Blue Circle Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 2939 Magazine Street, Saint Louis, Missouri 63106
- CMS Provider Number
- 265817
- Inspections on file
- 21
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Blue Circle Rehab And Nursing during CMS and state inspections, most recent first.
The facility failed to label insulin pens according to its own insulin labeling and storage policy, which required dating and resident identification when insulin is removed from refrigeration and a 28‑day limit after opening. During observation of a medication cart, an LPN showed surveyors a drawer containing 10 insulin pens in use, all with stickers for documenting the date opened and expiration date. Nine pens, including insulin aspart, insulin degludec, Lantus, and Humalog, lacked both the date opened and expiration date. The LPN stated that insulin pens should be labeled when removed from the refrigerator and acknowledged not knowing when the unlabeled pens had been opened or placed on the cart, while the administrator and DON reported they expected staff to follow the insulin labeling and storage policy.
Staff failed to follow a resident’s care plan and transfer requirements when a CNA and an LPN used a gait belt and underarm hold to transfer a dependent, cognitively impaired resident with hemiparesis/hemiplegia, despite documentation in the Kardex and staffing book that the resident required a Hoyer lift with assist x2 due to poor balance, unsteady gait, stroke-related deficits, dementia with impulsivity, and impaired decision making. During the observed transfer, the resident was lifted from a wheelchair, stood with bent knees and on toes, verbally expressed slipping and requested to be put down, and was then pivoted into bed with one foot twisting on the floor. The facility’s visual cue system for transfer status was incomplete, as no required color sticker indicating Hoyer transfer was present on the resident’s name plate, even though leadership confirmed that a Hoyer lift, not a gait belt, was required for this resident.
CMTs failed to administer prescribed nutritional supplements and ensure correct dietary items, such as whole milk, to several residents with significant medical needs, despite documentation indicating otherwise. Observations and staff interviews revealed that supplements were not provided as ordered, menu slips were not followed, and staff did not communicate or correct discrepancies, resulting in residents not receiving necessary nutritional support.
The facility used expired COVID-19 tests to test employees and residents, failing to ensure the quality of laboratory services. The tests, with lot number CP23B69, had an expired date, and the facility mistakenly believed a waiver extended their use. The Quality Control Lab Manager confirmed no further extension was applicable, and the tests should have been discarded. This issue was identified during observations and interviews with facility staff.
The facility failed to ensure recipes were followed during meal preparation, as observed in one meal service. Staff members prepared meals without using the prescribed recipes, resulting in incorrect ingredient proportions. Interviews revealed a lack of awareness and adherence to recipe usage, despite the administrator's expectation that recipes should be followed. This deficiency could impact the nutritional needs of residents.
The facility failed to reconcile resident trust accounts with bank statements for 12 months, only including RFMS statements without proper documentation. The BOM lacked full training due to the previous BOM's passing, and the administrator expected accurate and timely reconciliations.
The facility failed to provide a safe, clean, and homelike environment for residents, as evidenced by malodorous conditions due to unlaundered linen, drafts from poorly sealed air conditioners, and damaged furniture. Residents experienced discomfort from these conditions, and the facility did not address these issues promptly.
The facility failed to meet the ADL care needs of several residents, resulting in issues such as unclean nails, untrimmed facial hair, and inadequate repositioning and toileting. Observations revealed residents with soiled briefs, cracked lips, and strong body odors, indicating lapses in personal hygiene and care. Staff interviews highlighted inconsistencies in care documentation and adherence to care plans.
Several deficiencies in medication administration were observed, including a CMT failing to properly administer eye drops by not pulling down a resident's eyelid, a nurse not priming insulin pens for two residents, and a CMT leaving a resident unattended with medications in the therapy gym. These actions indicate lapses in following proper pharmaceutical protocols.
The facility failed to secure medications stored in the ADON's office, which was not designated as a medication storage room. The office contained multiple over-the-counter medications, including an open and unlabeled bottle of magnesium citrate, and was frequently observed with the door open and no staff present, allowing medications to be visible and accessible from the hallway. Interviews confirmed that the office should be locked if medications are stored there, but it was only locked at night.
The facility experienced a malfunction in the call light system affecting multiple residents, including two specific residents with cognitive impairments and mental health conditions. The system's failures led to delays in staff response, with issues such as 'ghost lights' and incorrect room indications on the console. Despite staff awareness, communication and resolution were inadequate, and temporary measures like bells were not effectively communicated to all staff.
A resident with cognitive impairment and dependent on staff for daily activities was not assisted out of bed as per their preference and physician's order due to the unavailability of a Hoyer lift pad. Despite the resident's care plan requiring the use of a mechanical lift, staff did not obtain another pad or notify the DON to resolve the issue, resulting in the resident remaining in bed with meals served at the bedside.
