Bethesda Dilworth
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 9645 Big Bend Blvd, Saint Louis, Missouri 63122
- CMS Provider Number
- 265764
- Inspections on file
- 31
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Bethesda Dilworth during CMS and state inspections, most recent first.
The facility failed to maintain accurate controlled substance records when required shift-change narcotic counts were not completed and documentation for a resident’s oxycodone-acetaminophen was inaccurate. A resident with multiple chronic conditions had an order for scheduled oxycodone-acetaminophen, and a CMT removed and administered a dose without signing it out before administration. Later, the CMT documented the dose based on a prior quantity of six pills, resulting in a recorded balance of five, while only four pills were actually present in the card. The CMT reported arriving late and not completing the narcotic count, and an LPN acknowledged assuming, but not verifying, that counts had been done, contrary to facility policy requiring beginning- and end-of-shift counts and immediate documentation of narcotic removal.
The facility did not complete required wound assessments, failed to document wound characteristics, and did not follow its own policies for wound photography and physician notification for multiple residents. One resident's pressure ulcer worsened, leading to sepsis and emergency surgery, and treatment orders were not followed for two residents.
The facility did not notify physicians or resident representatives when three residents developed new or worsening pressure ulcers. Despite facility policy requiring notification and documentation, staff failed to inform the appropriate parties or record these notifications in the medical record. Interviews confirmed inconsistent notification practices, and wound care orders were sometimes entered without prior physician contact.
A resident with multiple complex medical conditions and a history of falls was discharged home alone without necessary home health care services or wound care education. The facility did not involve the resident, family, or IDT in discharge planning, failed to document evaluation of discharge needs, and did not discuss or document safer discharge options, resulting in a lack of a comprehensive, person-centered discharge plan.
A resident with multiple comorbidities and a chronic coccygeal wound did not receive pressure ulcer treatments as ordered, and the physician was not notified when the wound developed drainage and a foul odor. The resident was discharged home alone without home health RN services or wound care instructions, and there was no documentation of appropriate wound care or education prior to discharge.
The facility failed to provide care consistent with professional standards for residents with PICC lines. A resident did not receive antibiotics for two days due to a lack of orders, and another resident's PICC line was not properly maintained. The admitting nurse did not verify the purpose of the PICC lines or obtain necessary orders, leading to deficiencies in care.
A resident with moderate cognitive impairment and mobility assistance needs was injured during a transfer when staff deviated from the care plan due to a dead battery in the sit-to-stand lift. The staff performed a two-person assist transfer, resulting in the resident's foot being caught under the bed and causing a tibial plateau fracture. The incident was not immediately reported, and the injury was discovered after the resident complained of pain.
A resident with moderate cognitive impairment and requiring substantial assistance was improperly transferred by two CNAs when a sit-to-stand lift's battery failed. This resulted in a tibial plateau fracture. The incident was not reported to DHSS as required by the facility's policy, as the Administrator believed it was a witnessed event.
A resident was discharged without an appropriate immediate discharge letter, which lacked essential information such as the effective date of discharge, the specific location of transfer, and details on how to appeal. The resident exhibited aggressive behavior after a medication change, leading to a psychiatric evaluation and transport to a hospital. The facility's discharge form was incomplete, and the Administrator was unaware of the correct Ombudsman's office address.
