Brooking Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Chesterfield, Missouri.
- Location
- 307 South Woods Mill Road, Chesterfield, Missouri 63017
- CMS Provider Number
- 265791
- Inspections on file
- 23
- Latest survey
- November 14, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Brooking Park during CMS and state inspections, most recent first.
Staff failed to provide necessary feeding assistance to two residents during meals and did not ensure oral hygiene or check for food debris after meals for a resident with severe cognitive impairment and a history of pocketing food. Observations showed that residents struggled to eat independently or did not eat at all until prompted or fed by staff, and staff were unclear about which residents required assistance, leading to inconsistent care.
A resident with severe cognitive impairment and limited mobility was transferred by a single staff member without the required mechanical lift or two-person assistance, contrary to the care plan and facility policy. The resident expressed pain during the manual transfer, and staff interviews confirmed knowledge of the proper procedures, which were not followed.
A resident admitted with a wound vac for an open abdominal surgical wound did not receive wound care as ordered by the hospital because facility staff failed to verify or obtain wound care orders and did not provide necessary treatments or supplies. The deficiency was discovered after the resident and family raised concerns, leading to the resident's discharge for hospital evaluation.
A resident was found unresponsive on the floor by a CNA, and the RN on duty failed to complete or document required physical and neurological assessments, including vital signs, lung sounds, oxygen saturation, and blood glucose, while waiting for EMS. The RN only checked the resident's pulse, which was not documented, and did not instruct the CNA to perform any assessments. This lack of assessment and documentation was confirmed by interviews and review of the resident's medical record.
Staff did not maintain privacy for a resident with severe cognitive impairment and multiple diagnoses during perineal care, leaving the door and window blinds open and failing to use privacy curtains or draping, which resulted in the resident being exposed to view from outside and anyone entering the room.
A resident with severe cognitive impairment and multiple diagnoses experienced repeated lapses in care, including missed rounds, improper medication administration, and lack of personal hygiene, as reported by a family member. The facility failed to follow its grievance policy, with incomplete documentation, lack of investigation, and poor communication with the complainant. The Social Services Director and DON did not ensure grievances were properly tracked, investigated, or resolved, and the family member was not informed of outcomes.
A resident with severe cognitive impairment and total dependence on staff did not receive required assistance with personal hygiene, including scheduled showers and grooming. Observations and interviews revealed the resident had poor hygiene, oily hair, and body odor, with missing documentation for showers over several weeks. Staff and family confirmed the lack of regular bathing and grooming, and the DON acknowledged incomplete records and failure to follow care plans.
Staff failed to follow policy and care plan requirements for safe transfers using a sit-to-stand mechanical lift for a resident with severe cognitive and physical impairments. Transfers were performed with only one staff member present and without properly securing the safety belt, despite the resident's need for maximum assistance and mechanical lift use.
A treatment cart was found unattended and unlocked with medications, including Exelon patches and Tamiflu, left on top and accessible to residents in the hallway. Facility policy requires medication carts to be locked unless under direct observation, and the DON confirmed that medications should not be left unsupervised.
A resident with severe cognitive impairment and multiple diagnoses did not receive breakfast within the facility's scheduled mealtime due to staff failing to assist the resident out of bed and into the dining room on time. Documentation of meal service was inconsistent, and staff interviews revealed a lack of coordination between nursing and dietary departments, resulting in meals being served late or missed.
The facility failed to maintain an effective grievance process, as a resident's family member received no response to multiple communications regarding care concerns. The facility's grievance policy lacked clarity on the designated Grievance Official, and staff interviews revealed confusion and inadequate follow-through on complaints. Resident Council meeting minutes indicated unresolved grievances, and the grievance log showed only two recorded grievances over several months.
The facility failed to serve meals in a timely manner due to staffing shortages and late arrivals, affecting residents with severe cognitive impairments who required assistance. Observations and interviews confirmed that meals were consistently late, with some residents missing meals. The Director of Culinary Services and other staff acknowledged the issues, but the facility's practices did not align with scheduled meal times.
The facility failed to provide necessary assistance with ADLs for two residents, leading to inadequate personal hygiene. One resident, with severe cognitive impairment, was observed with oily hair and strong body odor, and had not received a shower since admission. Another resident, also with severe cognitive impairment, was observed with oily hair and an unshaven beard, with no shower documentation for two months. Staff interviews revealed that showers were rarely completed as scheduled, and there was a lack of accountability due to the absence of a nursing manager.
The facility failed to provide adequate pressure ulcer care and prevention for two residents. One resident developed a new pressure ulcer without timely physician notification or treatment orders, and another resident did not receive required weekly skin assessments. Staff interviews revealed systemic issues in completing and documenting skin assessments, leading to deficiencies in care.
