Crestwood Health Care Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Florissant, Missouri.
- Location
- 11400 Mehl Avenue, Florissant, Missouri 63033
- CMS Provider Number
- 265823
- Inspections on file
- 38
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Crestwood Health Care Center, Llc during CMS and state inspections, most recent first.
A resident with a known history of obtaining and distributing illegal drugs was not consistently monitored or screened for drug use, despite exhibiting suspicious behaviors and previous incidents. This lack of supervision allowed the resident to bring and distribute unauthorized substances to others, resulting in multiple overdoses, hospitalizations, and severe harm, including one resident suffering cardiac arrest and being admitted to hospice care.
A resident with a history of hypertension, Alzheimer's disease, and schizophrenia experienced a significantly low blood pressure, but staff failed to notify the physician or hold antihypertensive medication as required. The CMT documented the hypotensive reading but did not inform nursing staff or withhold the medication, and there was no documentation of the event in the progress notes. Interviews confirmed that facility protocols for monitoring and responding to low blood pressure were not followed.
Two residents, both with psychiatric and medical diagnoses, were involved in a physical altercation during a smoke break, resulting in one resident sustaining a bloody lip and an elbow abrasion. The attack was unprovoked and motivated by perceived sexual orientation, with staff present but unable to prevent the initial assault despite monitoring and care planning.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including safe treatment and supports for daily living, as required under F584.
Staff failed to maintain a clean and sanitary environment, with two residents' rooms found dirty and cluttered, soiled linen and towels left on floors, and shower rooms not properly cleaned after use. Residents and staff reported unclean conditions, and there was no consistent cleaning schedule or checklist in place. The Housekeeping Supervisor and Administrator were unaware of the extent of the deficiencies and the lack of structured cleaning assignments.
A resident with a history of depression and bipolar disorder reported that a CMT threw Kool-Aid in their face after a verbal altercation. Although the incident was recognized as abuse and investigated internally, the facility failed to notify DHSS within the required timeframe, as both the Administrator and DON assumed the other had reported the event.
Two residents with a known risk of elopement left the facility without staff awareness on multiple occasions, including one instance where a resident was missing for several hours and found miles away. Staff failed to provide adequate supervision, did not consistently perform required checks, and did not respond to or hear door alarms. The facility's elopement policy and protocols for monitoring, alarm response, and timely notification of authorities were not followed, resulting in residents being unsupervised and unaccounted for.
A resident with a history of elopement was found several miles from the facility after being reported missing, but an RN, following instructions from the former ADON, inaccurately documented in the EMR that the resident was found on the facility parking lot. This false entry was made despite facility policy requiring factual and accurate documentation, resulting in a failure to maintain an accurate medical record.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A facility failed to prevent resident-to-resident abuse, resulting in two incidents where residents were physically harmed. In one case, a resident hit another with a towel rack, causing bruises and hematomas. In another, two residents fought, leading to a swollen eye. Despite care plans addressing aggression, the facility did not effectively prevent or de-escalate these situations.
Staff failed to supervise several residents, including individuals with cognitive impairment and psychiatric diagnoses, while they smoked in a designated area. The residents were found smoking and sharing a cigarette without staff present, despite facility policy requiring supervision. Staff did not immediately investigate how the residents accessed and lit the cigarette, and there was a delay in reporting and investigating the incident.
Two residents were involved in a physical altercation after one sold a non-functional phone to the other, leading to an attack and subsequent retaliation. Both residents, diagnosed with schizophrenia, were found with injuries, including bruising and lacerations. The facility's failure to prevent this altercation and protect the residents from harm constitutes a deficiency in ensuring residents' rights to be free from abuse.
A resident in an LTC facility was injured after being punched by another resident during a code green incident. The injured resident, who has severe cognitive impairment, was placed in another resident's room by staff to avoid an ongoing altercation in the hall. The aggressor, who was cognitively intact, claimed self-defense, stating they were kicked. The incident was not witnessed by staff, and the injury was discovered later, leading to an investigation based on resident accounts.
A facility failed to prevent two resident-to-resident altercations involving three residents, resulting in physical harm. The first incident involved a fight over a perceived racial slur, while the second was triggered by a dispute over a chair. Both incidents involved residents with cognitive impairments and behavioral issues, highlighting the facility's inability to prevent abuse and ensure resident safety.
Two residents were involved in a physical altercation after a verbal argument, with one resident striking the other. The facility's staff failed to effectively intervene, despite having policies in place to prevent such incidents. Both residents had care plans that included interventions to manage agitation, but these were not adequately implemented. A CNA attempted to de-escalate the situation by yelling for the residents to return to their rooms, which was deemed insufficient by the DON and Administrator.
The facility failed to provide RN coverage on each shift daily, resulting in a One Star Staffing Rating for low weekend staffing. Interviews revealed no RN coverage on night shifts, with LPNs taking charge and handling emergencies.
The facility failed to maintain sanitary conditions in food storage and preparation areas, with observations of soiled bins and improper dating of food items. Cooking temperatures were not consistently documented, and a large piece of roast beef was undercooked. The dish machine's temperature and sanitizer concentration were not routinely monitored, with no log of testing results maintained.
The facility failed to maintain accurate records for the reconciliation of petty cash in the resident trust account. The Activity Director had not reconciled the petty cash sheet with the current BOM for about a month. Discrepancies were found in the reconciliation forms, with missing receipt numbers and inconsistencies in cash balances. The BOM admitted to errors in the petty cash forms and could not provide checks for certain dates, indicating a lack of proper documentation and oversight.
The facility did not maintain an adequate surety bond for the resident trust fund account, as required by their policy. The bond amount was insufficient compared to the current trust account balance. The Business Office Manager and Assistant Administrator stated that the bond was recently lowered by the corporate office, and evaluations for adjustments are conducted annually.
The facility failed to maintain a clean and homelike environment, as observed in the rooms of two residents, which had stains, debris, and inadequate organization. The facility had been without housekeeping staff for six months, relying on department heads for cleaning, which was ineffective. Cleanliness improved after reinstating the housekeeping department, but issues persisted.