A resident with severe cognitive impairment was exposed to the hallway during care when a CNA failed to close the door and pull the privacy curtain. Despite facility protocols emphasizing privacy, the door remained open even after a Nurse Manager's visit. Interviews with staff, including an LPN and the DON, confirmed the expectation of maintaining resident privacy, highlighting a deficiency in practice.
A resident was immediately discharged after a minor altercation with another resident, despite the absence of severe behaviors or injuries. The facility cited the resident's care needs exceeding capacity, but failed to provide the required 30-day notice or adequate documentation. Staff had mixed observations about the resident's behavior, and the discharge did not align with state and federal regulations.
A facility failed to notify the Ombudsman after an immediate discharge of a resident following a resident-to-resident altercation. The resident, with a history of dementia and aggression, was discharged due to safety concerns. The facility's policy requires Ombudsman notification, but this was not done promptly.
A facility failed to complete a DA-124 Level 1 PASRR screen for a resident with multiple medical conditions, including stroke-related issues and bipolar disorder. The Business Office Manager could not locate the necessary documentation and was unable to obtain it from the Missouri Central Office Medical Review Unit. Interviews revealed that the Admission Coordinator was responsible for obtaining the PASRR pre-screening, but the required documentation was not provided by the survey's exit date.
A resident with aphasia and dementia was not provided with a communication board as required by their care plan, leading to diminished ability to communicate needs. Observations showed the absence of the board, and staff interviews revealed a lack of awareness and adherence to the care plan.
The facility failed to follow physician's orders for a resident's blood glucose checks and did not document a skin assessment for another resident's wound. The first resident's blood glucose checks were not alternated between morning and evening as ordered, and the second resident's wound on the right lower leg lacked documentation of assessment. Interviews with staff confirmed the expectation to follow orders and document assessments, but these were not met.
A resident with cognitive impairment and incontinence was found double briefed and very wet, indicating a lapse in care. The LPN discovered the issue and noted the need for two staff to assist due to the resident's size and mobility. Observations showed CNAs did not cleanse all areas potentially contaminated by urine. The DON confirmed double briefing is unacceptable and emphasized the need for regular checks and thorough cleaning.
A facility failed to follow physician orders for a resident's oxygen therapy, administering incorrect oxygen flow rates and not changing or dating the oxygen tubing as required. Despite orders for 2L/NC continuously, observations showed higher flow rates and undated tubing. Interviews with staff confirmed non-compliance with orders and facility policies.
The facility did not post the correct date for nurse staffing information on four out of five days. The staffing sheets, which detail RN and LPN hours, were outdated or missing. The DON confirmed that the information should be updated daily and accurately.
A LTC facility failed to maintain a medication error rate below 5%, with errors observed in insulin pen priming, vitamin D administration, and eye medication technique. Insulin pens were not primed before use, vitamin D capsules were improperly mixed with pudding, and eye drops were administered directly onto the eyeball without following proper procedure. Staff interviews confirmed non-compliance with facility policies.
The facility failed to follow infection control and medication administration protocols. Staff did not use enhanced barrier precautions for residents with indwelling devices, and catheter bags were improperly placed on the ground. Additionally, a CNA placed dirty linens on the floor, and a CMT held medications under their arm without proper hand hygiene. These actions were against the facility's policies, as confirmed by interviews with the DON and Administrator.
A resident in a wheelchair was intentionally burned on the forehead with a cigarette by another resident in the smoking area of an LTC facility. The incident occurred due to inadequate supervision, as the staff member present was assisting another resident and had their back turned. The aggressor, who had a history of schizophrenia, was later discharged for safety concerns.
A resident with multiple medical conditions developed a wound on the left lower leg due to a broken wheelchair, which was not documented or addressed by the facility. The facility failed to complete and document weekly skin and wound assessments, as required by their policy. Staff interviews revealed a lack of communication and documentation regarding the resident's wound and the condition of the wheelchair.
A resident with a history of aggressive behavior intentionally burned another resident on the forehead with a cigarette in the smoking area of an LTC facility. The facility's smoking policy requires supervision, but no staff were present at the time of the incident. The victim, who was cognitively intact but had functional impairments, was unable to defend themselves. Witnesses confirmed the act was intentional, and the victim sustained a blister. The facility's failure to provide adequate supervision directly contributed to the incident.
Failure to Label Insulin Pens per Facility Policy
Penalty
Summary
The facility failed to ensure insulin pens were labeled in accordance with its Insulin Labeling and Storage policy, which required all insulins removed from the refrigerator to be dated and labeled with the resident’s name and an expiration date, and specified that insulins are only good for 28 days after opening. During observation of the medication cart used for all residents receiving insulin, a nurse identified the drawer containing insulin pens in use and surveyors observed 10 insulin pens, each with a sticker intended for documenting the date opened and date expired. Of these, nine pens (including insulin aspart, insulin degludec, Lantus, and Humalog) had no date opened and no expiration date recorded. The LPN interviewed at the time stated that all insulin pens should be labeled when removed from the refrigerator and acknowledged they would not know when these unlabeled pens were opened or placed on the cart, despite the policy and the 28‑day usability limit after opening. In a subsequent interview, the administrator and DON stated they would expect staff to follow the facility’s insulin labeling and storage policy.