A facility failed to follow its policy requiring two-person assistance for a resident's mechanical lift transfers. Despite the resident's severe cognitive impairment and dependency on staff for transfers, video footage showed a CNA performing the transfer alone, leaving the resident unattended while attached to the lift. Interviews with staff confirmed the necessity of two-person assistance for safe transfers.
A resident with severe cognitive impairment and a history of UTIs did not receive proper urinary catheter care due to the facility's failure to have necessary supplies available, leading to delays in catheter change and urine specimen collection. Additionally, during a transfer, the resident's catheter bag was improperly positioned above the bladder, increasing infection risk. Staff interviews confirmed the facility's failure to adhere to catheter care policies.
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter, as staff did not wear isolation gowns or perform proper hand hygiene. Additionally, an LPN improperly handled medications by popping pills directly into their hands, contrary to policy. Interviews with staff confirmed these lapses in infection control and medication administration practices.
A resident with a history of falls and cognitive impairment was placed on a low air loss (LAL) mattress with bed rails by therapy staff without proper assessment, evaluation, or consent, as required by facility policy. Staff were unaware of protocols for combining LAL mattresses with siderails, and no documentation of safety checks or monitoring was found. The resident was later found with their head trapped between the rail and mattress, resulting in asphyxiation and death.
The facility failed to meet food safety standards, with numerous unlabeled and expired food items found during a kitchen tour. The Executive Chef admitted responsibility for ensuring proper labeling but failed to do so. Moldy onions and expired dairy products were not discarded promptly. Additionally, the facility did not maintain a clean food preparation area, with wet dishware used for meal service, uncovered food near trash cans, and unsanitary conditions like food debris and dust accumulation. Water dripped from the ceiling onto the steam table during meal service.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents at risk of MDROs, with no signage or PPE available. Respiratory equipment was improperly stored, lacking proper dating and bagging. Additionally, the facility did not adhere to its TB screening policy for employees, with missing documentation for required tests.
The facility failed to complete baseline care plans within 48 hours of admission for several residents, including those with severe medical conditions such as acute respiratory failure, dementia, and pressure ulcers. The absence of a unit manager or charge nurse to oversee the process contributed to this deficiency.
An LPN failed to verify the identity of a resident before performing a fingerstick blood sugar test, resulting in the wrong resident being tested. The resident, who had no diagnosis of diabetes, was tested without a physician's order. Interviews revealed that the LPN had the wrong administration record, and the facility lacked a specific policy for verifying orders, relying instead on standard practice expectations.
A resident with COPD and dependence on supplemental oxygen was observed using an oxygen concentrator without a physician's order, contrary to facility policy. The absence of an order was confirmed by an LPN, the DON, and the Administrator, highlighting a deficiency in respiratory care.
A facility failed to properly store and provide medications for two residents, leading to missed doses. One resident's gabapentin was misplaced in the medication cart, while another resident's medications were delayed due to late pharmacy orders. Staff interviews revealed issues with medication storage and delivery procedures.
Two residents were found with unsecured medications in their rooms without physician's orders or assessments for self-administration. Staff were unaware of proper procedures, and the facility's policy on secure medication storage was not followed, leading to a deficiency in medication management.
A resident with a history of knee fracture was administered oxycodone from the emergency supply, but staff failed to document the administration in the Treatment Administration Record. Interviews with two LPNs confirmed the medication was given, but documentation was overlooked, contrary to facility policy.
Failure to Provide Required Feeding Assistance and Oral Hygiene
Penalty
Summary
The facility failed to ensure that residents requiring assistance with Activities of Daily Living (ADLs), specifically grooming, eating, and oral hygiene, received the necessary services as outlined in their care plans and facility policies. Observations and interviews revealed that two residents who needed feeding assistance during meals did not consistently receive the required help. One resident with chronic fatigue, high blood pressure, and oropharyngeal dysphagia experienced significant weight loss and was observed struggling to feed themselves due to hand tremors and decreased alertness. Despite being listed as needing feeding assistance, staff were unclear about the resident's needs, and there was no documentation indicating the requirement for feeding assistance. Staff often relied on verbal reports rather than written care plans, leading to inconsistent care during mealtimes. Another resident with Alzheimer's disease, tremors, and cognitive deficits was documented in physician orders as needing to be fed at all meals. However, this resident was not included on the facility's list of residents requiring feeding assistance, and staff did not consistently provide the necessary help. Observations showed the resident playing with food and not eating until prompted and fed by staff, indicating a lack of awareness among staff regarding the resident's care needs. Interviews with staff and the DON revealed a lack of knowledge about which residents required feeding assistance, with some staff believing the resident only needed encouragement rather than direct feeding. Additionally, a resident with severe cognitive impairment and a history of pocketing food was left with a meal tray in their room without staff attempting to wake them to eat or providing oral hygiene after meals, as directed in the care plan. Observations showed that staff did not check the resident's mouth for debris or provide oral care after meals, and documentation of meal intake and episodes of falling asleep during meals was incomplete. Staff interviews confirmed that oral care was typically only provided in the morning and evening, not after meals, even when care plans specified otherwise. These failures demonstrate a lack of adherence to individualized care plans and facility policies regarding ADL support, particularly in feeding and oral hygiene.