The facility did not follow preplanned menus and portion sizes as specified in the Diet Spreadsheets. Observations revealed discrepancies in meal items and serving sizes, with incorrect utensils used for portioning. The Dietary Manager and Regional Food Service Supervisor confirmed these issues, attributing them to vendor substitutions and preparation challenges.
Staff in an LTC facility failed to follow hand hygiene protocols during medication administration, housekeeping, and dietary tasks. A CMT did not sanitize hands while administering medications to two residents. Housekeeping staff did not perform hand hygiene after handling trash liners, and dietary aides failed to wash hands between handling soiled and clean dishes. These actions were contrary to facility policies and expectations.
A medication cart was left unlocked and unattended outside a nurse's station, posing a risk to cognitively impaired residents. A CMT was aware of the oversight, and an LPN confirmed the security lapse. Observations later showed a resident attempting to open locked carts, highlighting the importance of securing medication carts.
The facility failed to protect a resident from abuse when one resident hit another in the mouth during two separate incidents. Despite the facility's policy requiring 1:1 monitoring and immediate reporting, the resident was not adequately supervised, leading to physical altercations and injury.
The facility failed to follow their abuse and neglect policy by not reporting timely after an allegation of physical abuse was made for one resident and an allegation of sexual abuse was made for another resident. Multiple staff members witnessed the incidents but did not report them immediately, leading to delays in addressing the allegations and ensuring the safety of the residents involved.
The facility failed to report and investigate physical abuse between two residents, despite incidents occurring on consecutive days. One resident, with severe cognitive impairment, wandered into another resident's room and was hit in the mouth on both occasions. The facility did not follow its policy to report the incidents to DHSS or conduct an investigation.
The facility failed to prevent resident-to-resident abuse, resulting in multiple altercations. One incident involved a resident with intact cognition and another with severe cognitive impairment, leading to a physical altercation. Another incident involved a resident with Alzheimer's and schizophrenia, who engaged in a physical altercation with a peer after a verbal exchange. The facility's investigation revealed these were isolated incidents, with factors such as non-compliance with medication and poor personal boundaries contributing to the altercations.
A resident, who is legally blind and hard of hearing, was physically abused by a Dietary Aide (DA) after requesting coffee. The DA grabbed the resident's wrists and throat, and although staff intervened, the DA remained in the facility until their regular clock-out time. The incident was not reported to the administration until the following day, leading to an Immediate Jeopardy (IJ) violation.
The facility failed to ensure consistent blood sugar checks and insulin administration for a resident with diabetes, leading to hospitalization and death. Another resident with a seizure disorder did not receive Valtoco as prescribed, and the physician was not consistently notified. A third resident did not receive medications as ordered, with no documentation explaining the omissions.
A facility failed to ensure a resident was free from unnecessary physical restraint when a CNA tied a sheet to a chair around the resident to prevent them from getting up. The resident, who was cognitively impaired and had dementia, was on one-on-one monitoring due to wandering behavior. The CNA's actions were against the facility's policy on restraints.
The facility failed to follow their abuse and neglect policy by not reporting timely after an allegation of physical abuse was made for one resident and an allegation of sexual abuse was made for another resident. Multiple staff members witnessed the incidents but did not report them immediately, assuming others would do so. The facility did not notify the Missouri Department of Health and Senior Services (DHSS) within the required time frames.
A facility failed to follow its abuse and neglect policy when a CNA used a sheet to restrain a resident with dementia to a chair. The incident was not immediately reported by other staff members, and the CNA continued to provide care for twenty minutes after the incident was reported. The resident was on 1:1 monitoring due to wandering behaviors.
A resident with a history of wandering and elopement eloped from the facility through an alarmed door, which did not function as expected. Staff failed to realize the resident was missing until the police brought him back over an hour later. The resident's care plan lacked adequate interventions, and staff did not follow the facility's elopement protocol.
The facility failed to ensure sufficient skilled and competent staff were available to meet the behavioral health needs of residents. A staff member left their 1:1 assignment without proper handover, leading to an altercation between two residents with schizophrenia. Both residents were sent to the hospital for evaluation and treatment.
Failure to Monitor and Supervise Resident with History of Drug Distribution Leads to Multiple Overdoses
Penalty
Summary
The facility failed to provide ongoing monitoring and close supervision of a resident with a known history of non-compliance with facility rules, specifically related to obtaining and distributing unauthorized and/or illegal drugs. Despite previous incidents and documented behaviors, the resident was not consistently placed on one-on-one monitoring or subjected to drug screening as required by facility policy when there was suspicion of drug use. On multiple occasions, this resident was able to bring illegal substances into the facility and distribute them to other residents, resulting in several overdoses. On one occasion, three residents required cardiopulmonary resuscitation (CPR) and were hospitalized after overdosing on unauthorized substances, with drug screens confirming the presence of illegal drugs. The facility's own investigation and video footage confirmed that the resident in question received money from other residents and was involved in the distribution of drugs. Despite these findings and the resident's return to the facility, staff failed to implement required monitoring and did not obtain a drug screen when the resident exhibited suspicious behaviors, such as being slow to respond and inappropriate laughter. As a result of these lapses, additional residents experienced overdoses, with one resident suffering cardiac arrest and being admitted to hospice care due to anoxic encephalopathy. Other residents also tested positive for illegal substances and reported purchasing drugs from the same resident. The facility's failure to follow its own policies for monitoring, drug screening, and supervision directly contributed to repeated incidents of drug use and distribution among residents, resulting in significant harm.