Failure to Maintain Accurate Controlled Substance Counts and Documentation
Penalty
Summary
The facility failed to maintain accurate records for controlled substances when shift-change narcotic counts were not completed and a narcotic count sheet for one resident was inaccurate. The facility’s policy required all controlled substances to be immediately added to the controlled substance log upon delivery, and required incoming and outgoing nurses or CMTs to count all Schedule II–V controlled substances at the beginning and end of each shift, documenting verification on the controlled substance log. The policy also required immediate reporting and investigation of any missing medications or discrepancies. For Resident #7, who had diagnoses including rheumatoid arthritis, chronic kidney disease, heart failure, low back pain, and diabetes, there was an active order for oxycodone-acetaminophen 10-325 mg to be given four times daily. During observation, a CMT opened the narcotic box, removed one oxycodone-acetaminophen tablet for the resident, and verified that four pills remained in the card. The CMT administered the medication but did not sign it out of the controlled substance book prior to administration, contrary to the facility’s expectations that narcotics be signed out immediately upon removal. When the CMT later went to sign out the dose, the controlled substance sheet showed a previous quantity of six pills, with one signed out for a total of five, while the actual card contained only four pills. The CMT reported that he/she had arrived late and the narcotic counts were not done at the start of the shift. The LPN on duty stated that counts should be done at the beginning and end of each shift but had assumed, without verifying, that the counts were completed. The DON and Administrator both stated they expected staff to complete shift-change counts and to sign out narcotics immediately upon removal, but these processes were not followed in this instance, resulting in an inaccurate narcotic record and inability to reconcile the controlled substance count.
Failure to Prevent and Manage Pressure Ulcers and Notify Physician
Penalty
Summary
The facility failed to maintain an effective skin management program to prevent the development and worsening of pressure injuries. Specifically, wound assessments were not completed as required for two residents, with missing documentation on wound location, stage, size, characteristics, periwound, and wound edge descriptions. Additionally, the facility did not follow its own policy regarding wound photographs and measurements for three residents. There was also a failure to contact the physician prior to initiating a wound treatment order for one resident, and the required SBAR communication tool was not completed when new or worsening wounds were observed. Notification of the physician and family was not performed for three residents experiencing changes in wound status. One resident's pressure ulcer deteriorated, developing drainage and a foul odor, which ultimately required emergency surgery and resulted in a diagnosis of sepsis. Treatment orders were not followed for two residents, further contributing to the deficiencies. The sample size for the review was four residents, with a facility census of 151 at the time of the survey. The facility's policies outlined clear procedures for wound assessment, documentation, and communication, including weekly wound rounds, use of the Braden Scale for risk assessment, and specific documentation requirements for wound characteristics and interventions. Despite these policies, the facility did not adhere to the established protocols, resulting in delayed or incomplete assessments, lack of timely physician notification, and failure to implement or document appropriate interventions for residents with pressure injuries.
Failure to Notify Physician and Family of Resident Condition Changes
Penalty
Summary
The facility failed to notify the physician and the resident's representative or family member after residents experienced a change in condition, specifically the development or worsening of pressure ulcers. This deficiency was identified through interviews and record reviews for three out of four sampled residents. The facility's policy requires licensed nurses to report changes in condition, incidents, or injuries to both the physician and the resident's representative or family member, and to document these notifications in the medical record. For one resident with severe cognitive impairment and multiple diagnoses, including acute kidney injury and altered mental status, skin assessments revealed the development of a coccyx pressure ulcer and a blister on the right heel. Despite these findings, there was no documentation of notification to the physician or family regarding these changes. Orders for wound care were entered without prior physician notification, and subsequent wound assessments continued to show no evidence of required notifications, even as the wounds progressed and developed drainage and odor. Another resident with moderate cognitive impairment and diagnoses such as hemiplegia, peripheral vascular disease, and diabetes developed multiple pressure injuries on the buttocks and heels. The medical record showed no documentation of physician or family notification for these wounds. A third resident, who was cognitively intact, also developed a coccyx pressure injury, with no evidence of notification to the physician or family. Staff interviews confirmed inconsistent practices regarding notification responsibilities, with some staff indicating that notifications were not routinely made for new or worsening wounds or changes in treatment orders.
