Carrie Elligson Gietner Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 5000 South Broadway, Saint Louis, Missouri 63111
- CMS Provider Number
- 265668
- Inspections on file
- 18
- Latest survey
- September 22, 2025
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Carrie Elligson Gietner Health Care Center during CMS and state inspections, most recent first.
The facility did not ensure an RN was present for at least 8 consecutive hours each day, as required, with staffing records showing multiple days without any RN coverage. The DON confirmed only two RNs were employed and was unaware that the DON could not also serve as the floor RN at the same time, potentially affecting all residents.
A staff member did not follow the facility's recipe for pureed breaded chicken breast, resulting in an improper consistency, and prepared pureed mixed vegetables without a standardized recipe, leading to small lumps in the final product. The Dietary Manager confirmed the lack of a recipe for mixed vegetables and stated that recipes are expected to be followed to ensure proper nutrition.
Surveyors observed significant build-up of dirt, grease, and grime on kitchen floors and walls, including under major appliances and behind sinks. Despite established cleaning protocols requiring daily deep cleaning by dietary staff, interviews revealed that restrictions on overtime and insufficient labor hours led to incomplete cleaning tasks. Facility management was aware of the ongoing cleanliness issues.
Staff did not schedule or document an urgent urology appointment for a resident with prostate cancer after a physician's order, resulting in the resident being turned away at the doctor's office and a lack of follow-up until much later. The facility's policy for transcribing and following physician orders was not followed, and required documentation was missing from the medical record.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents, resulting in an increased risk of incidents.
Staff failed to store medications in locked compartments as required, leaving multiple boxes of medication cards, some labeled with residents' names and containing prescription drugs, in open and accessible areas behind the nurse's station. Two residents with moderate cognitive impairment and significant medical conditions had their medications left unsecured, and staff interviews confirmed that medications were not stored promptly according to policy.
The facility did not complete or maintain required background checks and employment documentation for an administrator, including missing criminal background, EDL, and federal indicator checks, as well as lacking application, license, and reference records. Staff interviews revealed confusion over responsibility for these processes, and the facility's own policies requiring such screenings were not followed.
The facility did not ensure that a qualified and licensed Administrator was on duty, as required by state law. Review of licensing records and staff interviews revealed that the Administrator was not listed as a current Missouri Licensed Administrator, could not provide proof of licensure or renewal, and was not posted as required. This failure had the potential to affect all residents in the facility.
A resident experienced a delay in treatment for a fractured arm due to the facility's failure to ensure follow-up appointments with an orthopedic surgeon. Despite being cognitively intact and independent before the fall, the resident missed several appointments due to transportation issues and lack of communication among staff, leading to increased pain and decreased mobility. The orthopedic surgeon expressed concern over the resident's condition, highlighting the facility's failure to manage appointments and communicate effectively.
A resident with a fractured arm experienced inadequate pain management and missed medical appointments due to facility oversight. The facility failed to conduct timely pain assessments and ensure the resident received necessary medical follow-up, resulting in ongoing pain and mobility issues. Staff interviews revealed a lack of understanding of the electronic medical record system, contributing to poor documentation and communication with the resident's physician.
The facility failed to document medication administration and treatment for three residents over two months. This included missing records for medications and treatments such as Atorvastatin, Citalopram, and catheter care. The residents had conditions like schizophrenia and Alzheimer's, necessitating careful medication management, which was not documented as required.
A long-term care facility failed to control a bed bug infestation, affecting multiple residents. Despite having a prevention and management policy, the facility's efforts were insufficient, as residents continued to report bed bug sightings and bites. Staff confirmed the presence of bed bugs, and the facility had not yet engaged a pest control company, although estimates were obtained. The administrator believed the issue was improving, despite ongoing resident complaints.
A facility failed to report allegations of verbal abuse to the DHSS within the required timeline after two residents reported a CNA verbally abused them. The incident involved a confrontation about smoking outside designated times, where the CNA allegedly used threatening language. Despite residents' complaints and the CNA's admission, the facility administration was not informed in a timely manner, and the CNA returned to work without immediate corrective action.
A facility failed to thoroughly investigate an allegation of verbal abuse by a CNA towards residents during a smoking policy dispute. The CNA allegedly used threatening language, but the investigation was incomplete, lacking interviews and documentation. Despite the incident, the CNA returned to work the next day, raising concerns about resident safety and compliance with regulations.