Failure to Use Mechanical Lift and Two-Person Assistance During Resident Transfer
Penalty
Summary
Staff failed to provide adequate supervision and assistance during a transfer for a resident with severe cognitive impairment, arthritis, dementia, depression, and spinal stenosis. According to the resident's care plan and the facility's Safe Resident Handling/Transfer Policy, the resident required a mechanical lift with two-person assistance for all transfers. However, video footage showed a single staff member transferring the resident manually using a 'bear hug' technique, without the required mechanical lift or a second staff member present. During the transfer, the resident expressed discomfort and pain, specifically mentioning back pain, while the staff member continued the transfer without seeking additional help. Interviews with facility staff, including a CNA, RN, DON, and the Administrator, confirmed that staff were aware of the resident's need for two-person mechanical lift transfers and that manual lifting was not appropriate for this resident. The DON and Administrator were not aware of the incident until it was brought to their attention. The failure to follow the resident's care plan and facility policy resulted in a transfer being performed in a manner inconsistent with established safety protocols.
Failure to Verify and Provide Wound Vac Care Upon Admission
Penalty
Summary
The facility failed to ensure acceptable nursing standards of practice when a resident was admitted from the hospital with a wound vacuum (wound vac) in place for an open surgical abdominal wound. Upon admission, the facility did not verify or obtain the necessary wound vacuum treatment orders, including dressing change schedules and required supplies, as indicated in the hospital discharge summary. The resident's admission physician order sheet and treatment administration record did not contain any wound care orders for the abdominal wound vac, and the initial nursing assessment did not address the surgical wound or the wound vac. Throughout the resident's stay, there was no documentation of wound care being provided to the abdominal wound vac. Nursing staff, including the DON and LPNs, confirmed that the admitting nurse and subsequent staff did not verify or solicit wound care orders from the hospital or the resident's physician. The resident and family raised concerns about the lack of wound vac changes, noting that in the hospital, the wound vac was changed every 72 hours. Despite these concerns, the facility did not have wound care supplies available, and no orders were located or obtained during the resident's stay. As a result, the resident did not receive any wound care or wound vac changes while at the facility. The deficiency was identified when the resident and family requested discharge to the hospital for wound evaluation and treatment after discovering that no wound care had been provided since admission. Interviews with facility staff confirmed that the required assessments and order verifications were not completed, and the resident's wound care needs were not met during their stay.
Failure to Assess and Document Resident After Unresponsiveness
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) completed and documented required physical and neurological assessments for a resident who was found unresponsive in their room. According to the report, a Certified Nursing Assistant (CNA) discovered the resident sitting on the floor, leaning against a recliner, and notified the RN. Upon arrival, the RN attempted to arouse the resident, who remained unresponsive, and then left the room to call 911 and the physician, leaving the CNA with the resident. The RN did not perform or document a full assessment, including vital signs, lung sounds, oxygen saturation, blood glucose, or neurological checks, as required by facility policy. The facility's policy on observing, recording, and reporting condition changes specifies that after a fall, injury, or change in condition, staff must monitor for a range of symptoms, check vital signs, and document all observations and assessments. The RN's job description also requires charting all accidents or incidents and providing detailed, objective documentation of care and resident response. In this incident, the RN only checked the resident's pulse, which was not documented, and did not perform any other assessments or instruct the CNA to do so. The resident continued to exhibit snoring respirations until EMS arrived, at which point CPR was initiated. Interviews with the CNA, RN, Director of Nursing (DON), and the resident's physician confirmed that the expected assessments and documentation were not completed. Both the DON and the physician stated that they would have expected ongoing assessments and documentation until EMS arrived, in accordance with facility policy. The lack of assessment and documentation was also evident in the resident's electronic health record and the RN's written statement, which did not include required details about the resident's condition or care provided during the event.
Failure to Ensure Resident Privacy During Perineal Care
Penalty
Summary
Staff failed to maintain resident dignity and privacy during perineal care for one resident with severe cognitive impairment and multiple medical conditions, including diabetes, Alzheimer's disease, and Parkinson's disease. On two separate occasions, staff provided perineal care without closing the resident's door or window blinds, and without using privacy curtains or draping, resulting in the resident's genitalia and buttocks being exposed. The resident's room was visible from an outside walkway, and the absence of privacy curtains meant that anyone entering the room could see the resident exposed. Video footage and direct observation confirmed that staff did not take appropriate measures to protect the resident's privacy while changing briefs and providing personal care. Interviews with facility leadership revealed that staff were expected to close blinds and use privacy measures, but these steps were not followed, and the room lacked privacy curtains despite having tracks for them. The sample included seven residents, with a facility census of 63 and 28 in certified beds.
