Delhaven Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 5460 Delmar Blvd, Saint Louis, Missouri 63112
- CMS Provider Number
- 265392
- Inspections on file
- 29
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Delhaven Manor during CMS and state inspections, most recent first.
The facility failed to ensure appropriate physician orders and consistent monitoring for dialysis care for two residents with ESRD. One resident had a care plan directing staff to ensure dialysis attendance and monitoring of the fistula, bruit, and thrill, but there were no physician orders for dialysis or for access-site monitoring, and the resident reported that staff did not check the shunt before or after treatments. Another resident had an order for thrice-weekly dialysis but no orders to monitor the access site or assess bruit and thrill, and reported that staff did not always check vital signs or the access before or after dialysis. An LPN stated that standard practice should include vital signs and bruit/thrill checks with corresponding orders, but was unaware the orders were missing, and the DON and Administrator acknowledged there was no dialysis policy and that they were unaware of the lack of appropriate dialysis-related orders.
The facility failed to label, date, and cover food items properly, with multiple instances of opened and undated food observed in storage areas. Additionally, kitchen equipment was not maintained in a clean and functional state, with issues such as old grease in the fryer and a leaking fan in the cooler. Interviews confirmed that these practices did not meet the facility's expectations.
The facility did not maintain a sufficient surety bond to protect resident funds, with a bond amount of $75,000 instead of the required $78,000 based on an average monthly trust fund balance of $52,000. Both the Business Office Manager and the Administrator were unaware of this deficiency.
The facility failed to implement Enhanced Barrier Precautions for two residents with pressure ulcers and indwelling catheters, as staff did not wear gowns during high-contact care activities and there was no signage indicating EBP. Additionally, a resident's nebulizer mask was improperly stored uncovered, posing an infection control risk. Interviews revealed a lack of awareness about EBP among nursing staff.
The facility did not complete TPL forms within 30 days for deceased residents, affecting three individuals who had funds in their accounts beyond the required period. The Business Office Manager acknowledged the oversight and stated that the forms were not sent on time, which was not acceptable.
The facility failed to accurately document the MDS for two residents receiving hospice care, leading to discrepancies in their assessments. One resident with senile degeneration of the brain and another with metastatic lung cancer were both inaccurately noted as not having a life expectancy of less than six months, despite being on hospice care. Interviews with staff highlighted expectations for accurate MDS coding, yet deficiencies were identified.
The facility failed to document and monitor dialysis care for a resident with ESRD, as required by their care plan. The resident's dialysis access site was not consistently checked, and communication with the dialysis center was inadequate. Additionally, the facility did not have a copy of the dialysis contract on file, as expected by the DON and Administrator.
A resident with COPD and high blood pressure experienced medication administration errors, resulting in an 8.11% error rate. Errors included administering the wrong diuretic and not waiting the required time between inhalers. Facility policies were not followed, as confirmed by interviews with the pharmacist, DON, and Administrator.
The facility did not provide accessible information on the State Survey Agency hotline number, as it was not posted within the facility. Observations and interviews with alert and oriented residents revealed their unawareness of the hotline's location. The DON confirmed the absence of the posted information, and the Administrator acknowledged the expectation for it to be displayed.
A resident with a history of alcohol use and aggression was not provided necessary behavioral health care services, leading to multiple incidents of intoxication and aggression. The facility lacked a clear protocol for handling such behaviors, and staff were unsure of their responsibilities, resulting in an Immediate Jeopardy situation.
The facility failed to ensure that its transportation staff held the appropriate Class E driver's license as required by Missouri state regulations. Driver G, responsible for transporting residents, was observed operating a facility van without the necessary license, potentially affecting all residents transported. Both Driver G and the Administrator were unaware of the licensing requirement.
The facility, licensed for 156 residents, failed to employ a qualified full-time social worker. The current Social Services Designee lacked the required bachelor's degree and relevant experience. The administrator was unaware of the qualifications needed, mistakenly believing they were based on census rather than licensed beds.