A resident's care plan was not updated after a fall resulted in a fractured arm, leading to increased need for assistance with ADLs. Despite the resident's decline in functional abilities, the care plan continued to reflect prior independence, leaving staff without necessary guidance. Facility staff acknowledged the oversight, highlighting a gap in managing changes in residents' conditions.
A resident experienced a significant weight loss of 20 pounds over six weeks due to the facility's failure to provide prescribed health shakes three times a day. Despite recommendations from the RD, staff did not include the supplements on meal trays, and the resident's dietary needs were not adequately monitored. Interviews with staff revealed a lack of communication and adherence to dietary orders, contributing to the resident's nutritional decline.
The facility failed to maintain cleanliness and proper food preparation practices in the kitchen. Raw chicken was placed in a sink next to where dishes were being cleaned, leading to potential cross-contamination. The kitchen had accumulated debris, dust on fans and light fixtures, and a white powder spill on the dry storage rack. Staff interviews confirmed expectations for cleanliness and separation of food prep from dishwashing, but these were not met.
The facility failed to ensure accurate and consistent documentation of advanced directives for residents, with discrepancies noted between signed code status forms and physician orders. A resident's advanced directive did not match between the paper chart and the POS, and another resident lacked a current physician's order for code status. Additionally, annual reviews of advanced directives were not conducted for several residents, leading to outdated documentation. Staff interviews revealed inconsistencies in the process of obtaining and documenting code status orders.
The facility failed to ensure complete and accurate documentation of medication administration for several residents, as required by their policy. Reviews of MARs revealed missing documentation for various medications across multiple residents, with no supporting documentation provided. Interviews confirmed that the facility's procedures for transcribing orders and documenting missed medications were not followed.
The facility failed to assess and authorize two residents for self-administration of medications, leaving medications at their bedside without proper orders. Additionally, a resident was not adequately supervised during medication administration, receiving medications from a CMT and taking them unsupervised. Staff interviews confirmed the need for physician orders and assessments for self-administration, highlighting a breach in protocol.
A resident with cognitive intactness and several medical conditions experienced a deficiency in their living environment due to a malfunctioning hot water faucet in their bathroom. Despite informing staff, the issue was not addressed as the facility's maintenance reporting system was not utilized, leaving the resident without access to hot water.
A facility failed to involve a resident's legal guardian in discharge planning, despite the resident's expressed interest in transitioning to a lower level of care. The resident, who was cognitively intact and independent in most activities, had not been involved in discharge discussions. Facility staff faced difficulties contacting the legal guardian, who had not participated in care plan meetings. The resident's psychiatrist deemed them stable, but the evaluation for independent living was ongoing. The facility did not document attempts to communicate with the guardian regarding discharge planning.
The facility failed to provide adequate personal care and hygiene for several residents, including those with severe cognitive impairments and self-care deficits. Observations showed residents with long facial hair, unclean nails, and wearing the same soiled clothing over multiple days. Despite care plans indicating the need for assistance, staff did not consistently provide necessary hygiene care, as confirmed by interviews with CNAs, a CMT, an LPN, and the DON.
The facility failed to conduct and document neurological assessments for two residents after falls, contrary to policy. One resident, with moderate cognitive impairment, was found on the floor twice, once with a cheek bruise, but no neurological checks were documented. Another resident suffered a head laceration from a fall, yet no assessments were recorded. Additionally, the medication cart was left unlocked and unattended, accessible to residents and others, violating the facility's security policy.
A resident with multiple diagnoses, including high blood pressure and edema, was not administered the prescribed dose of Lasix for over two weeks due to a failure in transcribing the medication order to the MAR. Interviews with staff revealed that the process for transcribing orders was not followed, resulting in the omission of the medication and blood pressure monitoring.
Failure to Provide Required RN Coverage Seven Days a Week
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required by their own policy and federal regulations. Review of daily staffing sheets revealed that there were multiple days when no RN was scheduled, specifically from 8/20 through 8/22, 8/25 through 8/31, and 9/1 through 9/5. During an interview, the Director of Nursing (DON) acknowledged that only two RNs were employed in the building and admitted to working as both the DON and the floor RN, not realizing that these roles could not be fulfilled simultaneously. The facility census at the time was 86 residents, and the deficiency had the potential to affect all residents.