Failure to Develop and Implement Effective Discharge Planning
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process that addressed the resident's discharge goals, needs, and capacity for discharge. The discharge plan did not involve the resident, family, or the interdisciplinary team (IDT) in a meaningful way, nor did it include interventions to ensure a smooth and safe transition to the post-discharge setting. There was no documentation of an evaluation of the resident's discharge needs, nor evidence that the results of any such evaluation were discussed with the resident or family and incorporated into the discharge plan, which is required as part of the comprehensive care plan. The facility did not document discussions with the resident or family about the implications or risks of being discharged to a location that was not equipped to meet the resident's needs. There was no record of presenting or discussing other, more suitable discharge options, nor documentation that the resident refused those options. Additionally, the facility did not determine if a referral to Adult Protective Services or another state entity was necessary, despite the resident being discharged to a potentially unsafe environment. Changes in the resident's condition that impacted the discharge plan were not identified, and necessary revisions to interventions were not made. A resident with multiple complex medical conditions, including diabetes, chronic heart failure, atrial fibrillation, chronic kidney disease, and a chronic coccygeal wound, was discharged home alone without required home health care services or education on wound care. The resident required assistance with transfers, ambulation, and activities of daily living, and had a history of falls, including a recent fall at home after a previous discharge. The facility's own policies required comprehensive discharge planning, interdisciplinary involvement, and documentation, none of which were adequately followed in this case.
Failure to Provide Ordered Pressure Ulcer Care and Discharge Planning
Penalty
Summary
The facility failed to provide pressure ulcer care and prevention in accordance with its own policies and physician orders for one resident. Specifically, the facility did not administer pressure ulcer treatments as ordered and did not notify the physician when the resident's coccyx/sacral wound developed drainage and a foul odor shortly before discharge. The resident was ultimately discharged to home without home health registered nursing care services and without education or instructions on how to care for the wound. The resident involved had multiple significant medical diagnoses, including diabetes mellitus, chronic congestive heart failure, permanent atrial fibrillation, atherosclerotic heart disease, chronic kidney disease, and peripheral vascular disease. Upon admission, the resident was assessed as having a moderate risk for pressure ulcers, with a Braden score of 14, and required partial to moderate assistance with mobility and transfers. The resident's care plan included preventative skin care measures such as the use of barrier cream, but documentation showed only general references to skin abnormalities and did not provide detailed wound assessments or evidence of consistent wound care interventions. Despite the presence of a chronic coccygeal wound and a physician's order for hydrophilic wound dressing, the facility did not document that wound care was provided as ordered. Additionally, when the wound developed drainage and a foul odor, there was no documentation that the physician was notified or that the care plan was updated. The resident was discharged home alone, without arrangements for skilled nursing follow-up or wound care education, contrary to facility policy and standard practice for wound management.
Deficiencies in PICC Line Management and Antibiotic Administration
Penalty
Summary
The facility failed to ensure residents received care consistent with professional standards, particularly concerning the management of peripherally inserted central catheter (PICC) lines. A resident admitted from the hospital with a PICC line did not have orders for PICC line maintenance or antibiotic administration, resulting in a two-day lapse in receiving necessary antibiotics for a bacterial infection. The staff did not verify the purpose of the PICC line or ensure continuity of care from the hospital, leading to a delay in treatment. Another resident was admitted with a PICC line for antibiotic treatment due to a kidney infection and osteomyelitis. However, there were no orders for PICC line maintenance or dressing changes. The resident's PICC line dressing was undated and appeared compromised, indicating a lack of proper care and maintenance. The staff failed to adhere to the facility's policy requiring orders for dressing changes and maintenance for all IVs and PICC lines. Interviews with the Director of Nursing and Registered Nurse revealed that the admitting nurse is responsible for verifying the purpose of the PICC line and obtaining necessary orders. Despite this, the facility did not ensure that the admitting nurse followed through with these responsibilities, resulting in deficiencies in care for residents with PICC lines. The facility's failure to maintain professional standards in managing PICC lines and ensuring continuity of care from the hospital led to these deficiencies.
