Creve Coeur Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 1127 Timber Run Drive, Saint Louis, Missouri 63146
- CMS Provider Number
- 265720
- Inspections on file
- 30
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Creve Coeur Manor during CMS and state inspections, most recent first.
A resident with dementia, prior stroke, and documented swallowing difficulties, who relied on a g-tube for more than half of their nutrition and fluids, did not receive ordered continuous Jevity 1.5 Cal tube feeding and scheduled water flushes. Observations showed the formula and water hanging at the bedside while the resident was seated in the hallway without the feeding attached, and later in bed with the feeding still not connected. Despite clear physician orders for 23-hour tube feeding at a set rate and water flushes every four hours, and facility policies requiring adherence to physician orders, the RN responsible did not restart the feeding when the resident was taken out of bed, resulting in the ordered g-tube regimen not being followed.
Staff did not consistently wear gowns during high-contact care activities for several residents with wounds or indwelling devices, despite EBP signage and care plans indicating the need. Multiple residents requiring EBP received care where only gloves were used, and PPE carts or supplies were not available in their rooms. Facility leadership confirmed insufficient PPE availability, leading to noncompliance with infection control standards.
The facility did not maintain RN coverage for at least eight hours daily, as the DON was administering medications while also fulfilling her role as DON. This dual role was due to staffing issues, and the Administrator was unaware of the requirement that the DON could not serve as the RN on duty while acting as the DON.
The facility did not ensure that the Dietary Manager (DM) met the required qualifications, as the DM was not certified. The Registered Dietician (RD) was only present one day a month and was aware of the DM's lack of certification. The Administrator knew about the DM's lack of training at hiring, expecting completion before the survey. The job description required a dietary management certificate.
The facility did not adhere to dietary menus and portion sizes, affecting 69 residents. A dietary aide served incorrect portions of vegetables and used visual estimation for meat portions due to lack of guidance. Mechanical soft diets were improperly served with whole pieces instead of chopped, and dinner rolls were omitted. The dietary manager confirmed these discrepancies and could not provide a policy.
The facility failed to maintain food safety and sanitation standards, affecting all 69 residents receiving dietary services. Observations revealed a malfunctioning dishwasher, significant cleanliness issues in the kitchen, and improper food handling practices. Staff did not change gloves between handling dirty and clean dishes, and food items were improperly stored, with some left uncovered and undated. The facility's policies were outdated and did not address critical aspects like sanitizing rinses and glove changes.
The facility failed to maintain cleanliness around the garbage dumpsters, affecting all 69 residents. Over four days, surveyors observed debris, including a broken refrigerator, plastic gloves, food debris, and more. One dumpster was often left open. The Administrator stated that cleaning occurs weekly, but lacked documentation. Facility policy assigns maintenance the responsibility to keep the area clean and lids closed.
The facility failed to maintain a large walk-in refrigerator in the dietary department, which has been inoperable since July 2024. This deficiency potentially affects all 69 residents receiving food from dietary. Observations confirmed the refrigerator was empty, and interviews with the Dietary Manager and Administrator provided details on the issue and an estimate for replacing the compressor.
The facility failed to complete TPL forms within 30 days for deceased residents with account balances and did not notify residents when their trust accounts neared the SSI resource limit. This affected several residents, with balances ranging from $610.61 to $10,357.35, and was attributed to a lack of awareness and a new BOM still learning their duties.
The facility failed to maintain a clean and homelike environment on the secured second floor, affecting 30 residents. Observations revealed food splatters, missing ceiling tiles, malfunctioning door handles, and unclean surfaces. Interviews with staff indicated a lack of awareness and communication regarding these issues, with no plan provided to address the concerns.
The facility failed to conduct CNA registry checks for seven newly hired employees, including non-nursing staff, as required by their Abuse Prevention Program. The Business Office Manager, responsible for these checks, was not trained to perform them for non-nursing staff, leading to this oversight.