The facility failed to maintain a reliable system for recording and reconciling controlled drugs, with missing signatures and incomplete documentation on narcotic count sheets across multiple medication carts. Interviews with staff confirmed that the expected protocol of counting and signing off by both incoming and outgoing staff was not consistently followed, leading to a deficiency in managing controlled substances.
The facility failed to protect a resident from physical abuse when one resident hit another in the face after a verbal altercation involving racial slurs. Staff intervened and called EMS, but the incident highlighted a failure to address ongoing behavioral issues effectively.
The facility failed to follow physician orders for two residents by not administering multiple medications as prescribed and not documenting the reasons for these omissions. Staff interviews revealed uncertainty about the cause, with some attributing it to potential computer issues. The Administrator and DON acknowledged the problem and emphasized the importance of proper medication administration and documentation.
A facility failed to follow physician orders for a resident by not administering and documenting medications, leading to increased aggressive behavior and multiple hospital visits. Staff interviews revealed uncertainty about the missed medications, and a hospital lab result showed undetectable Lithium levels.
The facility failed to assist a resident out of bed upon request, leading to multiple falls and feelings of isolation and depression. Despite the resident's cognitive intactness and history of traumatic spinal cord dysfunction and quadriplegia, staff did not comply with the resident's requests, and the care plan did not address the need for assistance with transfers.
The facility failed to develop and implement a comprehensive care plan for a resident, including fall interventions and addressing changes in mood and socialization. The resident experienced three falls, resulting in injuries, but the care plan was not updated with new interventions. Additionally, Social Services did not document any interventions related to the resident's mood or inability to participate in activities.
A resident experienced multiple falls and injuries due to the facility's failure to identify safety hazards and implement appropriate interventions. Staff left a bed remote under the resident, causing a fall that resulted in a head laceration and C-2 neck fracture. Subsequent falls were not investigated, and no new safety measures were put in place.
The facility failed to provide necessary behavioral health care and services to a resident, leading to feelings of isolation and sadness. The resident, who was cognitively intact and had a history of traumatic spinal cord dysfunction and quadriplegia, was not able to participate in activities after a fall. Staff did not assist in getting the resident out of bed, and there was a lack of coordination and communication regarding the resident's needs. The care plan and social services progress notes lacked documentation and interventions to address the resident's change in mood and inability to participate in activities.
Failure to Ensure Appropriate Orders and Monitoring for Dialysis Care
Penalty
Summary
The deficiency involves the facility’s failure to provide dialysis services consistent with professional standards of practice for two residents with end stage renal disease (ESRD). For one resident admitted with ESRD and dependent on dialysis, the medical record showed an admission date of 2/5/26 and a care plan identifying risk for ineffective tissue perfusion and excessive fluid volume, with tasks to ensure attendance at dialysis and monitoring of the fistula, bruit, and thrill. However, the active physician order summary contained no orders for dialysis and no orders directing staff to monitor the dialysis site or assess bruit and thrill before and after treatments. Observation confirmed the presence of a dialysis shunt in the right upper arm, and the resident reported attending dialysis three times weekly and stated that staff did not check the dialysis shunt before or after treatments. A second resident, admitted on 3/4/26 with ESRD, had a care plan noting risk for imbalanced fluids and ineffective tissue perfusion related to ESRD, with tasks to ensure attendance at scheduled dialysis and nursing assessment as ordered. The physician order summary included an order for dialysis three times weekly with a specified chair time but did not include any orders for staff to monitor the dialysis access site or assess bruit and thrill. Observation showed a dialysis shunt in the upper left arm, and the resident reported attending dialysis three times weekly and stated that staff did not always check vital signs or assess bruit and thrill before or after dialysis. An LPN stated that standard practice should include obtaining vital signs, administering medications, and checking bruit and thrill before dialysis, with corresponding physician orders, but was unaware that proper orders were missing. The DON and Administrator acknowledged there was no dialysis policy, that the ADON was responsible for ensuring appropriate orders, and that they were unaware the residents lacked physician orders for dialysis and for monitoring bruit and thrill.