Failure to Maintain Effective Grievance Process and Prompt Resolution
Penalty
Summary
The facility failed to maintain an effective grievance process for residents and family members, as evidenced by the handling of grievances submitted on behalf of a resident with severe cognitive impairment, Alzheimer's disease, and Parkinson's disease. The facility's grievance policy requires prompt resolution, tracking, investigation, and communication with the complainant, but these procedures were not followed. Grievance forms submitted by the resident's family member detailed multiple concerns, including missed rounds, improper medication administration, missed meals, lack of personal hygiene care, and inappropriate staff behavior. The forms lacked essential documentation such as investigation details, tracking numbers, assigned investigators, and dates of response letters. Interviews revealed that the Social Services Director (SSD), who served as the Grievance Officer, did not consistently oversee or document the investigation and resolution process. The SSD reported forwarding grievances to relevant department heads but was unsure of the required response time and did not ensure that investigations were completed or communicated back to the complainant. The Director of Nursing (DON) admitted to not investigating specific allegations, such as staff failing to check on the resident, improper medication administration, and staff tampering with the resident's camera. The DON also did not interview staff or provide investigation documentation related to the grievances. The family member who filed the grievances reported ongoing issues with communication and lack of follow-up from facility staff. Despite providing specific dates and times for the alleged incidents, the family member was not informed of the results of the grievances and was not provided with the facility's grievance policy upon request. The grievance forms available in the facility did not include instructions on submission, expected response times, or identification of the grievance officer, further contributing to the ineffective grievance process.
Failure to Provide Required ADL Assistance and Hygiene Care
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs), specifically personal hygiene, bathing, and grooming, to a resident with severe cognitive impairment and diagnoses of Alzheimer's and Parkinson's disease. The resident was documented as being fully dependent on staff for toileting hygiene, showers/baths, dressing, and transfers. Physician orders and the resident's care plan required showers or baths twice weekly, with additional interventions for good hygiene due to a history of urinary tract infections. However, observation revealed the resident had oily, unkempt hair, long facial hair, and a strong body odor, indicating a lack of regular hygiene care. Family and staff interviews confirmed that the resident had not received showers as scheduled, and documentation for required showers was missing or incomplete for several weeks. Review of facility records showed only sporadic documentation of showers provided, with significant gaps in both February and March. Staff interviews indicated that showers were supposed to be given twice weekly and that nurses were responsible for signing off on shower sheets, but the Director of Nursing confirmed that no additional documentation was available. The resident's appearance and hygiene were consistently poor, and staff failed to provide shaving as required. These failures resulted in the resident not receiving the ordered and care planned hygiene services necessary to maintain personal cleanliness and skin integrity.
Failure to Follow Safe Transfer Protocols with Mechanical Lift
Penalty
Summary
Facility staff failed to follow established policy and the resident's care plan regarding the use of a sit-to-stand mechanical lift for a resident with severe cognitive impairment, Alzheimer's disease, and Parkinson's disease. The policy required two nursing staff to be present for each transfer and for the safety belt to be fastened securely around the resident's waist. However, video footage and direct observation revealed that staff repeatedly performed transfers with only one staff member present and did not secure the safety belt as required. In one instance, a CNA transferred the resident alone, with the belt hanging unattached. In another, a CNA turned the camera away during the transfer, and no second staff member was present, while the resident expressed discomfort. During a separate observed transfer, two CNAs assisted, but the belt was not properly clasped around the resident's waist. Interviews with staff confirmed a lack of adherence to the policy, with one CNA stating they thought the belt was secured but did not check the buckle, and the DON confirming that two-person assistance and proper belt fastening were expected. The resident involved was dependent on staff for all transfers and required maximum assistance due to significant physical and cognitive limitations. The failure to follow policy and care plan interventions resulted in unsafe transfer practices for a vulnerable resident.
Unattended and Unlocked Treatment Cart with Medications
Penalty
Summary
Surveyors observed that a treatment cart on the Avalon unit was left unattended and unlocked for a period of 17 minutes, with multiple medications, including two Exelon patches and one Tamiflu tablet, left on top of the cart. The cart was accessible to residents who were present in the hallway near the cart, and all drawers containing treatment supplies and various medications could be opened. The facility's policy requires all medication storage areas, including carts, to be locked at all times unless in use and under the direct observation of the medication nurse or aide. During an interview, the Director of Nursing confirmed that the expectation is for all treatment and medication carts to be locked and secured, and that medications should not be left unsupervised.