The facility failed to provide prescribed therapeutic diets to several residents, including health shakes and specific meal items, as ordered by physicians. This affected residents with conditions such as Alzheimer's, diabetes, and malnutrition. The Dietary Manager and Registered Dietician were unaware of the omissions, and the facility lacked a policy to address the issue.
The facility did not follow its TB screening policy, failing to complete timely two-step and annual one-step TB tests for five employees. The policy requires a two-step TST upon hire and an annual one-step test. Staff Members A and B lacked documentation of an annual test, while Staff Members C, D, and E had no documentation of the two-step test. The Administrator noted that the DON or ADON administers the tests, and the HRM ensures completion, but both were out sick during the interview.
The facility failed to maintain the dignity and respect of four residents by not providing clean clothing and socks, and by staff standing while assisting two residents with meals. One resident wore dirty socks without assistance to change them, and another lacked adequate clothing, wearing a hospital gown since admission. Additionally, a CNA stood while feeding two residents, against protocol. These actions led to undignified care for the residents.
A non-verbal resident with multiple diagnoses, including cerebral palsy and multiple sclerosis, was not provided with a communication device, hindering his ability to express needs. Despite a BIMS score indicating an inability to communicate verbally, the care plan lacked strategies for alternative communication. Staff interviews confirmed the absence of a communication board or device, and the resident indicated that such a tool would be helpful.
A resident with a prescription for white petrolatum gel to treat dry skin on her feet and legs did not receive the treatment as prescribed. Despite the resident's cognitive awareness and request for care, observations confirmed the lack of treatment over several days. Interviews with staff revealed that the task was not included in the CNA's daily assignments, and the LPN was unaware of the oversight.
The facility's medication error rate was 6.67%, exceeding the acceptable threshold due to three errors in medication administration. A CMT administered Buspirone late to a resident, and an LPN gave a Daily-Vite with folic acid without a physician's order. Interviews confirmed the facility's policy on medication timing and orders, highlighting the errors' potential impact on accurate dosing.
The facility failed to maintain appetizing food temperatures, affecting all 69 residents. Observations showed food cooled significantly by the time it was served, with the pot roast at 106°F. Interviews revealed no food temperature logs were maintained, contrary to expectations.
The facility did not post the required daily nurse staffing report in a prominent place, instead keeping it in a notebook at the nurses' station. The document lacked essential details such as the facility name, date, census, and total hours worked by RNs, LPNs, and CNAs. The staffing coordinator was unaware of the posting requirement, and the Administrator confirmed the oversight.
The facility failed to provide a safe, comfortable, and homelike environment by not addressing plumbing and roofing issues, resulting in stained and bulging ceiling tiles in residents' rooms and a shower room. Residents expressed concerns about potential mold or fecal contamination, and the maintenance director indicated that approval for necessary repairs had not been granted by the corporate office.
A resident with severe cognitive impairment did not receive their prescribed Hydrocodone-acetaminophen for an extended period due to miscommunication and confusion among staff. The medication was documented as unavailable on multiple occasions, and there was no documentation of communication with the hospice company, physician, or pharmacy regarding the issue.