Failure to Follow Pureed Diet Recipes During Meal Preparation
Penalty
Summary
During an observed mealtime preparation, a staff member in the kitchen failed to follow the facility's recipe for preparing pureed breaded chicken breast. Instead of using the specified amount of water and chicken base to create a broth as outlined in the recipe, the staff member added only approximately one tablespoon of water to the chicken breast and blended it. The resulting mixture was of ground meat consistency and not smooth, as required for pureed diets. The staff member acknowledged not following the recipe as written, despite having reviewed it. Additionally, the same staff member prepared pureed mixed vegetables by blending them until smooth, but the final product contained small lumps. The Dietary Manager confirmed that there was no recipe for pureed mixed vegetables and that cooks were expected to follow recipes to ensure proper nutrition. The Dietary Manager and the Administrator both acknowledged the expectation that recipes be followed and were unsure why this did not occur.
Failure to Maintain Kitchen Cleanliness Due to Inadequate Staffing and Cleaning Practices
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen, as evidenced by observations of built-up dirt, grease, and grime on the floors and walls in multiple areas, including under the refrigerator, stove, fryer, coffee station, and behind the sinks. The facility's dietary cleaning duties required both morning and evening crews to wipe down all stainless surfaces, clean ovens and stove tops, and mop the kitchen and dining room, with the cook on duty responsible for checking completion before clocking out and the manager ensuring the process was followed. However, during interviews, the Dietary Manager stated that dietary staff were not allowed overtime, resulting in inadequate cleaning, and confirmed that the department did not have sufficient labor hours for deep cleaning. The Administrator acknowledged awareness of the kitchen cleanliness concerns.
Failure to Schedule and Document Urgent Urology Appointment
Penalty
Summary
Facility staff failed to follow professional standards and the facility's own policy regarding the transcription and execution of physician orders for a resident with a diagnosis of prostate cancer. After a urologist contacted the facility and requested an urgent appointment for the resident, staff documented the need for an appointment and prepared transportation paperwork, but did not actually schedule the appointment. When a Certified Nurse Aide escorted the resident to the urologist's office, they were turned away because no appointment had been made. The CNA reported the incident to the charge nurse, but there was no documentation of any follow-up or rescheduling of the appointment in the resident's medical record. Interviews with staff revealed that the responsibility for making and documenting the appointment was unclear, with some staff believing the Director of Nursing and Administrator would handle the situation. The resident, who had moderate cognitive impairment and a history of prostate surgery, was unaware of any scheduled appointment and did not recall attending one. The facility's policy required that physician orders be transcribed, appointments scheduled, and all actions documented in the medical record, but these steps were not completed, resulting in a delay in the resident receiving necessary follow-up care.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details about the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Improper Storage of Medications in Unsecured Areas
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were stored in accordance with professional standards and facility policy. Multiple observations revealed that boxes containing medication cards, some labeled with residents' names and containing various prescription drugs, were left in open and accessible areas behind the nurse's station on the second floor. These areas were not secured, lacked doors, and allowed anyone to access the medications. Additionally, finished medication cards, some still containing medications, were found in trash bags and open boxes behind the nurse's station. The medications observed included antihypertensives, diabetic medications, and antihistamines, all of which were not properly secured as required. Interviews with staff confirmed that medications delivered by the pharmacy were routinely left behind the nurse's station, sometimes for several days, instead of being immediately stored in locked compartments as per facility policy. Staff acknowledged that medications should be put away promptly or locked in the storage room if immediate storage was not possible. The Regional Nurse Advisor and facility administration also confirmed that the observed medications had been delivered several days prior and had not been stored properly. Two residents with moderate cognitive impairment and significant medical diagnoses were specifically identified as having their medications left unsecured.
Failure to Conduct Required Background Checks and Maintain Employment Records for Administrator
Penalty
Summary
The facility failed to conduct required background screenings and maintain necessary employment documentation for one hired employee, identified as Administrator A. Specifically, there was no evidence of a Criminal Background Check (CBC), Employee Disqualification List (EDL) check, or federal indicator check for Administrator A. Additionally, the facility did not have records of Administrator A's employment application, resume, experience, education, references, or license verification, as required by state regulations. Administrator A was employed at the facility for approximately four months, during which time these deficiencies persisted. Interviews with facility staff revealed confusion and lack of clarity regarding who was responsible for completing and maintaining Administrator A's employment file and background checks. The Regional Human Resources (HR) representative stated that Administrator A was already employed when they returned to the company and assumed that the necessary documentation would be transferred from another facility within the same company. However, neither the HR representative nor the Business Office Manager (BOM) could locate or confirm the existence of Administrator A's employment file or background screening results. The BOM also could not recall any specific discussions about missing documentation. The facility's policies on abuse, neglect, and background screening explicitly require thorough background investigations and prohibit the employment of individuals with a history of abuse, neglect, or related offenses. Despite these policies, the facility did not follow its own procedures in the case of Administrator A, resulting in a lack of compliance with both internal policy and state regulations. This failure had the potential to affect all residents in the facility, which had a census of 86 at the time.