Improper Gait Belt Transfer Used Instead of Required Hoyer Lift
Penalty
Summary
Surveyors identified a deficiency in which staff failed to follow the resident’s care plan and transfer requirements, resulting in the use of an inappropriate transfer method. The facility’s policy for gait belt transfers required review of the Kardex for transfer assistance needs and specified proper use of the gait belt. Resident #3’s medical record showed diagnoses of hemiparesis and hemiplegia following a stroke on the right dominant side, severe cognitive impairment, and limited range of motion in one lower extremity. The resident’s care plan and staffing book indicated the resident was dependent for transfers and required a mechanical (Hoyer) lift with assistance of two staff for transfers, with interventions specifically directing use of a Hoyer lift due to fall risk, poor balance, unsteady gait, stroke with right hemiplegia, dementia with impulsivity, and impaired decision making. Despite these documented requirements, observation showed a CNA and an LPN entered the resident’s room to complete a skin assessment and transferred the resident using a gait belt instead of a Hoyer lift. The resident was assisted to stand from the wheelchair with staff on each side, each placing one arm under the resident’s armpit and one hand on the gait belt. The resident’s knees remained bent, the resident stood on toes, staff appeared to strain to hold the resident in a hunched position, and the resident yelled to be put down, stating they were slipping. Staff then repositioned the wheelchair parallel to the bed and again used the gait belt and underarm hold to stand and pivot the resident, during which one foot remained on the ground and twisted while the other foot lifted as staff swung the resident into bed. Interviews confirmed that transfer status is communicated via the Kardex, staffing book, and colored stickers on name plates, and that a pink sticker should have indicated Hoyer transfer status for this resident; however, no pink sticker was present on the name plate at the time of observation. The Administrator and DON stated that if a resident is identified as a Hoyer transfer in the care plan and staffing binder, it is not acceptable to use a gait belt.
Failure to Administer Ordered Nutritional Supplements and Dietary Items
Penalty
Summary
Certified Medication Technician (CMT) D failed to provide nutritional supplements as ordered to four residents, all of whom had physician orders and care plans specifying the need for supplements such as Ensure or Med Pass 2.0. Observations revealed that these supplements were not present on meal trays, not available on medication carts, and not administered during medication passes, despite CMT D initialing the Medication Administration Record (MAR) to indicate they had been given. Interviews with the CMT and other staff confirmed that the supplements were not administered as ordered, and the CMT admitted to documenting administration when it had not occurred, citing a lack of stock, which was contradicted by the Central Supply Clerk who confirmed adequate supply was available. Multiple residents with significant weight loss, malnutrition, and other medical conditions such as anemia, renal insufficiency, and pressure ulcers were affected by the failure to administer supplements. For example, one resident with a history of severe protein-calorie malnutrition and a stage 2 pressure ulcer did not receive Ensure as ordered, and another resident with cognitive impairment and a history of weight loss did not receive Med Pass 2.0. Observations also showed that dietary orders for whole milk were not followed, with residents being served 2% milk instead, and staff failing to verify or correct discrepancies between menu slips and what was served. Interviews with facility staff, including the Central Supply Clerk, Dietary Manager, and Administrator, confirmed that the responsibility for administering supplements and ensuring correct dietary items rested with both nursing and dietary staff. However, the process failed at multiple points, including communication, documentation, and direct care. The Medical Director stated an expectation that facility policies and physician orders be followed, but the observed and documented failures resulted in residents not receiving prescribed nutritional support.
Expired COVID-19 Tests Used in Facility
Penalty
Summary
The facility failed to ensure the quality of laboratory services by using expired COVID-19 tests to test employees and residents. The tests used were Access Bio COVID-19 Antigen tests with a lot number of CP23B69, which had an expiration date that had already passed. The facility believed they had a waiver extending the expiration date by six months, but upon review, it was found that the waiver did not apply to the lot number in question. The Quality Control Lab Manager from Access Bio confirmed that the lot number CP23B69 had no further extension beyond the 21-month period, and the tests should have been discarded. The deficiency was identified during observations and interviews with facility staff, including the Assistant Director of Nursing, Licensed Practical Nurses, and the Director of Nursing. The facility had one case of COVID-19 due to an employee testing positive, prompting testing of staff and residents. However, the expired tests were used during this process. The Director of Nursing acknowledged that the facility should have verified the expiration dates with the manufacturer before using the tests.
