straight into the drain, which could lead to contamination issues. Interviews with dietary staff and management confirmed that all dietary staff were responsible for cleaning duties, including deep cleaning the walk-in refrigerator, floors, and bulk bin room. The cook was specifically tasked with cleaning the deep fryer after each use. Despite these responsibilities, the observations indicated that the cleaning schedules and policies were not being followed. The Dietary Manager and Administrator both expressed expectations that the kitchen and appliances should be clean and that staff should adhere to the facility's cleaning policies and schedules. The Maintenance Director was unaware of the missing air gap in the ice machine and acknowledged the expectation for it to be present to prevent contamination.
Failure to Obtain and Document Necessary Medical Orders
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice by not obtaining necessary medical orders for a resident upon admission. Specifically, the facility did not obtain orders for Peripherally Inserted Central Catheter (PICC) line care and nephrostomy tube care. Additionally, the facility did not ensure that suprapubic catheter care orders were correctly documented in the Treatment Administration Record (TAR). This resulted in the resident not receiving appropriate care for these medical devices, as observed on multiple occasions when the resident did not have a dressing around the suprapubic catheter site. The resident in question had severe cognitive impairment and multiple medical conditions, including multiple sclerosis, seizures, high blood pressure, and schizophrenia. The resident was readmitted from the hospital with a urinary tract infection and bacteremia, and had a PICC line, nephrostomy tube, and suprapubic catheter in place. Despite these conditions, the facility failed to obtain and document the necessary care orders for these medical devices, leading to lapses in care. Furthermore, the facility did not complete a required yearly electrocardiogram (EKG) for the resident, who was on high-risk medications such as antipsychotics and antidepressants. The EKG was not performed due to a backlog with the EKG service provider. The Director of Nursing acknowledged that staff did not place the orders correctly in the computer system, which contributed to the failure in providing the required care and completing the EKG.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to ensure residents who required assistance with activities of daily living (ADLs) received necessary services to maintain adequate personal hygiene. One resident was left soiled for an extended period, resulting in a saturated bedspread, blanket, and clothing, as well as a bright red and inflamed rash under the resident's pannus. The resident expressed not knowing when they were last assisted with changing their brief, and the Certified Nursing Assistant (CNA) confirmed the resident had likely been left wet the entire night and morning. The CNA also noted that staff are expected to check and change incontinent residents at least every two hours, but this was not done for this resident. The Certified Medication Technician (CMT) and Licensed Practical Nurse (LPN) provided conflicting information about the resident's ability to care for themselves and any refusals of care, indicating a lack of proper documentation and communication among staff. Three other residents were observed with poor personal hygiene, including unshaven faces with food particles in their beards and long, jagged nails with dark matter underneath. These residents had severe cognitive impairments and were dependent on staff for personal hygiene and other ADLs. The care plans for these residents indicated the need for assistance with personal hygiene, but observations showed that staff did not provide the necessary care. Interviews with staff revealed that residents' nails had not been clipped because nail clippers could not be found, and shaving and nail care were supposed to be completed on shower days but were not consistently done. The Director of Nursing (DON) confirmed that staff are expected to change soiled residents in a timely manner and document any behaviors related to refusals of incontinence care. The DON also stated that staff should shave and provide nail care on residents' shower days and as needed. However, the observations and interviews indicated that these expectations were not being met, leading to deficiencies in the care provided to the residents.
Failure to Identify and Treat Skin Issues
Penalty
Summary
The facility failed to ensure residents received care consistent with professional standards when staff did not identify newly acquired skin issues and obtain treatment orders for two residents. Resident #64, who has severe cognitive impairment and multiple diagnoses including multiple sclerosis and schizophrenia, was observed with an open area on the right anterior abdominal area. Despite multiple observations and interactions with staff, the open area was not documented, and no treatment orders were obtained. The resident's care plan did not address the skin condition, and there was no documentation in the progress notes or physician order sheets regarding the open area. Resident #44, who has mild cognitive impairment and diagnoses including viral hepatitis and schizophrenia, was found with a saturated incontinence brief and a bright red, inflamed rash under the abdominal fold. The resident was unaware of the rash, and there were no treatment orders or documentation of the rash in the progress notes or physician order sheets. Staff interviews revealed that aides are expected to report new skin issues to nurses, who should then call the physician for new orders, but this protocol was not followed. Interviews with staff, including an LPN and the DON, confirmed that weekly skin assessments are required and that any new skin issues should be reported immediately to obtain new orders. However, the facility did not adhere to these procedures, resulting in the failure to address the skin issues of the two residents in a timely and appropriate manner.