Failure to Administer Ordered G-Tube Feeding and Water Flushes
Penalty
Summary
The deficiency involves the facility’s failure to provide gastrostomy tube (g-tube) feedings and water flushes as ordered for a resident who was dependent on tube feeding for nutrition and hydration. The resident had diagnoses including hypertension, stroke, dementia, short- and long-term memory loss, and required total staff assistance for all ADLs. The resident’s MDS indicated the presence of a feeding tube and that more than 51% of total calories and fluids were received via the tube. The care plan identified risk for altered nutrition and hydration related to difficulty swallowing and a history of failed swallow test, with approaches including providing tube feeding and water flushes as ordered. Physician orders directed Jevity 1.5 Cal at 45 ml/hr for 23 hours per day and g-tube water flushes of 150 ml every four hours. On the survey day, observations showed that at 10:38 A.M. the resident was not in the room while the Jevity and water were hanging on the IV pole next to the bed, and at 10:48 A.M. the resident was seated in the hallway across from the nurse’s station without the tube feeding or water attached, while an RN sat at the nurse’s station in full view of the resident. At 1:45 P.M., the resident was back in bed with the Jevity and water still hanging on the pole and not connected to the resident. A CNA reported getting the resident up around 9:00 A.M. and placing the resident at the nurse’s desk. The RN responsible for the resident initially stated the tube feeding was ordered to begin in the afternoon, but upon reviewing the physician orders acknowledged that the tube feeding should have been restarted when the resident was gotten out of bed. Facility policies required that tube feedings be administered according to physician orders and that any failure to implement an order be promptly reported to the physician and DON, but the ordered continuous tube feeding and scheduled water flushes were not provided during the observed period.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds and Indwelling Devices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) as required for residents with wounds or indwelling medical devices, such as urinary catheters. Observations revealed that staff did not consistently wear gowns during high-contact care activities, despite the presence of EBP signage and care plans indicating the need for such precautions. In multiple instances, staff provided wound care, catheter care, and assisted with transfers and hygiene for residents requiring EBP, but only wore gloves and not gowns as mandated by facility policy and CDC/CMS guidelines. Several residents with significant medical needs, including chronic wounds, indwelling catheters, and colostomies, were identified as requiring EBP. For these residents, care plans and physician orders often lacked specific instructions for EBP, and in some cases, the need for EBP was not addressed at all. Observations confirmed that staff failed to don appropriate PPE, such as gowns, during high-contact activities, and there was a lack of visible PPE carts or supplies in the rooms of affected residents. Staff interviews confirmed awareness of the requirement to wear gowns, but cited insufficient PPE availability as a barrier to compliance. Interviews with facility leadership, including the Assistant Director of Nursing and the Regional Nurse Manager, confirmed that EBP signage and PPE should be present and used for residents meeting the criteria. However, both acknowledged that the facility did not have enough PPE carts or supplies to meet the needs of all residents requiring EBP. This systemic failure to provide adequate PPE and ensure staff adherence to EBP protocols resulted in the facility not following acceptable infection control standards for multiple residents.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight hours daily, as required. Observations and interviews revealed that the Director of Nursing (DON) was performing dual roles by administering medications to residents while also fulfilling her responsibilities as the DON. This occurred despite the facility having an average daily occupancy of 68 residents. A review of the nurse schedule indicated that on seven out of fourteen days, there was no RN coverage for eight consecutive hours. The DON admitted to working as both the DON and charge nurse due to ongoing staffing issues, and the Administrator was unaware that the DON could not serve as the RN on duty while also acting as the DON.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) met the minimum qualifications required for the position when a Registered Dietician (RD) was not employed full-time at the facility. The DM admitted during an interview that he was not certified as a Dietary Manager. The RD, who was only present at the facility for eight hours one day a month, confirmed her awareness of the DM's lack of certification and stated that she was responsible for the clinical aspects of the facility, providing reports on sanitation and food service. The facility's Administrator acknowledged awareness of the DM's lack of training at the time of hiring, with the expectation that the training would be completed before the survey. The facility's job description for the Dietary Manager indicated that a certificate for dietary management was a minimum qualification.