Failure to Follow Recipes During Meal Preparation
Penalty
Summary
The facility failed to ensure that recipes were followed during meal preparation, as observed during one of two meal services. During the lunch meal service preparation, a staff member, [NAME] H, was seen removing steak patties from a box and placing them directly on the skillet without following the Swiss steak recipe, which required seasoning and additional preparation steps. Furthermore, [NAME] H prepared pureed stewed tomatoes and pureed Swiss steak without using the prescribed recipes, resulting in incorrect ingredient proportions. The absence of recipes in the food preparation area was noted, and [NAME] H admitted to not following any recipes, instead relying on personal judgment and package directions. Interviews with staff revealed a lack of awareness and adherence to recipe usage. [NAME] I, another staff member, acknowledged not knowing where to find recipes and often relied on package directions. Despite the expectation from the facility's administrator that cooks should use and know where to find recipes, the staff demonstrated a lack of compliance with this requirement. This deficiency in following recipes could potentially impact the nutritional needs and dietary requirements of the residents, although the report does not specify any direct consequences or risks to the residents.
Failure to Reconcile Resident Trust Accounts
Penalty
Summary
The facility failed to complete and maintain monthly account reconciliations of the facility's bank statements for all 12 months of the year. Additionally, the facility did not reconcile the resident trust at the end of the month for two specific months. The facility's undated resident rights policy outlines the right of residents to manage their financial affairs, receive information about available services and charges, and have personal funds over certain amounts deposited in a separate interest-bearing account with financial statements provided quarterly or upon request. However, the review of the facility's resident trust showed that for each month from January to November 2024, the reconciliations only included the Resident Fund Management Service (RFMS) statement without documentation of the bank statement or end-of-month reconciliation. Interviews conducted during the investigation revealed that the Business Office Manager (BOM) had some training but was not fully informed about the reconciliation process due to the previous BOM's passing. The BOM stated that she was instructed only to print the RFMS and reconciliation and did not receive the bank statements, which might be held by corporate. The facility administrator expressed an expectation for the resident trust to be reconciled accurately and timely with the bank statements, indicating a gap between the expected and actual practices in managing residents' personal funds.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple deficiencies observed during the survey. Residents were found to be living in rooms with malodorous conditions due to the facility's failure to launder dirty linen promptly. For instance, Resident #38 was observed with stained and odorous bedding, and the dirty linen was left in the room for an extended period, causing a strong feces odor. Similarly, Resident #24 complained about the infrequent changing of bedding and the persistent smell in the room due to the roommate's incontinence. Additionally, the facility did not maintain the physical environment adequately, leading to discomfort for the residents. Residents #23 and #37 experienced drafts of cold air due to gaps around their air conditioner units, which were not properly sealed. Resident #21 had broken tiles in the room, and Resident #13 had damaged baseboards and window blinds. These issues were not addressed in a timely manner, contributing to an environment that was not homelike or comfortable. The facility also failed to ensure that resident furniture was in good repair. Resident #1 reported broken bathroom drawers, which were observed to be in disrepair during multiple visits. Furthermore, Resident #65 had an active leak under the air conditioner unit, with a towel placed to absorb the water, and a ripped mattress cover. Despite these observations, there was a lack of prompt action to rectify these issues, indicating a failure in maintaining a safe and comfortable living environment for the residents.
Deficiencies in Resident ADL Care
Penalty
Summary
The facility failed to meet the Activities of Daily Living (ADL) care needs of several residents, as observed during a survey. Resident #4 was not repositioned or toileted in a timely manner, resulting in reddened areas in the genital region and heavily soiled briefs with a strong odor of urine. Additionally, the resident's nails were observed to be dirty and untrimmed, despite the care plan indicating the need for regular hygiene and nail care. Staff interviews revealed inconsistencies in the understanding of the resident's transfer needs and the documentation of care provided. Resident #65 was found to have dry, cracked lips, indicating a lack of proper oral hygiene and grooming, despite being dependent on staff for personal care. The Director of Nursing (DON) was unaware of the issue, highlighting a gap in communication and oversight. Similarly, Resident #3 exhibited a strong body odor and untrimmed facial hair, with bloody discharge observed at the catheter site, suggesting inadequate personal hygiene and catheter care. Staff interviews confirmed expectations for cleanliness and grooming, which were not met in this case. Resident #1 reported that staff did not consistently assist with washing their face, as evidenced by the presence of white matter around the mouth and eye. Resident #24 was observed with dark matter under their nails, which were not cleaned despite the resident eating with their hands. Staff interviews indicated that refusals of care should be documented and revisited, but this was not consistently practiced. Overall, the facility's failure to adhere to care plans and policies resulted in unmet personal care needs for multiple residents.