Failure to Serve Meals Within Designated Timeframes
Penalty
Summary
The facility failed to ensure that a resident received meals in a timely manner according to the designated meal times. Facility records showed that breakfast was to be served between 7:30 A.M. and 9:00 A.M., but on the observed date, the resident was not assisted out of bed and brought to the dining room until 9:57 A.M., after the scheduled breakfast period had ended. Camera footage confirmed that no breakfast tray was brought to the resident's room during the scheduled breakfast hours. The resident, who had severe cognitive impairment, required moderate assistance with eating, and had diagnoses including diabetes, Alzheimer's disease, and Parkinson's disease, was dependent on staff to be assisted out of bed and to receive meals. Family members reported that the resident was frequently left in bed during breakfast and sometimes went long periods, up to 14 to 16 hours, between dinner and breakfast. Interviews with dietary and nursing staff revealed a lack of coordination and communication regarding meal service, with dietary staff relying on nursing staff to bring residents to the dining room or notify them if meals needed to be served in resident rooms. Documentation of meal service times was inconsistent, and there was no effective system in place to ensure that every resident received a meal at each mealtime. Staff acknowledged that agency nurses were unfamiliar with the mealtime process, contributing to the failure to serve meals within the designated timeframes.
Failure to Maintain Effective Grievance Process
Penalty
Summary
The facility failed to maintain an effective grievance process for residents and family members, as evidenced by the case of a resident with severe cognitive impairment and diagnoses of Alzheimer's and Parkinson's disease. The resident's family member, who lived out of town, attempted to communicate concerns regarding the resident's care through multiple emails and voicemails to the Director of Nursing (DON) but received no response. The family member was informed by a staff member that the DON was on vacation and that there were issues with the facility's new phone system. Despite these attempts, the family member did not receive any follow-up until the DON returned from vacation and left a message requesting a meeting. The facility's grievance policy, dated 2017, outlines the requirement for a designated Grievance Official to oversee the grievance process, but the policy did not specify the name or title of this individual. Interviews with various staff members, including the Life Enrichment Director, Licensed Practical Nurse (LPN), Registered Nurse (RN), and Social Service Director (SSD), revealed a lack of clarity and communication regarding the grievance process. Staff members were unsure of who the Grievance Officer was, and there was a consensus that there was little follow-through on resident complaints. The absence of Unit Managers, who previously assisted with resident issues, was noted as a factor contributing to the lack of resolution for grievances. The Resident Council meeting minutes further highlighted the facility's failure to address grievances, as residents expressed that their questions and concerns were not being answered. The Life Enrichment Director mentioned that department heads were emailed the meeting minutes but did not respond or follow through on the issues raised. The Administrator acknowledged the lack of communication and expected staff to address grievances promptly, but there was no evidence of a systematic approach to resolving resident concerns. The facility's grievance log showed only two grievances recorded from June to December 2024, indicating a potential underreporting or mishandling of grievances.
Delayed Meal Service Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that meals were served in a timely manner, affecting at least two residents with severe cognitive impairments who required assistance with eating and transfers. Observations revealed that Resident #1 was left in bed until after breakfast, resulting in being served cold food or leftovers. Similarly, Resident #2 was observed being dressed and brought to the dining room late, receiving breakfast items after the scheduled meal time. Interviews with family members and staff confirmed that meals were consistently served late, with residents sometimes missing meals entirely. The delay in meal service was attributed to a shortage of staff and late arrivals of both dietary and nursing staff, including agency staff unfamiliar with the residents and meal processes. The Director of Culinary Services acknowledged the staffing issues and the impact on meal timing, while the Director of Nursing and the Administrator expressed expectations for timely meal service. Despite these expectations, the facility's current practices did not align with the scheduled meal times, leading to deficiencies in meeting residents' nutritional needs.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, resulting in inadequate personal hygiene. Resident #1, who has severe cognitive impairment and requires substantial assistance with toileting hygiene, showering, and bathing, was observed with oily, flat, and stringy hair and a strong body odor. Despite the care plan indicating the need for extensive assistance with showering, the resident's family member reported that the resident had not received a shower since admission, and the Director of Nurses (DON) confirmed the absence of shower documentation. Similarly, Resident #2, also with severe cognitive impairment and dependent on staff for showering and bathing, was observed with very oily hair and an unshaven beard. The care plan required maximum assistance for showering twice weekly, but the DON confirmed that there were no shower sheets for November and December, indicating a lack of showers during this period. Interviews with staff revealed that showers were rarely completed as scheduled, and there was a lack of accountability due to the absence of a nursing manager, contributing to the deficiency in care.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility staff failed to ensure proper pressure ulcer care and prevention for two residents, leading to deficiencies in their care. Resident #1, who was at moderate risk for developing pressure ulcers, developed a new pressure ulcer on the sacrum. The facility staff did not complete weekly skin assessments as required by the resident's care plan and facility policy. Additionally, the staff failed to notify the physician of the new pressure wound and did not obtain new treatment orders in a timely manner. Observations showed that the resident had deep red maroon-colored circles on the sacrum, indicating a pressure wound, but there was no documentation of physician notification or new treatment orders in the resident's progress notes. Resident #2, who had a history of pressure ulcers and was also at moderate risk, did not receive the required weekly skin assessments according to facility policy. The resident's care plan indicated a need for weekly treatment documentation, but there were no documented skin assessments after an initial observation of a Stage 2 pressure ulcer on the buttocks. The facility's Director of Nursing confirmed that there were missing shower sheets for November and December, which should have included skin assessments. Interviews with facility staff revealed systemic issues in completing and documenting skin assessments. The staff acknowledged that skin assessments were not being completed as required, and there was a lack of follow-up to ensure compliance with the facility's policy. The Director of Nursing and other staff members confirmed that newly acquired skin conditions should be reported to the physician and family immediately, but this was not done for the residents involved.