Failure to Follow Dietary Menus and Portion Sizes
Penalty
Summary
The facility failed to ensure that menus were followed for all four days of the survey, potentially affecting all 69 residents receiving food from dietary services. Observations on the first-floor food service revealed that a dietary aide used a three-ounce ladle to serve winter vegetables, contrary to the menu's specification of four ounces. Additionally, there was no method to measure double or single portions of pot roast. The dietary aide admitted to using visual estimation and serving tongs to determine meat portions, as portion sizes were not provided on the cards. Furthermore, mechanical soft diets were served with whole pieces of pot roast, vegetables, and scalloped potatoes instead of the required chopped form. Dinner rolls, which were indicated on the menu, were not served. The dietary manager confirmed that the items were not chopped, believing them to be soft enough, and acknowledged the omission of dinner rolls. The dietary manager was unable to provide a policy before the survey team's exit.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and distributed in accordance with professional standards, affecting all 69 residents receiving food from dietary services. Observations revealed that the dishwasher's temperature gauge was stuck at 105 degrees Fahrenheit, below the required minimum of 120 degrees Fahrenheit for sanitizing dishes. Despite this, the facility continued to use the dishwasher. Additionally, the kitchen had significant cleanliness issues, including dust and dirt accumulation on air vents, a cracked window with debris, and a walk-in freezer used for storage that was cluttered with dirty mopheads, food debris, and cleaning solutions. The Dietary Manager confirmed these issues and admitted to not having a cleaning schedule for the kitchen. Further observations showed improper food handling practices, such as staff not changing gloves between handling dirty and clean dishes. The dry storage area and back corridor had floors blackened with dirt and grease, and food items were improperly stored, with some left uncovered and undated. The refrigerator contained expired and moldy food items, and a pot roast was left at room temperature without refrigeration. The facility's policies on food labeling and machine ware washing were outdated and did not address critical aspects like sanitizing rinses and glove changes. The Registered Dietician's report also highlighted similar issues, indicating a pattern of non-compliance with food safety standards.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the cleanliness of the area around the garbage dumpsters, which has the potential to affect all 69 residents. Over the course of four days, surveyors observed the exterior garbage dumpster area littered with various debris, including a broken refrigerator, plastic gloves, food debris, medicine cups, fast-food bags, cardboard boxes, bottles of over-the-counter medicine, and other trash. Additionally, one of the dumpsters was consistently found with its lid open during multiple observations. An interview with the Administrator revealed that housekeeping and maintenance are responsible for cleaning the area once a week, but there was no documentation to confirm when the area was last cleaned. The facility's policy states that the maintenance department is responsible for ensuring the area is free of trash and that dumpster lids are kept closed.
Inoperable Walk-In Refrigerator in Dietary Department
Penalty
Summary
The facility failed to maintain essential equipment in working condition, specifically a large walk-in refrigerator in the dietary department. Observations on November 11, 2024, revealed that the refrigerator, measuring 15 feet deep by 10 feet wide, was empty of refrigerated food items. An interview with the Dietary Manager confirmed that the refrigerator has been inoperable since July 2024. This deficiency has the potential to affect all 69 residents who receive food from the dietary department. An interview with the Administrator provided an estimate to replace the refrigerator compressor.
Failure to Complete TPL Forms and Notify Residents of Account Balances
Penalty
Summary
The facility failed to complete third party liability (TPL) forms within 30 days for the final accounting of residents who had expired, affecting three residents who had money in their accounts. Specifically, Resident #104 had an ending balance of $4771.87, Resident #107 had an ending balance of $5833.00, and Resident #106 had an ending balance of $610.61, with no TPL forms completed for any of them. Additionally, the facility did not provide required notifications when residents' trust accounts reached $200 less than the Supplemental Security Income (SSI) resource limit, affecting four residents. These residents had significant balances in their accounts, ranging from $6196.57 to $10,357.35, without any documentation of Medicaid Resident Fund Notification. During an interview, the Administrator acknowledged that TPL and Resident Fund notifications had not been completed, attributing this oversight to a lack of awareness and the recent appointment of the Business Office Manager (BOM), who was still familiarizing themselves with their responsibilities. The facility's Resident's Rights Policy mandates that residents be notified when their account balance approaches the SSI resource limit and that funds be conveyed within 30 days upon a resident's discharge, eviction, or death. However, these requirements were not met, leading to the deficiencies identified in the report.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment on the secured second floor, affecting 30 residents. During an initial tour, surveyors observed numerous deficiencies, including food splatters on walls, missing ceiling tiles, and malfunctioning door handles. Additionally, there were holes in bedroom and bathroom walls, unclean surfaces on tables, and dirty equipment, such as the ice container. These conditions were confirmed through interviews with staff, including a certified nursing assistant who noted that the tables had always been in poor condition. Specific rooms on the second floor exhibited various issues. For instance, some rooms had broken window blinds, missing wardrobe drawers, and bathroom doors without handles, making them inaccessible. Other rooms had gaps around air conditioning units, allowing outside air and pests to enter, and wall damage exposing pipes and supports. The clean linen room also had missing ceiling tiles, exposing ductwork and wires, and lacked a doorknob, leaving a hole in the door. Interviews with the Administrator and Maintenance Director revealed a lack of awareness regarding these conditions. The Maintenance Director admitted to not having a communication system in place for staff to report needed repairs. Despite acknowledging the need for window cleaning and repairs, the Administrator did not provide a plan or documentation to address the identified concerns before the survey exit.