Failure to Notify Physician and Hold Antihypertensive Medication for Hypotensive Resident
Penalty
Summary
Facility staff failed to notify a resident's physician regarding a significantly low blood pressure reading and administered an antihypertensive medication despite the hypotensive state. The resident, who had diagnoses of hypertension, Alzheimer's disease, and schizophrenia, was prescribed two antihypertensive medications: losartan potassium and atenolol. On the day in question, the resident's blood pressure was recorded as 78/67, which is below the normal range. The Certified Medication Technician (CMT) documented this low blood pressure but did not notify the charge nurse or hold the antihypertensive medication as required by facility policy. The resident's care plan and physician orders indicated that blood pressure should be monitored, and antihypertensive medications should be held if hypotension occurred, with prompt notification to the physician. Despite these directives, the CMT administered losartan potassium and failed to communicate the low blood pressure to nursing staff. There was no documentation in the progress notes regarding the hypotensive episode, and the charge nurse was not made aware of the situation until after the resident experienced a medical emergency. Interviews with facility staff, including the LPN, DON, RN, and the resident's physician, confirmed that the expected protocol was not followed. The CMT should have held the antihypertensive medication and immediately informed the nurse, who would then have contacted the physician for further orders. The physician stated that, had he been notified, he would have ordered emergency interventions. The lack of communication and failure to follow established protocols directly contributed to the deficiency identified during the survey.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when two residents were involved in a physical altercation. One resident, who was cognitively intact and had diagnoses including hypertension, COPD, and schizophrenia, was outside during a smoke break when another resident approached and struck them in the face. The incident resulted in a bloody lip and an abrasion to the elbow after the resident fell to the ground. The resident denied pain or discomfort but required first aid for the injuries. The altercation was unprovoked, and the resident who was attacked did not retaliate. The resident who initiated the altercation was also cognitively intact and had a history of delusions, epilepsy, anxiety disorder, depression, psychotic disorder, COPD, and schizophrenia. This resident reported that the attack was motivated by the belief that the other resident was gay, as indicated by their choice of clothing. Staff interviews confirmed that the attack was sudden and unexpected, occurring while staff were present but momentarily distracted by routine duties such as letting other residents outside and distributing cigarettes. The staff intervened quickly once the altercation began, but were unable to prevent the initial assault. Multiple staff members and both residents provided consistent accounts of the event, describing how the aggressor walked directly up to the other resident and began striking them without provocation. The incident occurred in a common area near the back door, with staff nearby but unable to anticipate the aggressor's actions. The facility's policy required staff to identify residents at risk for abuse and to implement care planning to reduce the chances of mistreatment, but in this case, the measures in place did not prevent the altercation.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor residents' rights to a safe, clean, comfortable, and homelike environment, including the provision of safe treatment and supports for daily living. This issue remains uncorrected, as referenced in a previous Statement of Deficiencies. The deficiency is cited under F584 and is associated with Event ID Z3RV-H2. No additional details about specific actions, inactions, or the condition of residents at the time of the deficiency are provided in the report.
Failure to Maintain Clean, Sanitary, and Homelike Environment
Penalty
Summary
Facility staff failed to provide a clean, sanitary, and homelike environment for residents, as evidenced by multiple observations and interviews. Two residents' rooms were found to be inadequately cleaned, with heavy dirt build-up, sticky floors, overflowing trash cans, and soiled items left out. One resident, who was paralyzed from the waist down, reported that housekeeping had not cleaned the floor in a long time and that aides were no longer assisting with room cleanliness or organization. Another resident's room had a sticky floor, trash, a broken broom head, and dried food debris that remained unaddressed despite claims that the room had been recently cleaned. Staff interviews confirmed that the rooms were not up to standard, and the Housekeeping Supervisor was unaware of how long some items had been left on the floor. The facility also failed to follow proper procedures for handling soiled linen and towels. Observations revealed soiled bed pads and towels with stains resembling mildew left on the floor, and wet towels and wash rags left in shower rooms. Staff interviews confirmed that soiled linen should never be placed on the floor and should be bagged and taken to the soiled utility room, but this was not consistently done. The Housekeeping Supervisor was observed picking up wet towels with ungloved hands, and there was confusion among staff regarding responsibilities for removing soiled linen from shower rooms. Shower rooms on two halls were not thoroughly cleaned after resident use, with feces observed on the floor, wet towels left out, and visible hair, black soot, and debris in and around the showers. Residents expressed reluctance to use the showers due to their unclean state. The Housekeeping Supervisor admitted there was no checklist or schedule for daily or deep cleaning tasks, and cleaning assignments were inconsistent. The Administrator was unaware of the lack of cleaning schedules and the extent of uncleanliness in resident rooms and shower areas.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to follow its Abuse and Neglect policy by not notifying the Department of Health and Senior Services (DHSS) within the required timeframe after an incident involving a Certified Medication Technician (CMT) and a resident. The incident occurred when the resident, who was cognitively intact and had diagnoses of depression and bipolar disorder, called the CMT a derogatory name, and the CMT responded by throwing Kool-Aid in the resident's face. The resident reported the incident to the Administrator, who responded by sending the CMT home and later involving the Director of Nursing (DON) to begin an investigation. Despite the facility's policy requiring immediate reporting of abuse allegations to appropriate agencies, including DHSS, within 24 hours, the notification was not made as required. Both the Administrator and the DON assumed the other had notified DHSS, resulting in a failure to report the incident in accordance with state and federal regulations. The facility's own investigation confirmed the incident met criteria for self-reporting as abuse, but the required notification was not completed in a timely manner.
Failure to Prevent Elopement and Provide Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure adequate supervision and oversight for residents with a known risk of elopement, resulting in multiple incidents where residents left the premises without staff awareness. One resident with a history of elopement was left unsupervised in the courtyard during a smoking break and used a chair to climb over the fence, subsequently being found in the road by an off-duty staff member. On a separate occasion, the same resident again used a chair to climb over the fence and was not noticed missing for three to four hours, eventually being found several miles from the facility. Staff interviews revealed that required face checks and monitoring were not consistently performed, and door alarms did not sound or were not heard during these incidents. The resident involved had a history of elopement from a prior secure facility, diagnoses including schizophrenia and diabetes, and was assessed as cognitively intact on some assessments but with memory and decision-making difficulties noted in others. The care plan identified the resident as at risk for elopement, but interventions such as close monitoring and ensuring re-entry after smoking were not effectively implemented. Staff statements indicated confusion about the resident's whereabouts, lack of awareness of the resident's absence, and failure to respond to or hear door alarms. Additionally, there was a lack of timely notification to law enforcement when the resident could not be located on facility grounds, contrary to facility policy. A second resident, also identified as high risk for elopement, exited the building through a dining room door with a faint alarm and was found by staff in the parking lot. The facility had identified 45 residents as high risk for elopement, and issues were found with two residents. The report documents that the facility's elopement and wandering resident policy was not consistently followed, including the use of alarms, supervision, and timely response to missing residents. These failures resulted in residents leaving the facility unsupervised and unaccounted for, with staff and leadership interviews confirming lapses in monitoring, communication, and adherence to established protocols.