Failure to Follow Two-Person Assistance Policy for Mechanical Lift Transfers
Penalty
Summary
The facility failed to adhere to its policy and the resident's care plan by not ensuring that two staff members assisted a resident who required a sit-to-stand mechanical lift for transfers. The facility's policy, dated September 2017, mandates that two nursing personnel must be used for a Sara lift transfer. However, video footage from two separate occasions showed that a Certified Nursing Assistant (CNA) performed the transfer alone, without a second staff member present to assist or supervise, leaving the resident unattended while attached to the lift. This was contrary to the resident's care plan, which specified the need for two-person assistance for transfers. The resident involved had severe cognitive impairment and was dependent on staff for various activities of daily living, including transfers. Interviews with facility staff, including a Physical Therapist, Registered Nurse, and the Director of Nursing, confirmed that the resident required two-person assistance for safe transfers using the mechanical lift. The staff also emphasized that the resident should not be left unattended in the lift, and the second staff member should be actively involved in the transfer process to prevent potential accidents.
Deficiency in Urinary Catheter Care and Supply Management
Penalty
Summary
The facility failed to provide proper urinary catheter care for a resident, as they did not have the necessary catheter supplies readily available to change the resident's catheter according to physician orders. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, had a history of urinary tract infections (UTIs) and an indwelling urinary catheter. Despite physician orders to change the catheter and obtain a urine culture, the facility did not have the correct supplies, leading to a delay in the catheter change and urine specimen collection. The resident's catheter was not changed on the day it was ordered due to the unavailability of the correct Foley catheter supplies. The Central Supply Technician was unable to check or order the supplies due to a computer issue, and the nurse did not change the catheter until three days later. Additionally, the urine specimen was not picked up by the lab on the weekend, causing further delays in obtaining the necessary urine culture. During a transfer, the resident's urinary catheter bag was positioned above the bladder, contrary to the facility's catheter policy, which increased the risk of infection. Interviews with staff, including a CNA and the DON, confirmed that the catheter bag should always be kept below the bladder to prevent UTIs. The facility's failure to have adequate supplies and to follow proper catheter positioning procedures contributed to the deficiency in care for the resident.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to adhere to infection control standards by not implementing Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter. Despite having a policy in place that required the use of gowns and gloves during high-contact care activities for residents at risk of multi-drug resistant organisms (MDROs), staff did not follow these guidelines. Observations revealed that staff did not wear isolation gowns while providing care to the resident, and there was no EBP sign posted outside the resident's room. Additionally, staff did not perform proper hand hygiene after removing gloves, which is a critical step in preventing the spread of infections. Another deficiency was observed in the administration of medications to a resident. A Licensed Practical Nurse (LPN) was seen popping pills from bubble packs directly into their hands before crushing and mixing them with applesauce for administration. This practice is against the facility's medication administration policy, which requires medications to be popped directly into a medicine cup to maintain hygiene and prevent contamination. Interviews with staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed that the expected procedures were not followed. The RN stated that gloves should be changed during peri-care, and hand hygiene should be performed before applying new gloves. The DON emphasized that signs should be posted for residents requiring EBP, and staff should use gowns and gloves for residents with catheters or other indwelling medical devices. The failure to adhere to these infection control practices indicates a significant lapse in maintaining a safe environment for residents.