Improper Catheter Care and Positioning
Penalty
Summary
The facility failed to ensure that catheter bags remained positioned below the bladder and that catheter bags and tubing remained off the floor for two residents with indwelling urinary catheters. This failure was observed during multiple instances, including when CNAs were assisting residents with clothing changes and during Hoyer transfers. The improper handling of catheter bags and tubing created a potential for contamination and urinary tract infections (UTIs). The facility's Catheter Care policy, revised on 6/29/23, mandates that urinary drainage bags be kept below the level of the bladder and that they do not touch the floor, but these guidelines were not followed in the observed cases. Resident #64, who has moderate cognitive impairment and a supra-pubic catheter, was observed on two occasions where CNAs raised the urinary catheter bag and tubing above the resident's waist, causing cloudy urine to flow back towards the resident's abdomen. The resident's care plan included monitoring for signs of infection and ensuring proper catheter maintenance, but these protocols were not adhered to during the observed incidents. Resident #36, who has lower extremity impairment and uses a wheelchair, was observed with catheter tubing and bags frequently in contact with the floor. During a Hoyer transfer, the catheter bag was placed on the resident's stomach and later fell to the floor, with tubing dragging along the floor for approximately 50 feet. Multiple observations throughout the day showed catheter tubing coiled on the floor in various locations, including the resident's room and the dining room. Interviews with CNAs and nursing staff revealed a lack of understanding and adherence to proper catheter care procedures, contributing to the risk of infection for the residents involved.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure that residents requiring dialysis had appropriate physician orders for assessment and monitoring of dialysis access sites and did not maintain ongoing communication with dialysis centers. This deficiency was identified for one resident out of a sample of two residents receiving dialysis. The facility's policy required ongoing assessment and monitoring of residents before and after dialysis treatments, including checking vital signs and assessing the vascular access site for signs of infection or complications. However, the facility did not have physician orders for pre and post-dialysis assessments for the resident, and there was a lack of documentation of these assessments in the resident's medical records for several months. The resident, who had moderate cognitive impairment and a diagnosis of end-stage renal disease, reported that upon returning from dialysis treatments, the facility staff did not assess their dialysis site or check their vital signs. Interviews with facility staff, including LPNs and RNs, revealed inconsistencies in the documentation and communication processes. Some staff mentioned that pre and post-dialysis assessments were documented on the Treatment Administration Record (TAR), while others stated that a new communication form was being used to document these assessments and communicate with the dialysis center. However, there was no evidence of consistent use of these forms or documentation in the resident's electronic medical record (EMR). The Director of Nursing (DON) confirmed that nurses were expected to assess residents before and after dialysis and document these assessments. The DON also mentioned that a new form had been introduced to facilitate communication with the dialysis center, but there was no evidence that this form was consistently used or that the information was uploaded into the resident's medical record. The lack of proper documentation and communication led to the deficiency in providing safe and appropriate dialysis care for the resident.
Infection Control Deficiencies in Peri-Care and Catheter Treatment
Penalty
Summary
The facility failed to follow acceptable infection control standards when providing peri-care for one resident and when providing treatment for a supra-pubic catheter for another resident. In the first instance, a CNA provided peri-care to a resident with severe cognitive impairment and multiple diagnoses, including diabetes and dementia. The CNA did not change gloves or perform hand hygiene after providing peri-care, and continued to touch clean items, dress the resident, and assist with a transfer while wearing the same soiled gloves. This was against the facility's policy, which mandates changing gloves and performing hand hygiene after providing peri-care and before touching clean items. In the second instance, an LPN provided treatment for a resident with a supra-pubic catheter and severe cognitive impairment. The LPN did not clean the scissors used to cut a dressing before applying it to the resident's catheter site. The scissors had been placed on the resident's bathroom sink, a potentially contaminated surface, before being used. This action was contrary to the facility's infection control policy, which requires cleaning equipment with antibacterial wipes before use in wound care. Interviews with staff, including another CNA and the DON, confirmed that the observed practices were not in line with the facility's infection control policies. Both the CNA and the LPN acknowledged that they should have changed gloves and cleaned equipment as per the guidelines. The DON reiterated the expectation for staff to follow proper infection control practices, including changing gloves and performing hand hygiene after providing peri-care and cleaning equipment before use in wound care.
Non-Functioning Call Light in Resident Room
Penalty
Summary
The facility failed to ensure that all call lights in the facility were in working order, including a visual notification above the door and an audible notification at the nurse's station. This deficiency was observed in one of 17 resident rooms surveyed, affecting one resident diagnosed with hemiplegia, pseudobulbar affect, multiple sclerosis (MS), and hypertension. The resident required moderate assistance from staff with dressing and bathing tasks and used a wheelchair for locomotion. Despite the resident's care plan indicating the need for a functioning call light due to fall risk and musculoskeletal status, the call light in the resident's room had been non-functional for about three weeks. The resident reported this issue to staff, but it remained unresolved, and the call light did not illuminate or provide an audible alarm at the nurse's station during multiple observations over several days. Interviews with facility staff, including a CNA, RN, Maintenance Director, and the Director of Nursing (DON), revealed that the non-functioning call light had not been properly reported or addressed. The CNA and RN were unaware of the specific call light issue in the resident's room, although they acknowledged that a call light on the same hall had been reported that day. The Maintenance Director confirmed that he had not been informed of the non-functioning call light prior to that day. Both the DON and Administrator stated that they expected all resident call lights to function normally and provide both visual and audible notifications. The lack of communication and follow-through in addressing the non-functioning call light led to the deficiency noted in the report.
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Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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