Medication Administration Deficiencies
Penalty
Summary
The report identifies several deficiencies in the administration of pharmaceutical services to residents. A CMT was observed placing a box of eye drops under her arm and failing to pull down the left eyelid of a resident while administering eye drops. Additionally, a nurse did not prime the insulin pen for two residents, which is a necessary step to ensure accurate dosing. Another incident involved a CMT leaving a resident with medications unattended in the therapy gym while she went to retrieve a water bottle for the resident. These actions and inactions demonstrate a lack of adherence to proper medication administration protocols, potentially compromising resident care.
Unsecured Medication Storage in ADON's Office
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to acceptable standards of practice. Specifically, medications were found unsecured in the Assistant Director of Nursing's (ADON) office, which was not designated as a medication storage room. The ADON's office contained multiple bottles of over-the-counter medications and vitamins, including an open and unlabeled bottle of magnesium citrate. The office was frequently observed with the door open and no staff present, allowing medications to be visible and accessible from the hallway. Interviews with the Director of Nursing (DON) and the ADON confirmed that the facility had only two designated medication rooms, both located near the nurse's station. The DON acknowledged that the ADON's office should be considered a medication room if medications are stored there and should be kept locked. Despite this, the ADON admitted to locking the office only at night, leaving it unsecured during the day. Observations over several days consistently showed the office door open and medications visible, indicating a failure to adhere to the facility's Medication Administration Policy.
Call Light System Malfunction in LTC Facility
Penalty
Summary
The facility failed to ensure that the call light system was in working order for multiple residents, including two specific residents, Resident #24 and Resident #29. The call light system was found to be malfunctioning in 24 additional resident rooms, potentially affecting all residents in those rooms. The facility's call light policy outlines the importance of responding to residents' requests promptly, but the system's failures hindered this process. The nurse call system report indicated numerous issues, such as call lights not annunciating on the correct consoles or not lighting up corridor lights, which were not addressed in a timely manner. Resident #24, who was cognitively intact and diagnosed with dementia, anxiety, and major depressive disorder, experienced delays in staff response due to a malfunctioning call light. Observations showed that the call light panel at the nurse's station indicated activation, but the light above the resident's door was off. Staff referred to this as a 'ghost light,' and despite being aware of the issue, the problem persisted without immediate resolution. Similarly, Resident #29, who was also cognitively intact and diagnosed with high blood pressure and schizophrenia, faced issues with the call light system. The call light for this resident activated incorrectly, showing up as a different room on the console, and the resident was unaware of the ongoing issues. Interviews with staff, including CNAs, LPNs, and the Maintenance Director, revealed awareness of the call light issues but a lack of effective communication and resolution. The Maintenance Director acknowledged the need for repairs and mentioned that residents were given bells as a temporary measure. However, agency staff were not adequately informed about the malfunctioning call lights or the interim solutions, leading to further confusion and potential delays in resident care. The Administrator expected the call lights to be in working order and staff to be informed about the current system status, but the issues remained unresolved at the time of the report.
Failure to Facilitate Resident Choice Due to Equipment Unavailability
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice for a resident who had an order to be up in a wheelchair before lunch. The resident, who was cognitively impaired and dependent on staff for activities of daily living, was observed lying in bed throughout the morning and early afternoon on two consecutive days. Despite having an order to be up before lunch, the staff did not offer to assist the resident out of bed, and the resident remained in bed with meals served at the bedside. The deficiency occurred because the staff could not find a Hoyer lift pad, which was necessary for transferring the resident from bed to wheelchair. Although the resident's care plan indicated the use of a mechanical lift with the assistance of two staff members, the staff did not obtain another Hoyer pad or notify the Director of Nursing to find a solution. The resident's preference to be up during the day was not honored, and the staff failed to facilitate the resident's choice due to the unavailability of the necessary equipment.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure privacy during care for a resident, identified as Resident #3, who had diagnoses including aphasia, dementia, and major depressive disorder, and was noted to have severe cognitive impairment. During an observation, a Certified Nursing Assistant (CNA) was seen providing care to the resident with the door wide open and the privacy curtain not pulled, exposing the resident's stomach and brief to the hallway. This lack of privacy was further compounded when a Nurse Manager entered the room, asked if assistance was needed, and left the door open upon exiting. Interviews with staff members, including a CNA, an LPN, and the Director of Nursing (DON), revealed that the facility's protocol was to close the resident's door and pull the privacy curtain when providing care to ensure the resident's dignity and privacy. The DON confirmed the expectation that staff should provide privacy to residents during care. However, the observed actions of the staff did not align with these expectations, leading to a deficiency in maintaining the resident's privacy.