Failure to Assess Bed Rail and Mattress Combination Leads to Resident Entrapment and Death
Penalty
Summary
The facility failed to assess a resident for the risk of entrapment when installing bed rails in combination with a low air loss (LAL) mattress. The resident, who had a history of falls, moderate cognitive impairment, and required substantial assistance with mobility and activities of daily living, was admitted with a physician's order for a LAL mattress to prevent skin breakdown. Despite facility policy requiring evaluation and consent prior to the use of adaptive devices such as siderails and LAL mattresses, there was no documentation of an assessment, evaluation, or consent for the use of these devices in the resident's medical record. Therapy staff, upon noticing the LAL mattress in the resident's room, installed it on the bed with existing siderails without following any protocol or notifying appropriate nursing leadership. Both therapy and nursing staff were unaware of the required procedures for assessing the safety of bed rails in combination with specialty mattresses. The facility's policy specified that such combinations must be evaluated for safety and risk prior to placement, especially when a mattress is changed, but this was not done. There was also no evidence of monitoring or reassessment after the installation of the LAL mattress and siderails. The resident was later found on the floor with their head trapped between the bed rail and the mattress, resulting in asphyxiation and subsequent death. Staff statements and medical record reviews confirmed that no assessment or evaluation was performed for the use of assistive devices with the LAL mattress, and no consent was obtained. The lack of adherence to facility policy and absence of required safety checks directly contributed to the incident.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of improperly labeled and stored food items. During a kitchen tour, numerous open food items were found without labels or dates, including containers of flour, onions, and various condiments. The Executive Chef acknowledged responsibility for ensuring items were dated but admitted to lapses in this duty. The Director of Dining Services and the Director of Nursing also confirmed that all dietary staff were responsible for dating food items, and the Executive Chef was expected to check daily to ensure compliance. Additionally, the facility did not discard expired or moldy food items promptly. Moldy onions and expired dairy products were found in storage, and the Executive Chef admitted to being aware of the moldy onions but failed to discard them. The Director of Dietary Services and the Director of Nursing both stated that expired or moldy food should have been thrown away immediately, indicating a breakdown in the facility's food safety protocols. The facility also failed to maintain a clean and sanitary food preparation area. Observations included wet dishware being used for meal service, uncovered food items placed near trash cans, and unsanitary conditions such as food debris on floors and dust accumulation on ceiling vents. Water was observed dripping from the ceiling onto the steam table during meal service, a recurring issue when it rained. The Executive Chef and the Director of Dietary Services acknowledged these issues, with the latter noting that the kitchen floors were supposed to be cleaned nightly and the microwave daily, but these tasks were not consistently performed.
Infection Control Deficiencies in EBP and Respiratory Equipment
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents who were at increased risk for acquiring multidrug-resistant organisms (MDROs) due to their medical conditions. Observations revealed that there was no signage indicating EBP at the residents' rooms, and personal protective equipment (PPE) such as gowns was not available or used by staff during high-contact care activities. Interviews with staff indicated a lack of awareness and communication regarding which residents required EBP, despite the facility's policy mandating gown and glove use for residents with wounds, indwelling medical devices, or MDRO colonization. Additionally, the facility did not store respiratory equipment properly to decrease the risk of infection for three residents receiving respiratory care. Observations showed that oxygen tubing and nebulizer masks were not dated or stored in bags when not in use, contrary to the facility's policy. Interviews with staff confirmed that there were no orders in place to change the oxygen or nebulizer tubing regularly, and the equipment was not maintained according to the facility's standards. The facility also failed to adhere to its infection control policy regarding tuberculosis (TB) screening tests for employees. The review of employee files revealed that several staff members did not have documentation of the required two-step or annual one-step TB tests. Interviews with the Director of Nursing (DON) and the Administrator indicated that the facility's policy was not followed, and there was a lack of oversight in ensuring that TB testing was completed in a timely manner.
Failure to Complete Baseline Care Plans
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission for five residents. The facility's policy required that a baseline care plan be created upon admission, with a comprehensive care plan to be developed by day 21 of the resident's stay. However, the facility did not have a unit manager or charge nurse to oversee the completion of these care plans, leading to the deficiency. Resident #178 was admitted with a medical history of acute respiratory failure, congestive heart failure, and chronic obstructive pulmonary disease, but no baseline care plan was developed. Similarly, Resident #228, with chronic obstructive pulmonary disease, unspecified dementia, and a urinary tract infection, also lacked a baseline care plan. The absence of a unit manager left the responsibility for ensuring the completion of these plans unclear. Resident #230, who required assistance with personal care and had a urinary tract infection, did not have a baseline care plan completed by the admitting nurse. Residents #22 and #21, both readmitted with severe medical conditions, including pressure ulcers and cognitive impairments, also lacked baseline care plans. The facility's failure to have a designated staff member responsible for completing and verifying these plans contributed to the deficiency.