Failure to Accurately Document Resident Elopement in Medical Record
Penalty
Summary
The facility failed to ensure accurate documentation in a resident's electronic medical record (EMR) following an elopement incident. A registered nurse (RN) documented that the resident was found on the facility parking lot after eloping, despite knowing that the resident was actually found several miles away from the facility. This documentation was made at the direction of the former Assistant Director of Nursing (ADON), who instructed the RN to record that the resident was found on the facility campus. The Director of Nursing (DON) later verbally counseled the RN, emphasizing that false information should not be documented, regardless of who gives the instruction. The resident involved had a history of elopement from a prior secure facility and was identified as being at risk for elopement in their care plan. The resident was cognitively intact, had adequate hearing and vision, and had diagnoses including diabetes mellitus, seizure disorder, and schizophrenia. On the day of the incident, the resident was discovered missing during the morning medication pass, and a code white (elopement) was called. Staff later found the resident approximately 3.7 to 4.7 miles from the facility, after searching the surrounding area. Facility policy required that all documentation in the medical record be factual, accurate, and completed in a timely manner. The policy specifically prohibited the documentation of false information and required corrections to clarify inaccuracies. Despite this, the progress note entered by the RN did not accurately reflect the resident's location when found, resulting in a failure to maintain an accurate and complete medical record as required by facility policy and professional standards.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in two separate incidents involving four residents. In the first incident, a resident hit another resident in the head and face with a dismantled towel rack, causing bruises and hematomas. The aggressor had a history of being triggered by sounds and exhibited physical and verbal behaviors directed at others. The victim also had a history of physical and verbal aggression, with diagnoses including anxiety, bipolar disorder, and PTSD. The altercation occurred during smoke time, and staff responded by separating the residents and providing medical assessments. In the second incident, two residents engaged in a physical altercation, resulting in one resident sustaining a swollen eye. The aggressor had mild cognitive impairment and a history of delusions, while the victim was cognitively intact but had a history of psychotic disorder and schizophrenia. The altercation was triggered by verbal provocations, and staff intervened by separating the residents and conducting assessments. Both residents had care plans that included interventions for managing potential aggression, but these measures were not sufficient to prevent the incident. The facility's failure to prevent these incidents highlights deficiencies in managing resident-to-resident altercations and ensuring a safe environment. Despite having care plans and interventions in place, the facility did not effectively anticipate or de-escalate the situations, leading to physical harm. The incidents were substantiated as abuse, and the facility acknowledged that at least one of the altercations was preventable.
Failure to Supervise Residents During Smoking and Delayed Investigation
Penalty
Summary
Facility staff failed to provide adequate supervision to residents while they were smoking in the designated smoke room. Multiple residents, including those with severe cognitive impairment and various psychiatric and medical diagnoses, were found smoking unsupervised and passing a cigarette among themselves. The facility's policy required direct supervision for residents classified as not responsible, and all residents involved had smoking assessments indicating that supervision, designated smoking locations, and times were determined by facility policy. However, there was no documentation of a smoking care plan in any of the residents' care plans, despite their assessments. The incident was discovered when a CNA found six residents smoking unsupervised in the smoke room and reported the event to the charge nurse. Staff interviews revealed that a hall monitor had lit a cigarette for one resident, believing someone was monitoring the room, but no staff was present to supervise. The CNA instructed the residents to extinguish the cigarette and leave the room, but did not inquire who had lit the cigarette. The incident was reported up the chain of command, but there was a delay in initiating an investigation, as the ADON and Administrator were either not immediately informed or were occupied with other matters. Review of records showed that the residents involved had varying degrees of cognitive and physical abilities, with some requiring supervision or assistance with activities of daily living and others having diagnoses such as dementia, schizophrenia, and end-stage renal disease. Despite these needs, the facility did not ensure that the required supervision was provided during smoking, nor did it promptly investigate how the residents were able to smoke unsupervised, as required by facility policy and safety regulations.
Resident Altercation Due to Non-Functional Phone Sale
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when two residents were involved in a physical altercation. Resident #4 sold a cellular phone to Resident #5, which Resident #5 claimed did not work. This led to Resident #5 attempting to attack Resident #4, who then retaliated by hitting Resident #5, resulting in bruising to the right eye and a laceration to the right eyebrow. The incident was reported to the Administrator on 2/19/25, although it occurred on 2/1/25. Resident #4, who has diagnoses of end-stage renal disease and schizophrenia, was noted to have no cognitive impairment and was independent with activities of daily living. The resident reported that the altercation occurred because Resident #5 was upset about the non-functional phone and that he/she was defending him/herself. Resident #5, also diagnosed with schizophrenia and having no cognitive impairment, was found with blood on his/her face, hands, and right ear, along with swelling and bruising to both eyes and a laceration to the right eyebrow. The facility's Abuse and Neglect Policy requires immediate reporting of all allegations of abuse, including resident-to-resident altercations. The policy defines abuse as the willful infliction of injury or punishment resulting in physical harm or mental anguish. The incident was substantiated by the Administrator and Director of Nursing, who confirmed that both residents are being closely monitored. The facility's failure to prevent the altercation and protect the residents from physical harm constitutes a deficiency in ensuring residents' rights to be free from abuse.