Inappropriate Immediate Discharge Following Resident Altercation
Penalty
Summary
The facility failed to provide an appropriate discharge for a resident following a resident-to-resident altercation. The resident, who was cognitively intact with a Brief Interview Mental Status (BIMS) score of 15 out of 15, was involved in an altercation that was de-escalated by staff without incident or reported injuries. Despite the absence of severe behaviors, the facility issued an immediate discharge, citing that the resident's care and protective oversight exceeded the facility's current capacity. The facility's policy requires that discharges be conducted according to state and federal regulations, with adequate preparation and documentation. However, the immediate discharge of the resident did not align with these requirements. The resident's care plan indicated potential for physical and verbal aggression, but there was no documentation of aggressive behaviors towards other residents in the progress notes. The facility's investigation into the altercation showed that both residents involved were swinging at each other, but no physical injuries were reported. Interviews with staff revealed mixed observations about the resident's behavior, with some staff noting aggressive behaviors and others not witnessing any. The facility's decision for an immediate discharge was based on the resident's dementia progression and exit-seeking behaviors, as well as concerns for the safety of other residents. However, the facility did not provide the required 30-day written notice of discharge, nor did it adequately document the necessity of the discharge in the resident's clinical record.
Failure to Notify Ombudsman After Immediate Discharge
Penalty
Summary
The facility failed to notify the Ombudsman in a timely manner following the immediate discharge of a resident after a resident-to-resident altercation. The discharge was issued because the resident's care and protective oversight needs exceeded the facility's current capacity. The facility's policy requires notification of the Ombudsman, but this was not done promptly. The resident involved in the incident was cognitively intact but had diagnoses including dementia, depression, manic depression, and PTSD. The resident had a history of attempting to leave the facility unsupervised and exhibited physical aggression. The altercation occurred when the resident picked up another resident's Bingo card, leading to a physical confrontation. The facility's investigation confirmed that both residents struck each other, but no physical injuries were reported. The facility's policy mandates a 30-day written notice for discharges, except in emergencies. In this case, an immediate discharge was issued due to safety concerns, as the resident had been involved in two altercations. The Administrator acknowledged the failure to notify the Ombudsman, attributing the responsibility to the Social Worker. The decision for immediate discharge was made to ensure the safety of other residents, given the resident's progressing dementia and aggressive behavior.
Failure to Complete PASRR Screening for Resident
Penalty
Summary
The facility failed to ensure that a DA-124 Level 1 screen was completed for a resident being admitted to a Medicaid-certified facility, as required by PASRR regulations. The resident in question had a medical history that included right-sided weakness due to a stroke, diabetes, depression, aphasia, high blood pressure, epilepsy, and bipolar disorder. Despite these conditions, there was no record of a Level 1 or Level 2 PASRR screen being completed for the resident. The Business Office Manager (BOM) was unable to locate the necessary documentation and was unsuccessful in obtaining a copy from the Missouri Central Office Medical Review Unit (COMRU). Interviews conducted during the survey revealed that the BOM acknowledged that PASRR screens should be completed upon admission. The Administrator expected staff to adhere to the facility's policy for obtaining PASRR pre-screening. However, the BOM indicated that the Admission Coordinator was responsible for obtaining the PASRR pre-screening, while she was responsible for ensuring its completion. Despite these roles, the facility failed to provide the required documentation by the exit date of the survey.
Failure to Provide Communication Board for Resident with Aphasia
Penalty
Summary
The facility failed to provide necessary services to ensure that a resident's abilities in activities of daily living do not diminish due to a lack of accommodation for the resident's communication needs. The resident, who has diagnoses including aphasia, dementia, and major depressive disorder, was observed multiple times without a communication board, which is essential for their ability to communicate effectively. The resident's care plan specifically included interventions such as the use of a communication board, yet observations on several occasions showed the absence of this tool in the resident's room or within their reach. Interviews with staff, including a social worker, CNA, LPN, and the DON, revealed a lack of awareness and adherence to the resident's care plan regarding the communication board. The social worker indicated that staff should provide a communication board if it is not present, while the CNA and LPN acknowledged the importance of communication for residents but were unaware of the specific requirement for this resident. The DON confirmed that the communication board should be available and accessible to the resident as per the care plan and facility policy.
Failure to Follow Physician's Orders and Document Skin Assessments
Penalty
Summary
The facility failed to ensure that residents received care consistent with professional standards, as evidenced by two specific incidents. In the first case, a resident with multiple diagnoses, including diabetes, had a physician's order to check blood glucose levels daily, alternating between morning and evening on specific days. However, the Medication Administration Record (MAR) showed that blood glucose checks were only scheduled for the morning, contrary to the physician's order. Interviews with the LPN and the Director of Nursing (DON) confirmed that the expectation was for staff to follow physician's orders as written. In the second incident, a resident with a wound on the right lower leg did not have a documented assessment of the wound. The facility's Skin Program policy requires that all residents be observed and evaluated for skin problems, and any skin issues should be documented and addressed in a care plan. Despite this, there was no documentation of how the skin tear occurred, its location, or a description in the resident's nurse's notes. The Wound Nurse and LPN confirmed that there should have been documentation and assessment of the skin tear, and the DON stated that the expectation was for nurses to investigate, assess, and document skin issues. These deficiencies highlight a failure to adhere to the facility's policies and procedures regarding physician's orders and skin assessments. The lack of proper documentation and adherence to orders could potentially impact the quality of care provided to residents, as evidenced by the incidents involving the two residents.