Failure to Verify Resident Identity Before Blood Sugar Test
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) verified the identity of the intended resident before performing a fingerstick blood sugar test, resulting in the wrong resident being tested. This incident involved Resident #17, who was admitted to the facility on June 18, 2024, with a medical history of quadriplegia and no diagnosis of diabetes or hypoglycemia. The Minimum Data Set (MDS) assessment indicated that Resident #17 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. However, during an observation on July 16, 2024, LPN #3 conducted a fingerstick blood sugar test on Resident #17 without verifying the resident's identity or checking the physician's orders, which did not include an order for such a test. Interviews conducted with facility staff revealed that the Quality Control and Wound Care Specialist expected staff to follow physician's orders as a standard practice, although there was no specific policy addressing this. LPN #3 admitted to having the wrong resident's administration record during the test, and the Director of Nursing (DON) confirmed that LPN #3, as the charge nurse, should have verified the physician's orders before proceeding. The facility administrator also acknowledged that the nurse should have ensured the correct resident was identified before performing the blood sugar check.
Lack of Physician's Order for Oxygen Use
Penalty
Summary
The facility failed to ensure a physician's order was in place for the use of oxygen for a resident, leading to a deficiency in respiratory care. The facility's policy, dated February 2019, clearly states that a physician's order is required to apply oxygen, except in emergencies. Resident #228, who was admitted on July 10, 2024, had a medical history of chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen. However, as of July 16, 2024, the resident's Order Summary Report did not include any orders for the use of oxygen. Observations on July 15 and July 16, 2024, confirmed that Resident #228 was using a nasal cannula with an oxygen concentrator set at four liters per minute without a physician's order. LPN #3 acknowledged the absence of an order for the resident's oxygen use. The Director of Nursing and the Administrator both confirmed that physician's orders should be in place for oxygen use, and the charge nurse should ensure these orders are obtained. Despite these acknowledgments, the deficiency remained unaddressed at the time of the survey.
Medication Storage and Availability Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and availability of medications for two residents, leading to deficiencies in pharmaceutical services. For Resident #8, who had a medical history of hereditary spastic paraplegia and was cognitively intact, the facility did not administer gabapentin as ordered due to improper storage. Although the medication was delivered, it was misplaced in the medication cart, leading to missed doses. Staff interviews revealed that the medication was placed in an overflow drawer instead of behind the resident's name, causing confusion and delay in administration. Resident #232, who had multiple medical conditions including diabetes and hypertension, did not receive several medications upon admission due to a delay in pharmacy delivery. The facility faxed the medication orders after the pharmacy's cutoff time, resulting in a next-day delivery. The staff did not utilize the emergency kit to provide the necessary medications in the interim, leading to a lapse in care. Interviews with staff, including the DON and the pharmacist, highlighted a lack of communication and adherence to procedures for medication delivery and storage. The facility's policy required medications to be administered without interruption, but the failure to follow these guidelines resulted in deficiencies in meeting the residents' pharmaceutical needs.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were securely stored for two residents, leading to a deficiency in medication management. Resident #228 was observed with a small bottle of artificial tear eyedrops, hydrocortisone cream, and a package of cough drops on their bedside table. The resident did not have physician's orders for these medications or permission to store them at their bedside. The resident was unaware of the medications' presence, and staff members, including a CNA and an LPN, were not aware of the proper procedures for handling such situations. The Director of Nursing confirmed that the resident had not been assessed for self-administration of medications, and the Administrator stated that medications should not be stored on bedside tables. Similarly, Resident #21 was found with a tube of Triad hydrophilic wound dressing paste and a medication cup containing a white cream on their dresser. The resident had no physician's order to store medications at their bedside. An LPN admitted to leaving the Triad paste in the room after completing a dressing change, contrary to the facility's policy that required such medications to be stored in the treatment cart. Another LPN confirmed that medications should only be left in residents' rooms if there was a physician's order and the resident had been assessed for self-administration. The DON reiterated that all medications should be locked unless specific conditions were met. The facility's policy on medication storage, dated July 2021, mandates that medications and biologicals be stored safely and securely, accessible only to authorized personnel. However, the observations and interviews revealed lapses in adherence to this policy, as medications were found unsecured in residents' rooms without proper authorization or assessment. The DON and Administrator both emphasized the expectation for medications to be locked up unless residents were assessed and authorized to self-administer them.
Failure to Document Oxycodone Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident, specifically concerning the administration of oxycodone, a narcotic pain medication. The resident, who had a medical history of a periprosthetic fracture around an internal prosthetic right knee joint, was admitted to the facility and had an order for oxycodone hydrochloride 10 mg to be administered as needed for pain. On a specific day, the facility's emergency medication supply was accessed multiple times to provide the resident with oxycodone, yet there was no documentation in the Treatment Administration Record (TAR) indicating that the medication was administered. Interviews with staff revealed that the medication was indeed administered but not documented. An LPN admitted to administering the medication during her shift but forgot to document it in the TAR. Another LPN also confirmed administering the medication during his shift. The Director of Nursing stated that it was expected for staff to document the administration of pain medications in the TAR, highlighting a lapse in following the facility's policy on medication administration documentation.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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