Resident-to-Resident Altercation Results in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident hit them in the face, resulting in a black eye and the need for sutures. The incident occurred during a code green, which is called when a resident exhibits aggressive behaviors. A staff member, in an attempt to remove the resident from harm's way, propelled them into another resident's room. Shortly after, the resident was wheeled out with a bleeding injury above the left eye, having been punched by the other resident. The resident who committed the act of aggression was cognitively intact according to a recent assessment and claimed to have acted in self-defense, stating they were kicked by the other resident. However, no injuries were noted on the aggressor. The resident who was hit had severe cognitive impairment and was unable to recall the incident clearly. The altercation was not witnessed by staff, and the injury was only discovered after the fact, prompting an investigation based on the accounts of the residents involved. The Director of Nursing and Assistant Director of Nursing confirmed that the investigation relied heavily on the residents' statements due to the lack of staff witnesses. The Administrator explained that the decision to place the resident in another's room was made quickly to avoid further risk during the ongoing altercation in the hall. The facility's policies on abuse and resident rights emphasize the protection of residents from abuse, including from other residents.
Failure to Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, resulting in two physical altercations involving three residents. The first incident involved two residents who engaged in a physical fight after one resident believed the other had used a racial slur. This altercation resulted in one resident suffering a nosebleed. The facility's staff were present during the incident and intervened to separate the residents. However, the altercation highlights a failure in the facility's ability to prevent resident-to-resident abuse. The second incident occurred the following day and involved the same resident from the first altercation and a third resident. This altercation was triggered when the resident refused to vacate a chair, leading to a physical confrontation with the third resident. The staff were present and attempted to de-escalate the situation, but the altercation resulted in the resident being hit in the nose. This incident further underscores the facility's inability to prevent resident-to-resident altercations and ensure the safety of its residents. Both incidents involved residents with cognitive impairments and behavioral issues, including diagnoses of schizophrenia, anxiety disorder, and PTSD. The facility's failure to adequately address these residents' behavioral needs and prevent altercations contributed to the deficiency. The incidents were substantiated through interviews and record reviews, revealing a pattern of inadequate supervision and intervention to prevent resident-to-resident abuse.
Failure to Prevent Resident Altercation
Penalty
Summary
The facility failed to protect a resident from abuse when staff did not effectively intervene during a verbal argument between two residents that escalated into a physical altercation. The incident involved two residents, one of whom struck the other in the face. The facility's policy on abuse and neglect outlines the need for staff to identify, correct, and intervene in situations where abuse is likely to occur, but this was not adequately followed in this case. Resident #1, who was cognitively intact and had a history of being physically aggressive, was involved in the altercation. The resident's care plan included interventions to prevent escalation of agitation, such as guiding the resident away from the source of distress and engaging in calm conversation. However, these interventions were not effectively implemented, leading to the physical altercation with Resident #2. Resident #2, also cognitively intact, had a history of physical behavioral symptoms directed toward others. The resident's care plan included similar interventions to prevent escalation, but these were not successfully applied. During the incident, a Certified Nurse Assistant (CNA) attempted to de-escalate the situation by yelling for the residents to return to their rooms, but this approach was insufficient to prevent the physical altercation. The Director of Nursing (DON) and the Administrator acknowledged that the CNA's response was inadequate, as the CNA should have physically intervened rather than shouting from a distance.
Inadequate RN Coverage on Night Shifts
Penalty
Summary
The facility failed to maintain adequate Registered Nurse (RN) coverage on each shift daily, as required. According to the Payroll Based Journal (PBJ) Staffing Report from CMS for FY Quarter 1 2024, the facility received a One Star Staffing Rating due to excessively low weekend staffing. An interview with the Staffing Coordinator and the Human Resources Manager revealed that there was no RN coverage on the night shift from 11 p.m. to 7 a.m. on specific dates, including Saturday and Sunday, as well as upcoming shifts. During these times, Licensed Practical Nurses (LPNs) were responsible for taking charge, notifying physicians, and contacting families and emergency personnel in case of emergencies.
Sanitation and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and distribution areas. During a kitchen tour, it was observed that serving utensils were stored in open bins with crumbs, and dry goods bins had soiled lids with food matter inside. Dishware and equipment were not air-dried properly, and the grease tray under the grill was not cleaned after use. The convection steam oven had a cracked door seal, and the walk-in refrigerator contained items with unclear dating, such as Health Shakes with two different dates and baked potatoes dated beyond the facility's three-day storage policy. An open, undated carton of apple juice was also found in the dry storage room. The facility did not consistently monitor cooking temperatures of raw meats and the sanitizer concentration of the dish machine. A dietary aide failed to document the cooking temperatures of roast beef, and a large piece of roast was found undercooked. The dietary manager confirmed that final cooking temperatures were not logged. Additionally, the dish machine, which lacked a visible temperature gauge, was not routinely monitored for temperature or sanitizer concentration. The dietary manager admitted that testing was only done when staff suspected a malfunction, and no log of testing results was maintained.
Inaccurate Petty Cash Reconciliation in Resident Trust Account
Penalty
Summary
The facility failed to maintain complete and accurate accounting records for the reconciliation of petty cash in the resident trust account. The facility's policy required that the Resident Trust Clerk enter all transactions into the banking system daily and obtain the Administrator's signature for reconciliation approval. However, the monthly reconciled bank statements provided did not include the reconciliation of the petty cash kept on hand. The Activity Director, who was responsible for handing out money to residents, had not reconciled the petty cash sheet with the current Business Office Manager (BOM) for about a month, and the reason for this was unknown. The review of the Resident Trust Petty Cash Reconciliation Forms revealed discrepancies in the reconciliation process. The forms showed missing receipt numbers and inconsistencies in the cash balance and disbursement amounts. During an observation, the Human Resource Manager and BOM counted the petty cash without a reconciliation sheet, and the BOM admitted to errors in the petty cash forms for specific dates. The Assistant Administrator expected timely and accurate reconciliation, but the BOM could not provide checks for certain dates, indicating a lack of proper documentation and oversight in managing the resident trust petty cash.