Deficiencies in Food Safety and Kitchen Maintenance
Penalty
Summary
The facility failed to properly label, date, and cover food items in the kitchen, as observed on multiple occasions. Specific items such as mostaccioli noodles, cheese flakes, stuffing mix, tortilla shells, salad mix, cookies, French toast, biscuits, hot dogs, and an unidentified food item were found opened, wrapped in plastic, and without dates. These observations were made in the dry storage room, walk-in cooler, and freezer, indicating a consistent lack of adherence to food safety standards. Additionally, the facility did not maintain kitchen equipment in a clean and functional state. The deep fryer contained old grease and had caked-on grease and batter, while the stove had heavy stains and old food particles. Furthermore, a fan in the walk-in cooler was leaking water into a metal pan. Interviews with the Director of Dietary Services and the Administrator confirmed that the facility's expectations for food labeling, dating, and equipment cleanliness were not met, and maintenance issues were acknowledged but not yet resolved.
Insufficient Surety Bond for Resident Funds
Penalty
Summary
The facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The deficiency was identified through an interview and record review, revealing that the facility's surety bond amount was $75,000, which was insufficient compared to the required $78,000 based on the facility's average resident trust fund balance over the previous twelve months. The average monthly balance was $52,000, necessitating a higher bond amount to adequately protect the funds of all residents who have money in the resident trust fund. The Business Office Manager and the Administrator were both unaware of the insufficiency of the bond amount at the time of the survey.
Failure to Implement Enhanced Barrier Precautions and Proper Equipment Storage
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with pressure ulcers and indwelling urinary catheters. Observations revealed that there was no signage indicating EBP on the doors of the residents' rooms, and staff did not wear gowns during high-contact care activities. Resident #42, who had multiple pressure ulcers and an indwelling catheter, was transferred and provided personal hygiene care without staff wearing gowns. Similarly, Resident #38, who also had pressure ulcers and an indwelling catheter, received wound care without staff wearing gowns, and the catheter bag was observed lying on the floor. Additionally, the facility failed to properly store a nebulizer mask for Resident #45, who required oxygen therapy and had a diagnosis of COPD. The nebulizer mask was repeatedly observed uncovered on the windowsill, posing an infection control risk. The facility's policies did not address the storage of oxygen tubing and nebulizer masks, contributing to this oversight. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed a lack of awareness regarding EBP, indicating a gap in staff training and knowledge. The facility's administrator acknowledged the expectation for staff to use EBP and to keep catheter bags off the floor, highlighting a disconnect between policy and practice.
Failure to Timely Complete TPL Forms for Deceased Residents
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 longer than the stipulated period. Resident #314 had an ending balance of $390.49, Resident #315 had $29.04, and Resident #316 had $20.04. The TPL forms for these residents were sent after the 30-day period. During an interview, the Business Office Manager acknowledged that the facility was supposed to send the TPL forms within 30 days and admitted that this was not done, which was not acceptable.
Inaccurate MDS Documentation for Hospice Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of two residents, leading to deficiencies in documentation. Resident #57, who was admitted to the facility with diagnoses including high blood pressure, aphasia, and depression, was receiving hospice care. However, the MDS inaccurately documented that the resident did not have a condition or chronic disease that may result in a life expectancy of less than six months, despite physician orders and care plans indicating hospice care due to senile degeneration of the brain. Similarly, Resident #60, admitted with diagnoses such as cancer, asthma, malnutrition, and Parkinson's Disease, was also receiving hospice care. The MDS for this resident incorrectly noted that there was no condition or chronic disease that may result in a life expectancy of less than six months, even though the resident was on hospice care for metastatic lung cancer and subsequently expired at the facility. Interviews with the MDS Coordinator and the Administrator revealed expectations for accurate MDS coding, yet discrepancies were found in the documentation.