Inadequate Incontinence Care and Double Briefing
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bowel and bladder. The deficiency was identified when staff placed two briefs on the resident, which became saturated with urine, causing discomfort. The facility's policy requires incontinence care every two hours, but the resident was found to be very wet and moist, indicating a lapse in care. The resident, who has cognitive impairment and is dependent on staff for personal care, was unable to communicate effectively about their needs. During an observation, a Licensed Practical Nurse (LPN) discovered the resident was double briefed and very wet. The LPN noted that the resident's condition required two staff members to assist due to the resident's mobility and size. The LPN was unsure when the Certified Nursing Assistant (CNA) last provided care, and the resident could not confirm if care was given that morning. The LPN expressed concern about skin issues resulting from being left wet and instructed the CNAs to provide care and reassess the resident. Further observations revealed that the CNAs did not cleanse all areas potentially contaminated by urine, as one side of the resident's buttock area was not wiped. The Director of Nursing (DON) confirmed that double briefing is not acceptable due to potential skin issues and emphasized the importance of checking residents at least every two hours. The DON also stated that both sides of the resident's buttock area should be cleaned during incontinence care.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that respiratory services provided to a resident were consistent with professional standards of practice. Specifically, the staff did not adhere to the physician's orders regarding the rate of oxygen administration and the regular changing and dating of oxygen tubing. The resident, who was cognitively intact and required oxygen therapy, had a history of pneumonia, respiratory failure, and other significant health conditions. Despite the physician's orders for oxygen to be administered at 2 liters per nasal cannula continuously and for the oxygen tubing to be changed weekly, observations revealed discrepancies in the oxygen flow rate and the dating of the tubing. On multiple occasions, the resident was observed receiving oxygen at rates higher than prescribed, with the tubing not being changed or dated as required. For instance, the resident was seen with oxygen at 3 liters and 5 liters per nasal cannula on different days, contrary to the prescribed 2 liters. Additionally, the oxygen tubing was not dated correctly, and there was no record of the tubing being changed as scheduled. Interviews with the LPN and the DON confirmed that the nursing staff did not follow the physician's orders for oxygen therapy and tubing changes, which was against the facility's policies and expectations.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the correct date for staffing information on a daily basis for four out of five days, as required. The daily staffing sheet, which includes the total number of hours worked by categories of licensed staff such as Registered Nurses (RNs) and Licensed Practical Nurses (LPNs), was found to be outdated or missing on several occasions. Specifically, on December 5th and 6th, the staffing sheet was dated November 27th. On December 9th and 10th, the sheet was dated December 6th, with a correction made later on December 10th. On December 11th, there was initially no staffing sheet posted, but it was later updated to reflect the correct date. The Director of Nursing acknowledged during an interview that the nurse staffing information should be updated daily and accurately.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 14.28% error rate during the survey. This was due to several observed medication administration errors involving insulin pens, vitamin D tablets, and eye medication. Specifically, insulin pens were not primed before administration, which is a necessary step to ensure the correct dosage is delivered. This error was observed in two residents with diabetes, where the Licensed Practical Nurse (LPN) did not prime the insulin pens before administering the insulin, despite the facility's policy and manufacturer instructions requiring this step. Another error involved the administration of a vitamin D tablet to a resident with a diagnosis of vitamin D deficiency. The Certified Medication Technician (CMT) opened a vitamin D capsule and mixed it with pudding, instead of administering it in the form ordered by the physician. This substitution was made without a physician's order, contrary to the facility's medication administration policy, which requires medications to be given in the form as ordered by the physician. Additionally, an error was observed in the administration of eye medication to a resident with multiple diagnoses, including encephalopathy and stroke. The CMT administered the eye drops directly onto the resident's eyeball without pulling down the lower eyelid, which is against the facility's procedure for administering ophthalmic solutions. This procedure is intended to ensure safe and effective administration of eye medication. Interviews with staff, including the Director of Nursing (DON) and the Administrator, confirmed that the facility's policies were not followed in these instances.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to adhere to infection prevention and control standards, as evidenced by multiple observations of staff not using enhanced barrier precautions (EBP) when providing care to residents with indwelling medical devices. For instance, a resident with severe cognitive impairment, a gastric tube, and a urinary catheter was observed being cared for by staff who did not wear gowns, despite the facility's policy requiring such precautions. Additionally, the resident's catheter bag was found lying on the ground, contrary to expectations that it should be hung to prevent contamination. Another incident involved a resident with cognitive impairment and multiple dependencies for daily activities. During care, a CNA was observed placing dirty linens on the floor and using a washcloth directly from the sink, which is against the facility's infection control policy. The Director of Nursing confirmed that linens should not be placed on the floor and that a basin should be used for washcloths. Further deficiencies were noted in medication administration practices. A CMT was observed placing medication under their arm while administering eye drops to two residents, without performing hand hygiene afterward. This practice was acknowledged by staff as inappropriate, as medications should not be held under the arm, and hand hygiene should be maintained during administration. Interviews with staff, including the DON and Administrator, confirmed that these actions were against the facility's policies on medication administration and infection control.