Failure to Maintain a Licensed Administrator on Duty
Penalty
Summary
The facility failed to ensure that a qualified and licensed Administrator was on duty, as required by state law. Review of the Missouri Board of Nursing Home Administrators (MBNHA) license registry showed that Administrator A was not listed as a current licensed Administrator in Missouri. Administrator A was unable to provide proof of a valid administrator's license or evidence of renewal, and was not listed on the Health Services Executive (HSE) license registry. Corporate and facility staff, including the Regional Director of Operations and Regional HR, confirmed that Administrator A's license status was not verified at the time of employment, and there was no documentation of a completed background check or onboarding process for Administrator A. The Director of Nursing noted that the administrator's license was not posted as required, and Administrator A claimed it was unnecessary. The lack of a qualified Administrator on duty had the potential to affect all residents in the facility, which had a census of 86 at the time of the survey. The deficiency was identified through interviews and record reviews, which revealed gaps in the facility's process for verifying and maintaining required licensure for upper management positions, specifically the Administrator role.
Failure to Ensure Resident's Orthopedic Follow-Up
Penalty
Summary
The facility failed to ensure that a resident kept all necessary appointments with an orthopedic surgeon following an unwitnessed fall that resulted in a fracture of the right arm. The resident, who was cognitively intact and independent with activities of daily living prior to the fall, experienced significant pain and a decrease in their ability to perform daily activities due to the delay in treatment. The facility's policy required nursing staff to assist with scheduling appointments and coordinating transportation, but this was not effectively executed, leading to missed appointments and delayed surgical intervention. The resident's medical records indicated that after the fall, they were sent to the emergency room and returned with a splint and instructions to follow up with an orthopedic specialist. Despite these instructions, the resident missed several appointments due to issues with transportation and lack of communication between the facility staff and the orthopedic office. The resident's condition worsened, with increased pain, swelling, and bruising, yet there was no documentation of rescheduling missed appointments or notifying the physician of the resident's ongoing issues. Interviews with facility staff revealed a breakdown in communication and responsibility. The SSD was unaware of missed appointments, and the charge nurse failed to reschedule the surgery or inform the SSD to arrange transportation. The orthopedic surgeon expressed concern over the resident's pain and the potential for permanent loss of mobility due to the delay in surgical intervention. The facility's failure to manage the resident's appointments and communicate effectively with healthcare providers resulted in prolonged pain and decreased quality of life for the resident.
Failure in Pain Management and Timely Medical Follow-Up
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident who suffered a fall resulting in a fractured arm. The resident missed a scheduled surgery due to being fed by staff, which led to the surgery being canceled. Despite several attempts by the orthopedic physician's office to set up appointments, the facility did not ensure the resident was seen by the orthopedic physician or reschedule the surgery. Additionally, the facility did not complete a new pain assessment after the resident's arm was fractured, resulting in ongoing pain and loss of mobility for the resident. The facility's Pain Management policy outlines a systematic approach for recognizing, assessing, and monitoring pain, which was not followed in this case. The resident's electronic Medication Administration Record (eMAR) and Treatment Administration Record (eTAR) showed a lack of documentation for pain assessments and administration of prescribed pain medications. The resident's progress notes indicated that the resident experienced significant pain and swelling, yet there was no consistent documentation or follow-up on pain management. Interviews with facility staff revealed a lack of understanding and implementation of the electronic medical record system, leading to inadequate documentation of pain assessments and medication administration. The facility's failure to notify the resident's physician about missed appointments and ongoing pain further contributed to the deficiency. The resident continued to experience pain and swelling, with no effective pain management plan in place, highlighting the facility's failure to adhere to its own pain management policy.