Deficiency in Dialysis Care Documentation and Monitoring
Penalty
Summary
The facility failed to ensure proper documentation and monitoring for residents receiving dialysis services. Specifically, the facility did not maintain documented assessments and monitoring related to dialysis for Resident #53, who was cognitively intact and diagnosed with end-stage renal disease (ESRD) and dependent on renal dialysis. The care plan for this resident included monitoring for infections and checking the dialysis access site for bruit and thrill, but there was no documentation in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) to show that staff checked the dialysis access every shift or reported any issues to the dialysis provider and primary medical doctor. The facility's policy for the care of residents with ESRD required staff to be trained in the care and special needs of these residents, including monitoring for signs of complications and ensuring proper communication with the dialysis center. However, the review of the progress notes and dialysis communication records showed that only four out of 13 required assessments were completed in October, and no assessments were documented from November 1 to November 6. Interviews with LPNs and the Director of Nursing (DON) revealed that while vital signs and weights were taken before dialysis and documented on a communication form, there was inconsistency in receiving these forms back from the dialysis center, and the required monitoring was not consistently documented. Additionally, the facility did not have a copy of the dialysis contract on file, which was expected by the DON and the Administrator. The facility attempted to obtain a copy from the dialysis company but was informed that the contract was located at a different location. This lack of documentation and communication highlights a deficiency in the facility's ability to provide safe and appropriate dialysis care for residents requiring such services.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8.11% error rate during the observation of 37 medication administration opportunities. Three errors were identified involving a resident who was cognitively intact and diagnosed with high blood pressure and chronic obstructive pulmonary disease (COPD). The errors included the administration of Spironolactone-Hydrochlorothiazide instead of the prescribed Spironolactone, and the improper administration of inhalers without the required waiting time between different medications. The facility's policies require that only licensed personnel or certified medical technicians administer medications, and that medications be administered according to practitioner orders. During the observation, a certified medical technician administered the wrong diuretic medication and failed to adhere to the policy of waiting at least two minutes between different inhalers. Interviews with the pharmacist and the Director of Nursing confirmed that the medications were not interchangeable and that the facility's medication administration policies were not followed. The Administrator also stated that staff are expected to follow physician orders and facility procedures.
Failure to Post State Survey Agency Hotline Number
Penalty
Summary
The facility failed to provide accessible information regarding the location of the State Survey Agency hotline number, which was not readily available to residents without assistance. Observations conducted throughout the survey on multiple dates revealed that the State Survey Agency number was not posted within the facility. During a group interview, seven residents, identified as alert and oriented, reported that they were unaware of where the hotline number was posted. Additionally, the Director of Nursing confirmed that the State contact information was not posted, and the Administrator acknowledged the expectation for the hotline number to be displayed.
Failure to Address Resident's Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being, specifically for a resident with a history of alcohol use and verbal/physical aggression. The resident, who was cognitively intact and had diagnoses including high blood pressure, high cholesterol, and depression, exhibited behaviors such as alcohol intoxication and aggression towards staff and other residents. Despite these behaviors, the facility did not adequately address the resident's needs or inform staff on how to handle the escalating behaviors. The resident's care plan was insufficient, lacking specific details on who was responsible for monitoring the resident's behaviors, the frequency of monitoring, and the specific behaviors to be monitored. The facility's staff, including LPNs and CNAs, reported multiple instances of the resident returning to the facility intoxicated and being aggressive, yet there was no clear protocol or policy in place for handling such situations. The staff were unsure of their responsibilities, and incidents were not consistently documented or communicated to the resident's physician. Interviews with facility staff revealed a lack of communication and coordination in addressing the resident's substance use and aggressive behaviors. The Social Worker and DON acknowledged the resident's issues but did not implement a behavior contract or other interventions to manage the situation effectively. The facility's failure to provide appropriate behavioral health care and services resulted in an Immediate Jeopardy situation, highlighting significant deficiencies in the facility's handling of residents with substance use disorders.