Inadequate Supervision and Transfer Procedure Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and follow proper procedures for a resident who required assistance with transfers and mobility. The incident occurred when the resident, who had moderate cognitive impairment and required substantial assistance, was transferred to bed without the use of a sit-to-stand lift due to a dead battery. Despite the resident's insistence on being put to bed, the staff performed a two-person assist transfer, during which the resident's right foot was caught under the bed, resulting in a comminuted tibial plateau fracture. The facility's policy required the use of mechanical lifts for safe transfers, and the resident's care plan specified the need for a stand-up lift with two-person assistance. However, the staff deviated from this plan due to the lift's battery issue and the resident's insistence. The staff did not seek an alternative lift or battery from another floor, as suggested by the facility's Director of Nursing (DON). The incident was not immediately reported to the nurse, and the resident's injury was only discovered after the resident complained of pain and was subsequently sent to the emergency room for evaluation. Interviews with the staff involved revealed a lack of communication and adherence to the facility's policies. The Certified Nurse Assistants (CNAs) involved did not report the incident or the resident's pain to the Licensed Practical Nurse (LPN) on duty. The LPN and Staffing Coordinator were unaware of the injury until the resident was seen with a knee immobilizer after returning from the hospital. The facility's investigation highlighted the failure to follow the mechanical lift policy and the lack of proper assessment and reporting of the resident's condition.
Failure to Report Injury from Improper Transfer
Penalty
Summary
The facility failed to adhere to its abuse and neglect policy by not reporting an incident involving a resident and two staff members in a timely manner. The incident occurred when the staff performed an improper transfer of the resident, resulting in a comminuted tibial plateau fracture. The facility's policy requires immediate reporting of such incidents, especially those resulting in serious bodily injury, to the appropriate state agency. However, there was no documentation indicating that the Department of Health and Senior Services (DHSS) was notified of the incident or injury. The resident involved had moderate cognitive impairment and required substantial to maximal assistance for transfers, as indicated in their care plan. The care plan specified the use of a stand-up lift with two-person assistance for transfers. On the day of the incident, the sit-to-stand lift's battery was not charged, and the resident, who was upset about waiting, was transferred manually by two CNAs. During the transfer, the resident's leg got caught, resulting in a fracture. The resident reported pain immediately after the transfer, but the staff did not recognize the severity of the injury at that time. Interviews with the staff involved revealed that the CNAs attempted to charge the lift's battery but proceeded with a manual transfer when it did not work. The resident expressed discomfort during the transfer, but the CNAs did not report the incident to the nurse immediately. The LPN was informed of the manual transfer but not of the injury. The facility's Administrator and DON acknowledged the injury but did not report it to DHSS, as they believed the incident was witnessed and not an unknown injury.
Failure to Provide Appropriate Immediate Discharge Letter
Penalty
Summary
The facility failed to provide an appropriate immediate discharge letter to a resident, which did not include the effective date of discharge, the specific location to where the resident was transferred, information on how to obtain an appeal form, assistance in completing the form, and submitting the appeal hearing request. Additionally, the letter did not inform the resident that they could return to the facility if an appeal was filed. The Long-Term Care Ombudsman's office address was incorrect, and no email address was listed. The resident, who had diagnoses including unspecified dementia, anxiety, and osteoarthritis, became increasingly agitated and aggressive after the facility physician discontinued their oxycodone prescription. The resident exhibited behaviors such as barricading their door, attempting to throw a chair at staff, and using a sharp object as a weapon. The facility physician ordered a psychiatric evaluation and transport to a psychiatric hospital. The resident was escorted out of the building by police and EMTs and was transported to the hospital. The facility's discharge form used for the resident's immediate discharge was found to be incomplete and did not include necessary information such as the effective date of discharge, the location to which the resident was discharged, and information on how to obtain and submit an appeal form. The Administrator stated that the location was not applicable because the resident was going to the hospital and that the appeal information was not applicable because it was not safe to keep the resident in the facility. The Administrator also did not know that the Ombudsman's office address had changed.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