Inadequate Surety Bond for Resident Trust Fund
Penalty
Summary
The facility failed to maintain an adequate surety bond for the resident trust fund account, as required by their Resident Trust Policy. The policy mandates that the bond should be at least one and a half times the average total of the reconciled monthly balances. However, the bond report approved by the Department of Health and Senior Services showed a bond amount of $175,000, which was insufficient given the current trust account balance of $120,901.84. During an interview, the Business Office Manager and the Assistant Administrator revealed that the surety bond was recently lowered by the corporate office, and they only evaluate the bank reconciliation annually in August to determine if adjustments are needed.
Deficiency in Maintaining a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by observations and interviews. Resident #93's room and bathroom were found to be inadequately cleaned, with brown stains on the walls, dirty floors, and a brown substance around the base of the commode. Additionally, the exhaust fan above the commode had a dark brown substance on its vents. Similarly, Resident #130's room had dark stained tiles, debris behind the door and under the air conditioning unit, water-damaged grout, and stained baseboards. The bathroom lacked proper organization, with multiple unlabeled hand towels and toothbrushes, and a trashcan without a liner. Interviews with staff revealed that the facility had been without housekeeping staff for about six months, during which time department heads were tasked with cleaning duties. This arrangement was not effective, and cleanliness improved only after the housekeeping department was reinstated two months prior to the survey. The Housekeeping and Laundry Supervisor, appointed in April, had a plan to deep clean one hall each week, but was still in the process of implementing it. The lack of consistent and thorough cleaning affected the residents' mood and quality of life, as noted by an LPN.
Failure to Follow Preplanned Menus and Portion Sizes
Penalty
Summary
The facility failed to adhere to preplanned menus and Diet Spreadsheets, which specify the foods and portion sizes to be served to residents. During a meal service observation, it was noted that the menu items served did not match those listed on the Week at a Glance - Week 1 menu. Specifically, creamed corn and baked beans were served instead of corn casserole and cornbread. Additionally, during a breakfast trayline observation, a dietary aide used a ladle that served 1.6 ounces of sausage gravy instead of the 4-ounce portion size specified on the Diet Spreadsheet. Further discrepancies were observed during a noon meal service, where pureed diets were served mashed potatoes instead of the pureed pasta indicated on the Diet Spreadsheet. The serving utensils used did not match the portion sizes specified, with a yellow ladle serving 2 ounces instead of the required 2 2/3 ounces, and a white ladle serving 1.6 ounces instead of the 5.5 ounces specified. The Dietary Manager and Regional Food Service Supervisor confirmed these discrepancies, citing vendor substitutions and preparation issues as reasons for the deviations from the planned menu.
Infection Control Deficiencies in Hand Hygiene Practices
Penalty
Summary
Facility staff failed to adhere to proper hand hygiene protocols during medication administration and housekeeping tasks, leading to potential infection control deficiencies. Certified Medication Technician (CMT) HH was observed administering medications to two residents without sanitizing hands before entering the room, during the medication process, or after exiting the room. This lack of hand hygiene was acknowledged by CMT HH and confirmed by the Director of Nursing (DON) and a Registered Nurse (RN), who stated that hand sanitation is required during medication administration. Additionally, housekeeping staff were observed not performing hand hygiene after placing plastic liners in trash cans for resident rooms. One housekeeper was found wearing two pairs of gloves, discarding only the top pair after cleaning a room, and not performing hand hygiene due to the absence of hand sanitizer on the cart. The Housekeeping Supervisor confirmed that the expectation was to remove gloves and perform hand hygiene before applying new gloves. In the dietary department, staff failed to perform hand hygiene between handling soiled and clean dishes, as observed with Dietary Aides (DA) A, C, and B. These aides either did not change gloves or wash hands between tasks, despite the Dietary Manager's expectation for hand hygiene between handling soiled and clean items.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that one of the six medication carts was locked and that all drugs and biologicals were secured in locked compartments. This deficiency was observed on one of the six floors outside of the nurse's station. During a facility tour, it was noted that a medication cart was left unlocked and unattended, with the Certified Medication Technician (CMT) not having a visual view of the cart. This occurred in an area where visitors and residents, including those who are cognitively impaired, were present. Interviews conducted with staff revealed that the CMT was aware of leaving the medication cart unlocked. A Licensed Practical Nurse (LPN) confirmed that the cart should not have been left unsecured due to the presence of cognitively impaired residents who might attempt to access it. An observation two days later showed a resident attempting to open the drawers of locked medication carts, indicating the potential risk posed by unsecured medication carts. However, during this observation, all carts were locked, and the resident was unable to open any drawers.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure a resident's right to be free from abuse was not violated when one resident was involved in a physical altercation with another resident. In two separate incidents, one resident hit another resident in the mouth when the latter wandered into the former's room. The facility's Abuse and Neglect Policy outlines procedures for reporting and investigating complaints of abuse, but these procedures were not adequately followed in this case. The first incident occurred when a resident wandered into another resident's room and was struck in the mouth, resulting in a swollen lip and a small cut. Despite the facility's policy requiring immediate reporting and investigation of such incidents, the resident was not placed on 1:1 monitoring as required. The second incident happened during a shift change, and again, the resident was not under 1:1 monitoring, leading to another altercation and injury. Interviews with staff revealed that the resident was supposed to be on 1:1 monitoring but was not due to short staffing. The facility's investigation confirmed that the resident's lip was swollen and described as busted. The facility's failure to provide the required 1:1 monitoring and to promptly investigate and report the incidents contributed to the deficiency in protecting the resident from abuse.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to follow their abuse and neglect policy by not reporting timely after an allegation of physical abuse was made for one resident and an allegation of sexual abuse was made for another resident. This affected two residents. The facility's policy required immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. However, the facility did not report the incidents within the required time frames, leading to a delay in addressing the allegations and ensuring the safety of the residents involved. In the first incident, a resident with bipolar disorder, hearing loss, legal blindness, and dyskinesia reported that a staff member put their hands around the resident's neck and choked them. The incident was not reported to the Missouri Department of Health and Senior Services (DHSS) until the following day, and law enforcement was notified even later. The facility's investigation revealed that multiple staff members witnessed the incident but did not report it immediately, assuming others would do so. The staff involved received disciplinary actions and were re-in-serviced on abuse and neglect policies. In the second incident, a resident with anxiety, manic depression, schizophrenia, seizures, and PTSD accused another resident of being sexually inappropriate. The allegation was reported to management and the resident's guardian, but the facility did not notify DHSS until the next day. The facility's investigation showed that the incident occurred two days before it was reported. The Administrator acknowledged that all allegations of abuse and neglect should be reported within two hours, indicating a failure to adhere to the facility's policy and state regulations.