Failure to Conduct CNA Registry Checks for New Hires
Penalty
Summary
The facility failed to ensure that newly hired employees were screened to rule out the presence of a Federal Indicator, specifically by checking the Certified Nurse Aide (CNA) Registry. This deficiency was identified during a review of employee files, where it was found that seven out of ten sampled employees did not have a CNA registry check performed. These employees included a housekeeper, an activity director, two additional housekeepers, a dietary aide, a maintenance director, and a medical records staff member. The facility's Abuse Prevention Program mandates pre-employment screening, including checking the CNA Registry to ensure no findings of abuse, neglect, or misappropriation of property are present. During an interview, the facility's administrator acknowledged that the Business Office Manager (BOM), who also handles Human Resources (HR), was responsible for conducting these checks but had not been trained to do so for non-nursing staff. The BOM/HR person was out sick at the time of the interview, and the administrator confirmed that the oversight was due to a lack of training. This lapse in procedure indicates a failure to adhere to the facility's established policies for preventing abuse and neglect through proper employee screening.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to ensure that therapeutic diets were prepared and distributed as prescribed by the residents' physicians for several residents. Specifically, seven residents did not receive the diets ordered by their physicians, which included specific items such as health shakes, power potatoes, and cheesy eggs. These dietary components were crucial for managing their medical conditions, which included Alzheimer's disease, dementia, diabetes, and malnutrition, among others. The absence of these prescribed dietary items was observed over several days during the survey period. For instance, one resident with Alzheimer's disease and diabetes was prescribed a pureed diet with specific items like power potatoes and health shakes, but these were not provided. Another resident with traumatic subdural hematoma and anorexia was supposed to receive health shakes with each meal, but these were not served until the issue was highlighted during the survey. Similarly, other residents with conditions such as cerebral palsy, multiple sclerosis, and severe protein-calorie malnutrition also did not receive their prescribed health shakes and other dietary items. Interviews with the Dietary Manager and the Registered Dietician revealed a lack of awareness and preparation of the prescribed dietary items. The Dietary Manager admitted to not preparing or serving the required items, and the Registered Dietician was unaware of the omissions. The facility's failure to provide the prescribed diets was further compounded by the absence of a policy to address the issue, as the requested policy was not provided by the time the survey team exited the facility.