Failure to Ensure Proper Licensing for Transportation Staff
Penalty
Summary
The facility failed to ensure that staff responsible for transporting residents in the company vehicle held the appropriate driver's license as required by Missouri state regulations. Specifically, the facility's transportation escort, identified as Driver G, was observed transporting a resident to a dialysis appointment without possessing the necessary Class E driver's license. The Missouri State Driver's Guide mandates that anyone transporting 14 or fewer passengers for pay or as part of their job must have a Class E license. However, Driver G only had a Class F license, which is insufficient for the duties performed. The deficiency was identified during an observation where Driver G was seen transporting a resident in a facility van equipped with a wheelchair lift. During interviews, Driver G admitted to being unaware of the requirement for a Class E license and confirmed that he was hired specifically for transportation duties. The facility's Administrator also acknowledged a lack of awareness regarding the licensing requirement for operating the van. This oversight had the potential to affect all residents transported in the facility vehicles, given the facility's census of 61 residents.
Facility Lacks Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified social worker on a full-time basis, despite being licensed and certified for 156 residents. At the time of the survey, the facility had a current census of 61 residents. The job description for the social worker position required a minimum of a bachelor's degree in social work or a related human services field, along with at least one year of supervised social work experience in a healthcare setting. However, the individual employed as the Social Services Designee (SSD) did not meet these qualifications. Her educational background included accounting, cosmetology, and massage therapy, with no documentation of a bachelor's degree in a human services field or relevant social services experience. During interviews, the SSD confirmed that she did not possess a bachelor's degree and had not taken the SSD test due to its cost. The facility's administrator admitted to being unaware of the specific qualifications required for a social worker and mistakenly believed that the need for a qualified social worker was based on the current census rather than the number of licensed beds. This lack of awareness and oversight led to the employment of an unqualified individual in a critical role, failing to meet the regulatory requirements for social services in the facility.
Deficiency in Controlled Drug Reconciliation
Penalty
Summary
The facility failed to establish a reliable system for recording and reconciling controlled drugs, as evidenced by the review of narcotic count books for four different medication carts. The review revealed numerous instances where required signatures from outgoing and incoming staff were missing, and documentation under 'Count ok' was incomplete. This deficiency was observed across multiple dates and carts, indicating a systemic issue in the facility's process for managing controlled substances. The facility's policy required that controlled substances be counted and reconciled at the end of each shift by both the oncoming and outgoing staff, with both parties signing off on the count sheets. However, this procedure was not consistently followed, as shown by the missing signatures and incomplete documentation. Interviews with facility staff, including a Registered Nurse, the Staffing Coordinator, and the Director of Nurses, confirmed that the expected protocol was not adhered to. The Director of Nurses acknowledged that an in-service training was conducted for nurses but not for Certified Medication Technicians (CMTs), who were also involved in administering narcotics. The Administrator expressed that only licensed nurses should administer narcotic medications and that both incoming and outgoing nurses should sign off on the narcotic count. Despite these expectations, the facility's records showed that the required procedures were not consistently implemented, leading to the deficiency in the management of controlled substances.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure a resident's right to be free from physical abuse when one resident hit another resident in the face. Resident #4, who has moderate cognitive impairment and a history of schizophrenia, hypertension, obesity, intellectual disabilities, hypothyroidism, and bipolar disorder, was struck by Resident #5 after a verbal altercation. The incident occurred in front of the nursing station, where Resident #4 called Resident #5 a racial slur, prompting Resident #5 to hit Resident #4, causing them to fall to the floor. Staff intervened and separated the residents, and EMS was called to transport Resident #4 to the hospital for further evaluation. Resident #4 exhibited verbally aggressive behavior towards staff and other residents, including using racial slurs and making threats of physical violence. Resident #5, who is cognitively intact and has a history of high blood pressure, anxiety disorder, and depression, reported that Resident #4 had previously used racial slurs and had been verbally abusive on multiple occasions. Staff interviews confirmed that Resident #4's behavior was a known issue, and the facility's policies on abuse and investigation were not effectively implemented to prevent the altercation. The facility's investigation report indicated that the altercation was triggered by Resident #4's use of a racial slur, leading to Resident #5's physical response. Staff members intervened to separate the residents and called EMS, but the incident highlighted a failure to protect residents from abuse and to address ongoing behavioral issues effectively.