Failure to Document Medication Administration and Treatment
Penalty
Summary
The facility failed to maintain proper documentation of medication administration and treatment for three residents over a period of two months. This deficiency was identified through interviews and record reviews, which revealed that the staff did not document the administration of various medications and treatments as required by the facility's Medication Administration policy. The policy mandates that medications be administered by licensed nurses or authorized staff, following the six rights of medication administration, and that documentation be completed immediately after administration. For Resident #11, there was a lack of documentation for multiple medications, including Atorvastatin, Citalopram, Ferrous Sulfate, Melatonin, and others, from October 1 through December 31. Additionally, there was no documentation of catheter care, pain assessments, or monitoring for side effects of anticoagulant and antipsychotic medications. Resident #11's medical history included schizophrenia, diabetes, and chronic kidney disease, among other conditions, which necessitated careful monitoring and medication management. Resident #12 also experienced a lack of documentation for medications such as Alendronate, Aspirin, Calcium-Vitamin D3, and Donepezil from October 1 through December 18. There was no record of pain assessments or monitoring for side effects of anti-anxiety and antipsychotic medications. Resident #12 had diagnoses including Alzheimer's disease and heart disease, requiring consistent medication administration. Similarly, Resident #10's records showed no documentation for medications like Atorvastatin, Ingrezza, Lisinopril, and others from October 1 through November 30. The resident's conditions, including schizophrenia and bipolar disorder, required regular medication and monitoring, which were not documented as per the facility's policy.
Bed Bug Infestation in LTC Facility
Penalty
Summary
The facility failed to maintain effective pest control, resulting in a bed bug infestation affecting multiple resident rooms. Observations and interviews revealed that residents were experiencing bed bug bites, and live bed bugs were found in various locations, including mattress seams and folded linen. The facility's Bed Bug Prevention and Management Policy outlined measures for prevention, eradication, and containment, but these measures were not effectively implemented, as evidenced by the ongoing presence of bed bugs in the facility. Residents reported seeing bed bugs in their rooms and on their belongings, with some residents experiencing bites and finding bed bugs in their personal spaces. Interviews with staff, including housekeepers and CNAs, confirmed the presence of bed bugs throughout the facility. Despite efforts to treat affected areas with diatomaceous earth and bed bug spray, the infestation persisted, and residents continued to report sightings and bites. The facility's maintenance director acknowledged the use of safe treatment methods but did not treat adjacent rooms unless bed bugs were reported there. The administrator was aware of the bed bug issue but believed the problem was improving, despite ongoing complaints from residents. The facility had not yet hired a pest control company, although estimates for treatment had been obtained. The failure to effectively manage the bed bug infestation had the potential to affect all residents in the facility.
Failure to Report Verbal Abuse Allegations
Penalty
Summary
The facility failed to report allegations of verbal abuse to the Department of Health and Senior Services (DHSS) within the required timeline after two residents reported a staff member verbally abused them. The incident involved a Certified Nursing Assistant (CNA) who allegedly used threatening language towards residents during a confrontation about smoking outside of designated times. Despite the residents' complaints and the CNA's admission of using inappropriate language, the facility administration was not informed of the verbal abuse allegations in a timely manner. Resident #1, who has a history of major depressive disorder and bipolar disorder, reported feeling threatened by the CNA's aggressive stance and language. The resident attempted to report the incident to facility administration but was upset to see the CNA back at work the following day. Resident #2, who has a history of stroke and anxiety, also felt threatened during the incident and expressed frustration with the smoking policy. Despite these reports, the facility staff, including the Maintenance Director and LPN, did not report the allegations of verbal abuse to the appropriate authorities. The facility's failure to report the allegations of verbal abuse was compounded by a lack of communication and understanding among staff members about their responsibilities in such situations. The Director of Nursing (DON) and Administrator were not made aware of the verbal abuse allegations until informed by a surveyor, and the CNA was allowed to return to work without any immediate corrective action. This lack of timely reporting and response to the allegations of abuse highlights a deficiency in the facility's adherence to its own policies and procedures for handling such incidents.
Inadequate Investigation of Verbal Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of verbal abuse involving a Certified Nursing Assistant (CNA) and several residents. The incident occurred when a CNA allegedly cursed and threatened a resident after a confrontation about smoking outside of designated times. The resident reported feeling threatened by the CNA's aggressive stance and language. Despite the resident's complaint, the facility did not adequately interview all involved parties or document verbal statements, and the CNA was allowed to return to work the following day. The facility's abuse and neglect policy requires immediate reporting and thorough investigation of all allegations of abuse, including verbal abuse. However, the investigation was incomplete, as not all staff and residents involved were interviewed, and there was a lack of documentation of the incident in the residents' progress notes. The Maintenance Director and other staff members provided inconsistent accounts of the incident, and the CNA admitted to using inappropriate language, but this was not reflected in the written statements provided to the administration. The facility's failure to follow its own policy and procedures for investigating allegations of abuse resulted in an inconclusive determination of whether verbal abuse occurred. The lack of proper documentation and communication among staff members hindered the investigation process, and the CNA's return to work without proper resolution of the allegations raised concerns about resident safety and the facility's compliance with federal regulations.