Failure to Report and Investigate Physical Abuse Between Residents
Penalty
Summary
The facility failed to follow their policy to report to the Department of Health and Senior Services (DHSS) and investigate physical abuse between two residents. The first altercation occurred when one resident wandered into another resident's room and was hit in the mouth. This incident was not reported to DHSS and was not investigated. The following day, a second altercation occurred under similar circumstances, with the same resident wandering into the other resident's room and being hit again. Both incidents involved physical abuse, but the facility did not take the necessary steps to report and investigate as required by their policy. Resident #4, who has severe cognitive impairment, wandered into Resident #3's room on two separate occasions. Resident #4 was supposed to be on 1:1 monitoring due to their wandering behavior, but this was not implemented due to short staffing. During the first incident, Resident #4 was found with a swollen lip and a small cut, while Resident #3 had their fist balled up. The incident was reported to management, but no further action was taken to investigate or report it to DHSS. The second incident occurred the next day, resulting in Resident #4 being sent to the hospital for evaluation. The facility's failure to report and investigate these incidents is a clear violation of their Abuse and Neglect Policy. The policy mandates immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing (DON) or designee, as well as to outside persons or agencies. Additionally, the policy requires an investigation to be initiated upon learning of the report of abuse or neglect. The facility did not adhere to these procedures, resulting in a lack of protective oversight and appropriate response to the incidents of physical abuse between the residents.
Resident-to-Resident Altercations Due to Inadequate Abuse Prevention
Penalty
Summary
The facility failed to protect residents from abuse, resulting in multiple resident-to-resident altercations. One incident involved a resident with intact cognition and no behavioral issues, who had a physical altercation with another resident with severely impaired cognition and multiple diagnoses, including schizophrenia and depression. The altercation began when the first resident entered the second resident's room, leading to a verbal exchange and the throwing of a food tray, followed by physical violence. Both residents were assessed, and the incident was reported to the necessary parties. Another incident involved a resident with intact cognition and a history of Alzheimer's disease, anxiety, and schizophrenia, who engaged in a physical altercation with a peer. The altercation began with a verbal exchange, during which racial slurs were used, and escalated when one resident attempted to hit the other with a chair. Staff intervened, and both residents were separated and assessed. The incident was reported to the appropriate authorities, and the residents were sent to the hospital for evaluation. The facility's investigation revealed that these incidents were isolated occurrences, with contributing factors including non-compliance with medication and poor awareness of personal boundaries. The residents involved had varying levels of cognitive impairment and mental health diagnoses, which may have contributed to the altercations. The facility's failure to prevent these incidents highlights a deficiency in ensuring residents' rights to be free from abuse.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse. The incident involved a legally blind and hard-of-hearing resident who asked a Dietary Aide (DA) for coffee. The DA refused, stating the kitchen was almost closed. During the conversation, the resident raised their hands while talking, prompting the DA to grab the resident's wrists and then their throat. A Floor Technician (FT) intervened and separated the DA and the resident, but the DA remained in the facility and clocked out at their regular time. The facility staff failed to ensure the safety of other residents on the evening of the incident. The resident's records showed they were cognitively intact but had significant sensory impairments, including legal blindness and hearing loss. The resident's care plan included interventions to help with communication and behavior management. Despite these measures, the incident occurred, and the resident reported the abuse the following day. A head-to-toe assessment showed no injuries, and the resident's guardian and physician were notified. The facility's investigation revealed that the DA had only been employed for a few days and had not received adequate training on handling such situations. Witness statements and video evidence confirmed the DA's physical abuse of the resident. Staff members present during the incident did not report it to the administration, assuming others would do so. The facility's Director of Nursing (DON) and Administrator were unaware of the incident until the resident's family member called. The DA was terminated immediately after the video was reviewed, and the police were notified. The facility's failure to promptly address and report the incident led to an Immediate Jeopardy (IJ) violation, which was later removed after corrective actions were implemented.
Failure to Administer Medications and Notify Physicians
Penalty
Summary
The facility failed to ensure that a resident with diabetes consistently received blood sugar level checks and insulin administration. The resident had a blood sugar level of 550, and the facility did not notify the physician as required. The resident was later transferred to the hospital and diagnosed with diabetic ketoacidosis with coma and passed away. The facility's records showed multiple instances where blood sugar levels and insulin administration were not documented, and there was no explanation provided for these omissions. Another resident with a seizure disorder did not receive consistent administration of Valtoco, a medication prescribed for seizure clusters. The facility staff failed to clarify physician orders and obtain specific parameters for the use of Valtoco. There were multiple instances where the resident experienced seizures, but the medication was not administered, and the physician was not consistently notified. The facility's records did not show any documentation of the administration of Valtoco or reasons for its omission. A third resident did not receive medications as ordered, and there was no documentation explaining why the medications were not administered. The resident had multiple diagnoses, including high blood pressure, diabetes, and schizophrenia, and was on several medications. The facility's records showed that the medication administration record (MAR) was not consistently signed, and there were blanks where medication administration should have been documented. The facility staff did not provide explanations for these omissions in the MAR or the resident's progress notes.
