Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monarch Springs Wellness & Rehabilitation | 1.5 mi | ★★★★★ | 3 | 0 |
| Bernard Care Center | 1.7 mi | ★★★★★ | 31 | 0 |
| Oak Park Care Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Grand Manor Health Care Center | 2.6 mi | ★★★★★ | 7 | 1 |
| U-city Forest Manor | 2.6 mi | ★★★★★ | 5 | 0 |
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