Failure to Update Care Plan After Resident's Fall
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated and accurate to reflect the resident's increased need for assistance with activities of daily living (ADLs) following a fall that resulted in a fractured arm. The resident, who was previously independent in performing ADLs, required additional staff assistance after the incident. However, the care plan did not document these changes, leaving staff without the necessary guidance to provide appropriate care. The resident's medical records indicated a significant decline in functional abilities after the fall, necessitating increased assistance with transferring, dressing, toileting, and showering. Despite these changes, the care plan continued to reflect the resident's prior level of independence, failing to incorporate the new requirements for staff assistance. Interviews with facility staff, including the MDS Coordinator and the Interim Director of Nursing, confirmed that the care plan should have been updated to reflect the resident's new needs. The lack of an updated care plan resulted in a deficiency, as it did not provide staff with the necessary information to care for the resident effectively. The resident's physician's office representative also noted that the resident would not be independent with ADLs due to the fractured arm and the use of a sling, emphasizing the need for an updated care plan. The failure to update the care plan was acknowledged by the facility's staff, highlighting a gap in the facility's processes for managing changes in residents' conditions.
Failure to Provide Nutritional Supplements Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable nutritional status, resulting in a significant weight loss of 20 pounds over six weeks. The resident, who had moderate cognitive impairment and required partial assistance with meals, was supposed to receive health shakes three times a day as recommended by the Registered Dietician (RD). However, staff did not provide these supplements as ordered, contributing to the resident's weight loss. Observations and interviews revealed that the resident's meal trays often lacked the prescribed health shakes, and staff did not offer alternatives when the resident refused the served food. The resident expressed a lack of appetite and was not provided with the necessary assistance to consume meals, such as cutting food. The facility's policy required staff to monitor and document dietary intake and notify the physician of significant weight changes, but these procedures were not adequately followed. Interviews with staff, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), indicated a lack of communication and adherence to dietary orders. The meal tickets did not reflect the required supplements, and staff failed to ensure the resident received the necessary nutritional support. The Director of Nursing (DON) and the Administrator acknowledged the oversight in providing the health shakes and the resident's weight loss, highlighting a breakdown in the facility's processes for managing and monitoring nutritional interventions.
Deficiencies in Kitchen Cleanliness and Food Preparation Practices
Penalty
Summary
The facility failed to maintain proper food preparation and cleanliness standards in the kitchen and related areas. During lunch preparation, the Dietary Supervisor was observed placing raw chicken in a sink while another staff member cleaned dishes in an adjacent sink, resulting in water splashing onto the raw chicken. This indicates a failure to separate food preparation from dish cleaning, which is essential to prevent cross-contamination. Additionally, the facility's dietary cleaning duties were not adequately followed, as evidenced by the accumulation of debris and substances on the floors, baseboards, and walls in various kitchen areas, including under the sink, cereal/toaster station, and around the oven and deep fryer. Further observations revealed that the dishwashing room had fans covered with thick dust, which were positioned to blow on clean dishes, and the light fixture above the food preparation table had significant dust buildup. The dry storage rack was also found with a white powder spill in various areas. Interviews with kitchen staff, the Dietary Supervisor, and the Administrator confirmed that all kitchen staff were responsible for cleaning duties and that food should be prepared away from dishwashing areas. However, the observed conditions indicated a lack of adherence to these expectations, resulting in unsanitary conditions and potential contamination risks.