Failure to Follow TB Screening Policy for Employees
Penalty
Summary
The facility failed to adhere to its tuberculosis (TB) screening policy for employees, resulting in a deficiency. The policy, dated 2005, mandates that all healthcare workers undergo a two-step tuberculin skin test (TST) upon hire, with the first dose administered within seven days of employment and the second dose one to three weeks later if the first test is negative. Additionally, an annual one-step test is required. However, the facility did not complete these screenings in a timely manner for five employees. Specifically, Staff Members A and B, hired on 10/1/22 and 7/18/23 respectively, lacked documentation of an annual one-step test. Staff Members C, D, and E, hired on 2/22/24, 3/7/24, and 9/12/24 respectively, had no documentation of the required two-step test. During an interview, the Administrator stated that the Director of Nursing (DON) or Assistant Director of Nursing (ADON) administers the TB test, and the Human Resource Manager (HRM) is responsible for ensuring completion and documentation. However, the DON and HRM were out sick at the time of the interview.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of four residents by not providing adequate assistance and care. One resident, who was severely cognitively impaired, was observed multiple times wearing dirty non-skid socks, and despite acknowledging the issue, did not receive assistance from staff to change them. Another resident, who was cognitively intact, reported wearing a hospital gown since admission due to a lack of clothing. Despite having a few items in her closet, she expressed a desire for more clothing, but staff had not noticed her need, and the facility's administrator was unaware of the situation. Additionally, during meal service, two residents were assisted by a CNA who stood while feeding them, contrary to the facility's protocol of sitting and making eye contact with residents during meals. One of these residents was moderately cognitively impaired, while the other was severely cognitively impaired. The CNA admitted to standing for convenience, and the Director of Nursing confirmed that staff should sit while assisting residents with meals. These actions and inactions contributed to an undignified manner of care for the residents involved.
Failure to Provide Communication Device for Non-Verbal Resident
Penalty
Summary
The facility failed to provide an alternative communication device for a non-verbal resident, identified as R35, which hindered his ability to express his needs and wants. R35 was admitted with multiple diagnoses, including cerebral palsy, generalized anxiety disorder, mood disorder, conversion disorder with seizures or convulsions, dysphagia, and multiple sclerosis. The resident's Minimum Data Set (MDS) assessment indicated a Brief Interview for Mental Status (BIMS) score of zero, confirming his inability to verbally communicate. Despite this, the resident's care plan did not include any strategies or devices to facilitate communication. Interviews with facility staff, including the Administrator and a certified nursing assistant (CNA), revealed that R35 had never been provided with a communication board or device. The Administrator acknowledged that a communication board would be beneficial, yet no such device was in place. During an interaction with R35, he confirmed through non-verbal gestures that he had never used a communication board or device and indicated that such a tool would be helpful for communication. This lack of provision for an alternative communication method constitutes a deficiency in the facility's care for R35.
Failure to Administer Prescribed Skin Care Treatment
Penalty
Summary
The facility failed to provide necessary care in accordance with a resident's preferences and physician orders, specifically regarding skin care. The resident, who was admitted with acute kidney failure, generalized muscle weakness, and obesity, was observed to have extremely dry and flaking skin on her feet and legs. Despite having a prescription for white petrolatum gel to be applied daily, the resident reported that the ointment was not being applied, and this was confirmed through multiple observations over several days. Interviews with facility staff, including a CNA and an LPN, revealed that the task of applying the prescribed cream was not included in the CNA's daily assignment sheet, and the LPN was unaware of why the cream had not been used. The Director of Nursing expressed an expectation for the nursing staff to be more attentive to the resident's skin condition and to apply the ointment as prescribed, indicating a lapse in communication and task assignment within the facility.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 6.67%. This was due to three errors out of 30 opportunities for error during medication administration. One resident did not receive their medication on time, and another resident received a medication without a physician's order. Specifically, a Certified Medical Technician administered Buspirone to a resident at 9:55 AM, which was ordered for 7:30 AM, exceeding the acceptable administration window of one hour before to one hour after the scheduled time. Additionally, a Licensed Practical Nurse administered a Daily-Vite with folic acid to a resident without a corresponding physician's order. Interviews with the LPN, CMT, and the Director of Nursing confirmed the facility's policy that medications should be administered within one hour before or after the scheduled time and that medications should not be given without a physician's order. The failure to adhere to these protocols resulted in the medication errors observed during the survey, which had the potential to affect the accurate dosing of medication administered to the residents.