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice by not following physician orders for two residents. For Resident #1, the facility did not administer multiple medications as ordered, including Amiodarone, Loratidine, Klor-Con, Lisinopril, and Furosemide on several occasions. There was no documentation explaining the reasons for these omissions, and the resident confirmed that they did not refuse the medications. The RN interviewed was unsure why the medications were not given, citing potential issues with the computer system used for documentation. For Resident #4, the facility also failed to document the administration of several physician-ordered medications, including Miralax, Senna, and a multivitamin, over multiple months. The resident's physician was unaware of these missed medications and expressed concern about the potential negative outcomes. Interviews with staff, including a Certified Medication Technician and the Assistant Director of Nursing, revealed uncertainty about why the medications were not given or documented, with some attributing it to possible computer issues. The Administrator and Director of Nurses acknowledged the missing medication administration dates and stated their expectation that all residents receive their medications as ordered. They also emphasized the importance of documenting reasons for any missed medications, highlighting the potential impact on residents' mental and physical health if medications are not administered as prescribed.
Failure to Administer and Document Medications
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice by not following the physician orders for a resident. The facility did not administer the resident's medication and did not document the reasons or notify the physician. This failure was observed over several months, with multiple instances of missed medication administration documented in the Medication Administration Record (MAR). The resident had a history of moderate cognitive impairment, schizophrenia, high blood pressure, obesity, intellectual disabilities, hypothyroidism, and bipolar disorder. The resident's care plan included administering behavior medications as ordered by the physician to manage socially inappropriate and disruptive behavior. However, the MAR showed numerous instances where medications such as Chloropromazine, Haloperidol, Lithium carbonate, Quitiapine, Lorazepam, Divalproex ER, Metoprolol Tartrate, Abilify, Atorvastatin, Benztropine, Lasix, and Medroxyprogesterone were not documented as administered. Interviews with staff revealed uncertainty about why the medications were not given or documented. Some staff mentioned potential computer issues or resident refusals, but there was no clear documentation to support these claims. The resident experienced increased aggressive behavior, leading to multiple hospital visits. A hospital lab result showed the resident's Lithium level was undetectable, indicating a failure to consistently administer the medication. The facility's administration acknowledged the issue and expected staff to administer medications per physician orders and document any deviations.
Failure to Assist Resident Out of Bed
Penalty
Summary
The facility failed to provide reasonable accommodation of needs and preferences for a resident when staff did not assist the resident out of bed upon request. The resident, who was cognitively intact and had a history of traumatic spinal cord dysfunction and quadriplegia, was found on multiple occasions on the floor after attempting to get out of bed independently. Despite the resident's requests to be assisted out of bed, staff repeatedly did not comply, leading to the resident feeling isolated, sad, and like a hostage. The resident had not participated in activities since the falls, which further contributed to their feelings of isolation and depression. The resident's care plan did not address the need for staff assistance with transfers, and there were no new physician orders indicating that the resident could not get out of bed. Interviews with various staff members revealed inconsistencies and misunderstandings about the resident's ability to get out of bed and participate in activities. Some staff believed the resident needed to wait for a follow-up appointment with a physician, while others mentioned the resident's pressure sore as a reason for not getting out of bed. However, the resident had a pressure-relieving cushion for their chair, which should have allowed them to get up. The Director of Nursing expected staff to get the resident up out of bed if there were no documented reasons preventing it. Despite this expectation, the resident remained in bed, leading to a decline in their psychosocial well-being. The facility's failure to assist the resident out of bed as requested and to address the resident's needs and preferences in their care plan resulted in a deficiency in providing reasonable accommodation for the resident's needs and preferences.