Resident Burned by Another Resident Due to Lack of Supervision
Penalty
Summary
The facility failed to protect a resident from abuse when one resident intentionally burned another resident with a cigarette. The incident occurred in the designated smoking area where a resident, who was cognitively intact and had no prior behaviors, was sitting in a wheelchair. Another resident, also cognitively intact but with a history of schizophrenia and anxiety disorder, approached and demanded the resident in the wheelchair to move. When the resident did not comply, the aggressor used a lit cigarette to burn the resident's forehead, causing a blister. The facility's policy required residents involved in altercations to be separated until an investigation was completed. However, at the time of the incident, there was no staff member directly supervising the smoking area. A dietary aide was present but was assisting another resident and had their back turned to the incident. This lack of supervision allowed the altercation to occur without immediate intervention, leading to the resident sustaining a burn injury. Interviews with other residents who witnessed the incident confirmed that the aggressor intentionally burned the resident with the cigarette. Despite the facility's policy and the presence of a staff member, the incident was not prevented, indicating a failure in monitoring and supervision in the smoking area. The aggressor was later discharged from the facility due to safety concerns for other residents.
Failure to Document and Address Resident's Wound and Equipment Issues
Penalty
Summary
The facility failed to ensure that nurses completed and documented weekly risk skin assessments and wound assessments for residents, particularly for a resident with multiple medical conditions including heart failure, end-stage kidney disease, and diabetes mellitus. The resident, who was cognitively intact and dependent on staff for various activities, was found to have a wound on the left lower leg that was not documented in the electronic medical record (EMR) in a timely manner. The facility's skin program policy required weekly assessments and documentation, but these were not consistently performed or recorded. The resident's wound was reportedly caused by a broken wheelchair, which had a missing left leg pad, exposing metal and screws that likely caused the trauma. Despite the resident's report of the wheelchair causing the wound, there was no documentation of the incident or investigation into the cause of the wound. The Wound Nurse and other staff failed to document the discovery of the wound, the condition of the wheelchair, or any measures taken to address the issue. The facility's policy required nurses to notify the primary care physician and responsible party, initiate new treatment, and document the wound in progress notes, but these actions were not completed. Interviews with staff revealed a lack of communication and documentation regarding the resident's wound and the condition of the wheelchair. The Wound Nurse was aware of the wound but did not document it in the progress notes, expecting others to do so. The Administrator expected staff to follow facility policies, complete assessments, and document findings, but these expectations were not met. The facility also failed to upload wound management team reports into the resident's EMR, further contributing to the lack of documentation and oversight.
Lack of Supervision Leads to Resident Harm in Smoking Area
Penalty
Summary
The facility failed to provide adequate supervision in the smoking area, leading to an incident where one resident intentionally burned another resident on the forehead with a cigarette. The facility's smoking policy mandates that all residents be supervised while smoking, and staff are responsible for lighting smoking products and providing necessary assistance. However, during the incident, there was no staff member present in the smoking area to monitor the residents, which allowed the altercation to occur. The resident who committed the act had a history of behavioral issues, including verbal aggression and difficulty adjusting to living in the facility. Despite being cognitively intact, the resident had diagnoses of schizophrenia and anxiety disorder, which contributed to their challenging behavior. Prior to the incident, the resident had been involved in verbal altercations and had exhibited aggressive behavior towards staff and other residents. The care plan for this resident included monitoring for safety during smoking and reporting any concerns, but these measures were not effectively implemented at the time of the incident. The victim of the incident was a resident with functional impairments due to a stroke, requiring a wheelchair for mobility. This resident was also cognitively intact and had no history of behaviors. The lack of supervision in the smoking area allowed the aggressive resident to approach and harm the victim without intervention. Witnesses confirmed that the act was intentional, and the victim sustained a blister on the forehead as a result. The facility's failure to ensure staff presence and oversight in the smoking area directly contributed to the occurrence of this incident.
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.