Deficiency in Maintaining Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was at an appetizing temperature, as observed during one of three meals on one of four survey days. This deficiency potentially affected all 69 residents receiving food from the dietary department. Observations revealed that the pot roast, scalloped potatoes, and winter vegetables were initially at high temperatures on the steam table, but by the time the food was served, the pot roast had cooled to 106 degrees Fahrenheit, which was considered cold by both the Dietary Manager and a resident. The lunch was scheduled for 12:00 PM, but the food cart left the kitchen at 12:40 PM and arrived at the first floor at 12:42 PM, with the test tray temperatures being taken at 1:10 PM. Interviews with the Dietary Manager and Registered Dietician indicated that there were no food temperature logs maintained either in the kitchen or on the unit prior to food service, which was against the facility's expectations. The facility policy regarding food temperature logs was requested but not provided before the survey team exited the facility.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing report in a prominent place accessible to residents and visitors. Observations from 11/12/24 to 11/14/24 revealed that the nurse staffing information was not posted anywhere in the facility but was instead kept in a notebook at the nurses' station. This document lacked essential details such as the facility name, date, census, and the total number and actual hours worked per shift for RNs, LPNs, and CNAs responsible for resident care. During an interview, the staffing coordinator admitted to being unaware of the requirement to post the nurse staffing sheets prominently. She confirmed that the daily nurse documents were kept in a notebook at the nurse's station and did not include the necessary information for proper staffing posting. The Administrator also confirmed that the staffing sheets had not been posted in a prominent place in the facility.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment by not addressing plumbing and roofing issues that resulted in bulging, brown, and rust-colored ceiling tiles in three residents' rooms and a shower room used daily by another resident. Observations and interviews revealed that the ceiling tiles in these areas had been in disrepair for several weeks to months, causing concern among residents about potential mold or fecal contamination. The maintenance director acknowledged the issues but indicated that approval for necessary repairs had not been granted by the corporate office, despite plans and proposals being submitted. Resident #10, who is cognitively intact and has diagnoses including heart disease and diabetes, reported that the ceiling tiles in their bathroom and above their door had been stained and bulging for a couple of months. Resident #11, with mild cognitive impairment and diagnoses including heart failure and diabetes, also reported a stained ceiling tile above their bed that had been present for several weeks. Resident #12, with severe cognitive impairment and multiple diagnoses, had a ceiling tile above their closet that was stained and bent out of place. Additionally, Resident #1, who is cognitively intact and has a history of scoliosis and frequent falls, expressed concerns about the stained ceiling tiles and light fixture cover in the 100 hall shower room, which they used daily. The facility's main entrance lobby hallway also had visible disrepair, with partially painted walls and a clear dried film flaking off in some areas. The maintenance director and administrator both acknowledged the poor condition of the facility and the need for repairs, but indicated that corporate approval had not been received to proceed with the necessary renovations. The overall appearance and maintenance issues were not in line with providing a homelike environment for the residents.
Failure to Obtain Prescribed Narcotic in a Timely Manner
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not obtaining the resident's prescribed narcotic in a timely manner. The resident, who had severe cognitive impairment and was on a scheduled pain medication regimen, did not receive their prescribed Hydrocodone-acetaminophen for an extended period. The medication was documented as not administered due to unavailability on multiple occasions from 2/13/24 to 3/6/24. There was no documentation of communication with the hospice company, physician, or pharmacy regarding the resident's Hydrocodone during this period. Interviews with staff revealed that there was confusion and miscommunication regarding the responsibility for obtaining the medication. The LPN was unaware of the medication's unavailability, and the CMT noticed the issue after a week and informed the DON. The DON assumed the hospice nurse was handling the prescription and was unaware of the medication's absence until informed by the CMT. The facility's emergency kit was also not functioning properly, and staff failed to document their attempts to resolve the issue in the resident's progress notes.
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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