Inconsistent Documentation of Advanced Directives
Penalty
Summary
The facility failed to ensure that the advanced directives of residents were accurately documented and consistently updated. Specifically, Resident #7's advanced directive did not match between the paper chart and the physician's orders sheet (POS), with discrepancies noted between a signed Do Not Resuscitate (DNR) form and a Full Code status listed in the physician orders. Additionally, Resident #72 did not have a current physician's order for code status, despite having a signed form indicating full resuscitation. The facility also did not conduct annual reviews of advanced directives for several residents, including Residents #62, #25, #2, #19, #26, and #41. Observations revealed that outdated code status forms were being replaced with updated ones by the social worker, indicating a lapse in timely updates. Interviews with staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), highlighted inconsistencies in the process of obtaining and documenting code status orders, with some staff treating all residents as Full Code by default. The social worker was responsible for obtaining code status upon admission and updating it annually, but there were delays in placing updated forms into the medical records. The nursing department was tasked with obtaining physician orders for code status, yet discrepancies persisted between the signed code status sheets and the POS. The DON confirmed that code status should be documented on the face sheet, POS, and in the Activities of Daily Living (ADL) tool, but the process was not consistently followed, leading to the deficiencies noted in the report.
Incomplete Medication Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented, particularly concerning the administration of medications and treatments for five residents. The facility's policy mandates that medications be administered safely, timely, and as prescribed, with documentation by licensed personnel. However, the review of the Medication Administration Records (MAR) for several residents revealed multiple instances where staff failed to document the administration of prescribed medications, with no supporting documentation provided. For Resident #50, the MAR showed missing documentation for the administration of hydralazine, atorvastatin, docusate, and accu-checks over several months. Similarly, Resident #20's MAR indicated missing documentation for medications such as memantine, potassium chloride, Tradjenta, furosemide, Senna Plus, calcium antacid, citalopram, buspirone, amlodipine, and olopatadine solution. Resident #67's records also lacked documentation for simvastatin and vitamin B-12 administration. Resident #7's MAR showed missing documentation for Xifaxan, benztropine, atorvastatin, and mirtazapine. Lastly, Resident #51's records indicated missing documentation for aspirin, Eliquis, atorvastatin, olanzapine, and furosemide. Interviews with the LPN and the Director of Nursing confirmed that the facility's procedures require nurses to transcribe orders correctly and document any missed medications, notifying the doctor and making a note in the resident's chart, which was not adhered to in these cases.
Failure to Assess and Supervise Medication Self-Administration
Penalty
Summary
The facility failed to ensure that residents were properly assessed for self-administration of medications and that physician orders were maintained for such self-administration. This deficiency was observed in two residents who had medications left at their bedside without proper authorization or assessment. Resident #42 had a bottle of Flonase nasal spray at the bedside without any documented assessment or physician order for self-administration. Similarly, Resident #62 had inhalers stored in their room without a current self-administration assessment or physician order, despite using them throughout the day. Additionally, the facility did not adequately supervise Resident #77 during medication administration. The resident, who was new to the facility and not assessed for self-administration, was handed a cup of medications by a Certified Medication Technician and allowed to walk away unsupervised. The resident took the medications at the nurse's station without staff observation, which is against the facility's policy that requires supervision unless a resident has been assessed and authorized to self-administer medications. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the facility's policy requires a physician's order and a completed self-administration assessment before residents can self-administer medications. The staff acknowledged that Resident #77 should have been supervised during medication administration to ensure safety, and that any resident wishing to take medications in a private area should still be supervised. The lack of adherence to these protocols led to the deficiencies observed during the survey.
Failure to Maintain Homelike Environment Due to Malfunctioning Faucet
Penalty
Summary
The facility failed to provide a homelike environment for a resident due to a malfunctioning hot water faucet in the resident's bathroom. The resident, who has diagnoses including depression, Alzheimer's disease, high blood pressure, high cholesterol, and mood disorder, is cognitively intact and can shower independently with only setup assistance needed. The resident expressed a preference for bathing in the sink in their room due to delays in being taken to the shower room and had informed the nursing staff about the issue with the hot water faucet. Despite the resident's report, the facility staff, including a CNA, maintenance personnel, an LPN, and the Administrator, were unaware of the malfunctioning faucet. The facility has a system in place for reporting maintenance issues, involving paper slips and a box on the maintenance door, but this system was not utilized in this instance. The lack of awareness and action from the staff resulted in the resident not having access to a functioning hot water faucet in their bathroom.