Failure to Implement Comprehensive Care Plan and Address Fall Interventions
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address a resident's specific needs, including fall interventions. The staff did not conduct fall investigations to determine the causes and necessary interventions for three separate falls experienced by the resident. Despite the resident's history of falls and the presence of significant medical conditions such as quadriplegia and a traumatic spinal cord dysfunction, the care plan was not updated to reflect new interventions after each fall. Additionally, there was no documentation of fall screenings or assessments being completed by therapy staff, and the care plan lacked specific details regarding the resident's transfer assistance level of care. The resident experienced three falls within a short period, resulting in injuries, including a fracture of the second cervical vertebra. Despite these incidents, the care plan was not revised to include new fall prevention strategies. The facility's staff, including the Director of Nursing and the Therapy Manager, were unaware of the family's requests for bedrails, physical therapy, or a restorative nursing program. The resident's medical record did not contain any documentation of fall investigations or assessments, and the care plan meeting notes did not reflect any new interventions to address the falls. Furthermore, the facility failed to address the resident's change in mood and lack of access to socialization. The resident, who was previously active and attended activities, became confined to bed due to a pressure sore and expressed feelings of depression. Social Services did not document any interventions related to the resident's mood or inability to participate in activities. The facility's failure to update the care plan and implement appropriate interventions contributed to the resident's continued risk of falls and decline in psychosocial well-being.
Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to identify potential safety hazards in a resident's environment, who was assessed as being unable to move while in bed. Staff left the bed remote control under the resident's back, causing the bed to elevate to its highest position. This resulted in a one-centimeter laceration on the resident's head and a C-2 neck fracture. In the two weeks following this incident, the resident experienced two additional falls, but the facility did not investigate or implement additional safety interventions after each fall. The facility's Falls-Clinical Protocol and Repositioning Level II Policy were not adequately followed. The protocol required staff and physicians to identify individuals with a history of falls, document recent injuries, and assess the causes of falls within 24 hours. However, there was no documentation of fall investigations, post-fall tools, or fall assessments in the resident's medical record. The resident's care plan did not address new interventions after each fall or specify steps staff should take to ensure safety. Interviews with staff revealed a lack of awareness and communication regarding the resident's care needs and fall prevention measures. The Director of Nursing (DON) was unaware of the care plan meeting bedrail assessment request, and the Therapy Manager did not know about the care plan meeting. The resident expressed fear of falling again due to the absence of bedrails and described multiple incidents where the bed remote or pillow contributed to falls. Despite the resident's repeated falls and injuries, the facility did not take appropriate actions to prevent further incidents.
Failure to Address Resident's Emotional and Social Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, leading to feelings of isolation and sadness. The resident, who was cognitively intact and had a history of traumatic spinal cord dysfunction and quadriplegia, was found on the floor after a fall. Following the fall, the resident was not able to participate in activities and felt isolated and sad. The resident expressed that staff did not assist in getting him/her out of bed, despite his/her desire to participate in activities such as dominoes, bingo, and going outside. Staff repeatedly told the resident that he/she would be assisted the next day, but this did not happen, leading the resident to feel like a hostage in his/her own room. Interviews with various staff members revealed a lack of coordination and communication regarding the resident's needs. A Certified Medication Technician (CMT) mentioned that the resident used to get up every day before the fall but had not been out of bed since. A therapist was unaware of any evaluation or assessment request for getting the resident out of bed. A CNA confirmed that the resident was waiting to see a doctor before being allowed out of bed. The Activity Assistant and Social Worker both acknowledged that the resident had not participated in activities since the fall and that there was no documentation or interventions in place to address the resident's change in mood and inability to get out of bed. The resident's care plan and social services progress notes lacked documentation related to the resident's change in mood and the sudden inability to participate in activities. The Director of Nursing (DON) expected Social Services to address the resident's feelings of depression and for the Activity Director to provide activities to the resident while he/she was confined to the room. The deficiency was evident in the facility's failure to meet the resident's emotional and social needs, as well as the lack of appropriate interventions and documentation to address these issues.
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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