Failure to Ensure Resident Free from Unnecessary Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary physical restraint. Certified Nurse Aide (CNA) E picked up a resident who was wandering, placed the resident over their shoulder, and carried the resident to a chair. CNA E then tied a sheet to the chair around the resident to prevent them from getting up. This action was observed by another staff member, who reported it to the charge nurse. The resident involved was cognitively impaired and had a diagnosis of dementia, with behaviors including wandering and rummaging through items. The facility's investigation revealed that the sheet was tied to the arms of the chair, effectively acting as a restraint, although it was not tied directly to the resident. CNA E admitted to using the sheet in this manner, believing it might help the situation. Additionally, CNA E was observed to have picked up the resident in a manner similar to carrying a baby, which was also reported by another staff member. The resident was on one-on-one monitoring due to their wandering behavior, and CNA E's actions were deemed inappropriate and against the facility's policy on restraints. The facility's policy clearly states that residents have the right to be free from physical restraints imposed for discipline or convenience and not required to treat medical symptoms. The policy also outlines the procedures for reporting and investigating allegations of abuse, neglect, and mistreatment. Despite this, CNA E's actions were not immediately addressed by other staff members, and the resident was left restrained for a period before the situation was reported and CNA E was removed from their assignment.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to follow their abuse and neglect policy by not reporting timely after an allegation of physical abuse was made for one resident and an allegation of sexual abuse was made for another resident. This affected two residents. The facility's policy required immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. However, the facility did not report the incidents within the required time frames. In the first incident, a resident alleged that a staff member put their hands around the resident's neck and choked them. The incident was not reported to the Missouri Department of Health and Senior Services (DHSS) until the following day, and law enforcement was not notified until two days after the incident. Multiple staff members witnessed the incident but did not report it immediately, assuming others would do so. The staff involved received disciplinary actions and were re-in-serviced on abuse and neglect policies. In the second incident, a resident accused another resident of being sexually inappropriate. The allegation was reported to management and the resident's guardian, but the facility did not notify DHSS until the following day. The facility's investigation revealed that the incident occurred two days before it was reported. The Administrator acknowledged that all allegations of abuse and neglect should be reported within two hours, indicating a failure to adhere to the facility's policy.
Failure to Follow Abuse and Neglect Policy
Penalty
Summary
The facility failed to follow their policy when a Certified Nurse Aide (CNA) used a sheet to restrain a resident to a chair because the resident wandered. This incident was observed by another Nurse Aide (NA) who did not immediately report it due to uncertainty about the facility's policy on restraints. Additionally, a Certified Medication Technician (CMT) observed the CNA carrying the resident to a different area and asking for medication to stop the resident from wandering, but also failed to report this immediately. The resident involved was cognitively impaired with a diagnosis of dementia and had a history of wandering and other behaviors related to mental illness. The resident was on 1:1 monitoring due to these behaviors. The CNA tied the resident to a chair with a sheet, which was observed by another staff member who later reported it to the charge nurse. The charge nurse then contacted the Director of Nursing (DON) and the CNA was eventually removed from the facility. Despite the facility's policy requiring immediate reporting and removal of staff accused of mistreatment, the CNA continued to provide care for approximately twenty minutes after the incident was reported. The facility's investigation confirmed that the resident was restrained with a sheet tied to the chair, and the CNA was subsequently terminated. The facility's policy on abuse and neglect was not followed, leading to a delay in addressing the mistreatment of the resident.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide protective oversight to a resident with a known history of wandering and elopement. The resident, who was cognitively intact and had diagnoses including manic depression, PTSD, seizures, and high blood pressure, eloped from the facility through an alarmed door. Staff did not realize the resident had left until the resident was found at a gas station and brought back by the police over an hour after he was last seen by staff. The facility's elopement protocol was not followed, and the resident's elopement assessments were incomplete, lacking necessary interventions to prevent such incidents. The resident had a history of expressing a desire to leave the facility and had previously attempted to elope. Despite this, the resident's care plan did not include adequate interventions to address the elopement risk. On the night of the incident, the resident was last seen at the nurse's station around 9:30 PM and was found missing when the police brought him back around 11:00 PM. The door alarm system, which should have alerted staff to the resident's exit, did not function as expected, and staff failed to conduct the required hourly checks and immediate headcounts when the alarm was triggered. Interviews with staff revealed inconsistencies in the monitoring and response protocols. Some staff were unaware of the resident's previous elopement attempts, and there was confusion about the functioning of the door alarm system. The maintenance supervisor confirmed that the door alarms were tested regularly, but the specific door the resident used to elope did not trigger the alarm as it should have. The facility's investigation concluded that the resident's elopement was due to a failure in the alarm system and inadequate staff response to the resident's known elopement risk.
Failure to Ensure Sufficient Skilled and Competent Staff
Penalty
Summary
The facility failed to ensure sufficient skilled and competent staff were available to meet the behavioral health needs of residents. A staff member assigned to provide one-on-one (1:1) intensive supervision to a resident left the hall without notifying the nurse or waiting for a replacement. This left the hall insufficiently staffed, leading to a resident-to-resident altercation between two residents. The staff member had been educated on the importance of not leaving their 1:1 assignment but chose to leave inappropriately, resulting in the incident. Resident #12, who has a history of behavioral challenges including poor impulse control, agitation, and aggression due to schizophrenia, was left unattended. This resident approached Resident #11 and struck them in the face. Resident #11, who also has schizophrenia and a history of potential aggression, retaliated by hitting Resident #12 back. Both residents were assessed and sent to the hospital for evaluation and treatment. The incident occurred shortly after the staff member assigned to Resident #12 left the hall. Interviews with other staff members confirmed that the staff member assigned to Resident #12 left the building to move their car and did not properly hand over the 1:1 responsibility. Another staff member, already assigned to a different 1:1, attempted to keep an eye on Resident #12 but was unable to prevent the altercation. The facility's investigation concluded that the staff member's failure to adhere to 1:1 supervision protocols directly led to the incident, resulting in their suspension and eventual termination.
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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