Failure to Involve Legal Guardian in Discharge Planning
Penalty
Summary
The facility failed to implement and document a discharge planning process involving the legal guardian for a resident who expressed interest in transitioning to a placement with a lower level of care. The facility's Discharge Summary and Plan policy requires that every resident is evaluated for discharge needs and has an individualized post-discharge plan developed with the assistance of the resident and their family. However, there was no documentation of the legal guardian's involvement in care plan meetings or discharge planning for the resident, who was admitted with a history of major mental illness and had a public administrator appointed as their legal guardian. The resident, who was cognitively intact and independent in most activities of daily living, expressed feeling confined in the facility and had not been involved in any discharge planning discussions. The resident had previously communicated with their legal guardian about the desire to live independently, but no further steps were taken. The facility's Social Worker and Social Services Director acknowledged difficulties in contacting the legal guardian, who had not participated in care plan meetings or communicated about discharge planning. The resident's psychiatrist considered the resident stable, but the evaluation for independent living was ongoing. The facility staff, including the Administrator, reported challenges in reaching the legal guardian, who was a public administrator in another county. The resident had been compliant with medication and exhibited no problematic behaviors, yet the facility had not documented attempts to communicate with the guardian regarding discharge planning. The Administrator was unaware of the lack of documentation by the Social Services Director and expected discharge planning to be discussed and documented during quarterly care plan meetings.
Deficiency in Personal Care and Hygiene for Residents
Penalty
Summary
The facility failed to provide adequate personal care, nail care, and facial hair hygiene for five residents who required assistance with activities of daily living (ADL). Observations and interviews revealed that Resident #2, with severe cognitive impairment and multiple diagnoses, was found with long facial hair, dark debris under fingernails, and wearing stained clothing over consecutive days. Despite being incontinent and requiring full assistance with hygiene, the resident was not properly cleaned during perineal care, leaving feces between the buttocks. Resident #19, also with severe cognitive impairment and paralysis, was observed with long nails and dark debris under fingernails over multiple days, indicating a lack of proper nail care. Similarly, Resident #20, who has Alzheimer's disease and frequently refuses care, was seen wearing soiled clothing and with unkempt nails and hair. Despite the care plan indicating the need for assistance and encouragement for good hygiene, the resident's personal care needs were not adequately addressed. Resident #7, diagnosed with dementia and other conditions, was observed wearing the same stained clothing for three days and had a dark substance under fingernails. Resident #17, who is cognitively intact but requires supervision for hygiene, expressed dissatisfaction with long facial hair, which staff failed to address. Interviews with staff, including CNAs, a CMT, an LPN, and the DON, confirmed that residents should receive assistance with showers, nail cleaning, and facial hair shaving, but these were not consistently provided.
Failure to Conduct Neurological Assessments and Secure Medication Cart
Penalty
Summary
The facility failed to complete and document neurological assessments for two residents who experienced falls. Resident #79, with moderate cognitive impairment and a high fall risk, was found on the floor on two occasions, once with a bruise on the cheek. Despite the facility's policy requiring neurological checks after falls, no such documentation was found in the nurse's notes for these incidents. Similarly, Resident #42, who had no prior fall history, suffered a fall resulting in a head laceration. The resident reported hitting their head and bleeding, yet no neurological assessments were documented post-fall, contrary to the facility's policy. Additionally, the facility did not secure the medication cart on the 200 unit, leaving it unlocked and unattended. Observations noted the cart was left open with the medication administration record binder and keys on top, accessible to residents and others in the vicinity. This was against the facility's policy, which mandates that medication carts be locked when not in use and keys not left unattended. Interviews with staff, including the Director of Nursing and Licensed Practical Nurses, confirmed the expectations for conducting neurological assessments and securing medication carts. However, these protocols were not followed, leading to deficiencies in both resident care and medication security. Staff acknowledged the lapses in securing the medication cart and conducting necessary assessments post-fall.
Failure to Administer Lasix as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a resident was not administered the ordered dose of Lasix, a diuretic, for over two weeks. The resident had multiple diagnoses, including high blood pressure, diabetes, anxiety, high cholesterol, and pain, and had an order for Lasix 20 mg by mouth daily for seven days, with specific instructions to monitor blood pressure and withhold the medication if the blood pressure was below 100/50. However, the medication administration record (MAR) for June 2024 showed no entry for the Lasix or the resident's blood pressure, indicating a failure to administer the medication as prescribed. Interviews with facility staff revealed that the process for transcribing medication orders involved the nurse transcribing the order to the MAR as written or verbally given by the physician. The Licensed Practical Nurse (LPN) stated that for orders with specific time frames or parameters, the nurse would block out the days on the MAR or transcribe the order as written. The Director of Nursing (DON) confirmed that she expected the nurse to transcribe the order as written on the physician's order sheet to the MAR. This deficiency highlights a lapse in the facility's medication administration process, leading to the resident not receiving the necessary medication for their condition.
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Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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